A lot of guys aren’t happy with how their penises look—so many, in fact, that a multi-million dollar male enhancement industry has emerged. Companies are now offering everything from pills to pumps to extenders to surgeries that promise to add extra length and/or girth to your manhood (unfortunately, however, most of them don’t work as advertised).

Male genital enhancement isn’t just limited to the penis, though. A growing number of guys are seeking to enhance their scrotums too. To be clear, guys tend to be far more worried about their penises than they are about their scrotums. In fact, in a recent nationally representative survey of more than 4,000 U.S. men who were asked how they felt about their junk, just seven percent expressed dissatisfaction with their testicles whereas almost four times as many said they were dissatisfied with their flaccid penis size.

So for those who have scrotal hang-ups, what kinds of enhancement techniques are available? And are they safe? Let’s take a look.

First, some guys are getting scrotal injections that temporarily increase the size of their balls. It’s a relatively simple procedure: saline is injected into the scrotum until it expands to the desired size. The effect is temporary because the fluid is typically absorbed by the body within a couple of days.

Some guys do this because they simply like the feeling or appearance of larger balls; however, others do it as part of BDSM play, injecting large quantities of saline to the point where it becomes physically painful.

Either way, this is a dangerous practice. Accidentally injecting the testicle itself could cause physical damage (including infertility), there’s a risk of an embolism if air bubbles are injected and sometimes the body doesn’t reabsorb the fluid, necessitating a costly and embarrassing trip to the ER for drainage that just might make you the subject of a medical case report (like what happened to this guy. Warning: don’t click if you don’t want to see the photos).

For those who want bigger scrotums and are in the market for something a little more permanent, you may be surprised to learn that scrotal implants have actually been around since the 1940s. Most commonly, they are used for guys who have had a testicle surgically removed, but they’re sometimes used for guys who have experienced testicular atrophy (that is, permanent shrinkage), as well as guys who just want to fill out their sacs a little more.

These are basically silicone balls that are, well, added to your own balls. (You can see an example of what one looks like here.) As is the case with breast implants, if the procedure is performed by an experienced surgeon, it’s probably fairly safe; however, complications can arise in rare cases, such as infections or leakage.

Now, not all guys who have scrotal anxiety want to make their balls bigger. Some want precisely the opposite: a smaller or less droopy scrotum. And that’s why some plastic surgeons are now offering “scrotal reduction” and “scrotal tightening” procedures.

These are generally performed on an outpatient basis and can be completed in just 30 to 60 minutes. Of course, as with all surgeries, there are potential risks and side effects; however, it appears to be relatively safe overall, with hematomas (a pooling of blood near the surgical site) being the most common complication.

Finally, rather than changing the size of their scrotums, some guys want to make them less wrinkly. This can be accomplished through Botox injections of the scrotum, also known as Scrotox, a term popularized in a 2010 SNL skit. Alec Baldwin plays the Scrotox spokesperson who deadpans to the camera, “Aren’t you ready for your prunes to become plums?”

Botox is a drug that can smooth wrinkles pretty much anywhere on the body—most commonly on the face—by temporarily paralyzing muscles at the injection site for a few months. In addition to reducing scrotal wrinkles, Scrotox can potentially make your sac appear larger because, with the scrotal muscles paralyzed, your body won’t be able to automatically pull it closer when it’s cold or when you’re sexually aroused.

There are only isolated media reports of Scrotox being used and no research has been conducted on it yet, so we don’t know much about how safe or effective it is. However, believe it or not, scientists have actually been injecting scrotums with Botox for years for non-cosmetic purposes. In fact, they have found that it’s an effective treatment for “retractile testes” (a condition in which the testes basically get pulled up into the groin when the attached muscles contract) as well as chronic scrotal pain.

So is scrotal modification the next big thing in male enhancement? Probably not. For one thing, not a lot of guys are cool with the idea of scalpels and needles going anywhere near their manhood. Plus, remember that not that many guys are concerned with their scrotal appearance anyway and, at least according to Amy Schumer, “girls don’t care about your balls” (unless you’re missing them entirely).

Justin Lehmiller, PhD is a sex educator and researcher at Ball State University, a Faculty Affiliate of The Kinsey Institute, and author of the blog Sex and Psychology. Follow him on Twitter @JustinLehmiller.