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.  

1) Pediatrics. 2000;106;843-843.
2) Pediatrics 2001;108;1233

Contributed by Daniel Kolinsky, PGY-2.