A Happy Ending?
Your patient is a young adult male with no significant past medical history presenting with a chief complaint of
testicular pain and heaviness. He reports that the pain occurred 2 hours prior
to presentation. It was gradual in onset, progressively worsened, and is now
plateaued. The pain is constant, dull, and achy. It is not localized to a
single side. The patient feels like his scrotum is heavy, like someone is
weighing it down. It is worse with movement, better when still. The
patient could not recall any inciting trauma.
Prior to onset of symptoms, the
patient reports “getting my swerve on” with a new female partner, which he
insisted did not consist of penetrating vaginal or anal intercourse would not further elaborate. He denies ejaculation prior to pain onset. He denies a history of penetrating intercourse altogether, but does endorses receptive oral sex activity. He denies a history of
STI. Further ROS is negative.
The physical exam is notable for bilaterally descended testes, and normal-appearing Tanner stage 4 genitalia. There is generalized bilateral testicle tenderness to palpation, without scrotal discoloration, testicular deformation, or penile discharge. There is no transverse lie, nor change in symptoms with elevation. The cremasteric reflex is intact.
You’re pretty sure you are least
colloquially familiar with this patient’s current affliction, but have no idea
if there’s any evidence-based interventions to lessen his discomfort.
Clinical Question:
What are suggested treatments for
male pelvic congestion?
The Literature:
There is a paucity of academic information
regarding this phenomenon: scrotal pain following sustained sexual arousal
unrelieved due to lack of orgasm and ejaculation. In the limited literature
available, it is known as male pelvic congestion or epididymal hypertension. In
lay terms, it has been referred to as “blue balls,” “lover’s nuts,” or “deadly
sperm build-up” (DSB). Most of the available information is from anecdotal
reports – “common knowledge and experience,” as one (unreferenced) article from
a human sexuality journal described in 1989. Prior to the publication of a case
report, with responding letters to the editor/author, published in Pediatrics in 2000, there was no
information on the subject to be found in textbooks or online searchable
databases (as concluded by medical librarians in three different institutions
queried by the authors of this case report).
The included signs and symptoms are
similar to the patient’s presentation above. In most cases the tenderness
appears to be localized to the epididymis. The remainder of the GU exam and
urinalysis should be normal. The pain usually resolves spontaneously within
three hours of onset.
Proposed pathophysiology involves
sexual arousal that produces increased blood flow to the penis and testes
leading to pelvic venous dilatation. If this persists over time, testicular
venous drainage slows, pressure builds, and this causes pain.
Anecdotal
treatments include sexual release via ejaculation, Valsalva maneuver, or
lifting a heavy object. The case report included an anecdote about a physician
in Los Angeles in the 1940s who, while teaching a course on human sexuality,
gave a lecture on “lover’s nuts” in which he advised that masturbation was an
appropriate medical treatment. This view is shared by most sexual health "experts" in the lay press.
Take home:
Male pelvic congestion is a real
phenomenon, but is rarely discussed in medical literature.
It is a self-limiting and
non-morbid process, but anecdotal evidence suggests that Valsalva,
weight-lifting, or ejaculation via masturbation may expedite relief of
discomfort.
References:
1) Pediatrics. 2000;106;843-843.
2) Pediatrics 2001;108;1233
Contributed by Daniel Kolinsky, PGY-2.