Blue Balls: Fact or Fiction?

“Blue balls” is a term used to describe scrotal pain (pain in “the balls”) following heightened sexual arousal that did not result in ejaculation (Challet et al., 2000). But what is “blue balls” really? Many would be surprised to learn that there has been next to no research surrounding the prevalence or cause of this condition. The first and only case report published to date about a patient with “blue balls” was by Dr. Jonathan Chalett in 2000, in which a 14-year-old boy reported sharp scrotal pain following engagement in sexual activity without ejaculation; the patient had no other symptoms and the pain subsided in a few hours (Chalett, 2000). This report caught the attention of several medical doctors that responded in support of a greater awareness and investigation of this condition, but it never happened. Why?

How common is blue balls?

Although the exact prevalence of blue balls remains unknown, becoming sexually aroused without the opportunity to ejaculate seems like a situation many people may find themselves in. Despite the lack of initiative seen from the scientific community to investigate blue balls, many health-focused outlets such as Healthline and Medical News Today have published articles pertaining to its potential causes, treatments, and myths. More recently, entertainment magazines such as Cosmopolitan have contributed to the literature as well, fuelling the debate about “What really is blue balls?” (Kobola, 2018). Not only is blue balls a hot topic in North American magazines but European headlines have also capitalized on people’s curiosity of this condition, referring to it as “lover’s nuts” (Lexico, 2022). If blue balls is as common as social media has portrayed, why has it not been met with the corresponding level of research?

Science Vs, a popular science podcast, thought the same thing; they conducted a survey asking whether blue balls was real. With over 2,200 responses, more than half of the respondents with penises reported that they either did not believe that it exists or that they were not sure (Science Vs, 2021). Shockingly, this “well-known” cause of scrotal pain, supposedly feared by many, did not appear to be believed by many. Interestingly, in a follow-up survey, Science Vs asked their listeners whether they had experienced pain or achiness around or within their tesicles after approaching orgasm without ejaculation and with 1,200 responses, over 60% of respondants said yes (Science Vs, 2021). In the same survey, only 7% of respondants who reported this pain described it as “severe”, and the majority describing it as mild. Perhaps people do indeed experience blue balls but it is just not painful enough for most to seek a diagnosis or treatment (Science Vs, 2021). Nevertheless, there are still people who have reported suffering from this scrotal pain great enough to seek medical attention, such as the case reported by Dr. Chalett (2000). If this condition is not as common or painful as initially thought, what could be causing it?

What causes blue balls?

One theory concerning blue balls attributes the pain to “sperm build up", in which sustained sexual arousal results in a build-up of sperm within the epididymis and without ejaculation, it remains within the testis, causing pain (Phoenix, 2021). The epididymis functions as a sperm storage unit, containing the fluid that both supports the development of maturing sperm as well as allows for the disposal of older sperm (Cosentino & Cockett, 1986). The epididymis is composed of three parts: the head, body and tail, and it can be up to 3 to 4 metres long when straightened out (Cosentino & Cockett, 1986). It is housed in the scrotum, along with the testis and spermatic cord, with the epididymal head attached to the testis, playing a role in sperm transport (Cosentino & Cockett, 1986; Patel, 2017). Although this theory may make sense to some, sperm production can take up to an average of 64 days, making it unlikely that it is created and held in the epididymis in a manner that results in a build-up large and fast enough to cause the pain associated with blue balls (Science Vs, 2021; Misell et al., 2006).

Alternatively, a more promising explanation has been proposed in which the slowed drainage of blood from the testicles following sexual arousal could be at least part of the source of discomfort associated with blue balls, a phenomenon frequently referred to as epididymal hypertension (Science Vs, 2021; Duggal, 2021). The penis is made up of three chambers that are maintained by a fibrous skeleton that allows blood flow into the penis and aids in sustaining an erection (Panchatsharam, 2022). During an erection, the penis becomes engorged with blood via the internal pudendal artery, increasing its blood flow by up to 40 times, expanding the chambers and increasing its blood pressure substantially (Panchatsharam, 2022). Not only does this happen within the penile chambers but blood flow to the testicles also elevates, predominantly via the testicular artery, accompanied by an increase in size (Science Vs, 2021; Seeley et al., 1980). Once no longer aroused or following ejaculation, the corresponding veins decompress, allowing the blood to empty from the genitals (Panchatsharam, 2022; Patel, 2017). According to this theory, blue balls results from the slowed drainage of blood from the testicles following sexual arousal, leaving it within the scrotum along with the increased pressure it creates, subsequently causing pain and discomfort (Science Vs, 2021). But what about the erection? If blood flow from the testicles is slowed, why is the blood flow from the penis left unaffected? The testicles and the penis have different main blood supplies; hence, it is possible for the penis to be emptied of excess blood while it remains in the testicles (Science Vs, 2021; Patel, 2017; Panchatsharam, 2022).

Now that we have a potential explanation for this mysterious form of scrotal pain, this brings us back to the question of why there has been little to no research on whether this is the true cause of blue balls. Acute scrotum pain accounts for approximately 0.5% to 2.5% of all emergency room visits (Velasquez et al., 2017), although it is impossible to know how many of these visits could have been attributed to blue balls.

Why the hesitancy to research blue balls?

The feedback following the release of Dr. Chalett’s (2000) case report was mostly positive in supporting the greater awareness of this condition, although some did express concern. Dr. Chalett suggested in the report that the treatment for blue balls may involve a ‘sexual release’ (Chalett, 2000). Of course, if blue balls results from sustained sexual arousal without ejaculation or orgasm, a sensical solution could involve either continuing with the sexual act through to ejaculation (with enthusiastic consent from any partner or partners in the room, of course!) or doing so through solitary or consensual partnered masturbation. The concern arising from this statement were the ethical implications of deeming masturbation or a ‘sexual release’ a legitimate medical treatment and more specifically, what it would mean for both healthcare providers and for the partners of those who may use this “treatment” to demand sexual satisfaction (Weinzimer & Thornton, 2001). These concerns are consistent with findings of the survey conducted by Science Vs (2021) where over 40% of respondents with vaginas said they had been pressured into a sexual act because of their partner’s fear of blue balls. Would making ‘sexual release’ a viable treatment for blue balls only make matters worse?

At present, blue balls has been left behind by sexual health literature, and in the hands of social media; the mystique surrounding blue balls may be fuelling its power and misperception, such as leading people to believe that its prevention is a means to demand sexual acts (Chalett, 2001). Shedding light on this condition and educating people on other ways to treat blue balls such as using the Valsalva maneuver, a breathing technique used to slow one’s heart rate, as suggested by Chalett (2000), may aid in both addressing the fear of blue balls as well as provide partners with the knowledge necessary to confront the pressure they may face from others trying to avoid it (DiLonardo, 2020).

The second ethical implication for blue balls research is what it would mean to administer masturbation as a self-treatment. This solitary sexual act has been overlooked as a viable medical treatment for years because of its false association with negative physical and mental health consequences (Kaetle et al., 2011) and other reasons (e.g., faith-based ideologies). In the past, several medical professors and teachers that have suggested masturbation as a medical treatment for blue balls or even mentioned it in an educational setting have faced a large amount of backlash, including losing their jobs (Chalett, 2001). At present, masturbation exercises have been shown to help treat several sexual dysfunctions, including premature ejaculation (Kaetle et al., 2011). Although the stigma surrounding masturbation has not entirely disappeared, it is beginning to be recognized as a safe way to experience sexual pleasure. Individuals with a higher education tend to perceive masturbation more positively than those who do not, suggesting that greater access to sexual education may be associated with a reduction in an individual’s fears surrounding masturbation (Fischer et al., 2021). These findings further support the idea that the investigation into blue balls, with the proper sexual education and consideration of these ethical implications, could only benefit peoples’ understanding of sexual functioning and contribute to the recognition of masturbation as a safe way to learn about their sexual response.

What’s next?

The investigation into the causes and treatment for blue balls still has a long way to go. As a wildly misunderstood form of genitopelvic pain, there is potential for sexual health research to further explore this condition. Despite the concerns surroundings blue balls research, rather than avoid these obstacles, a proper investigation into this condition could address these issues in an objective and educational way. Altogether, better understanding of blue balls can have great implications for the sexual health of those with penises as well as their partners. Additionally, the ethical implications of acknowledging that blue balls exists could aid in calling into question the lack of attention that masturbation and genitopelvic pain have received in sexual education curricula.  

Robin Neish (She/Her) 
Fourth Year Biology & Psychology Specialization Student 
Special Directed Lab Student with the Sex Lab (PSYC 575)

Literature Cited  

Chalett, J. M., & Nerenberg, L. T. (2000). “blue balls”: A diagnostic consideration in testiculoscrotal pain in young adults: A case report and discussion. Pediatrics, 106(4), 843–843. https://doi.org/10.1542/peds.106.4.843

Cosentino, M. J., & Cockett, A. T. K. (1986). Review article: Structure and function of the Epididymis. Urological Research, 14(5). https://doi.org/10.1007/bf00256565

DiLonardo, M. J. (2020). Valsalva maneuver: How to do it and when to use it. WebMD. Retrieved March 16, 2022, from https://www.webmd.com/heart-disease/atrial-fibrillation/valsalva-maneuver#:~:text=The%20Valsalva%20maneuver%20is%20a,go%20back%20into%20normal%20rhythm.

Duggal, N. (2021, October 14). Blue balls: Understanding epididymal hypertension. Healthline. Retrieved March 23, 2022, from https://www.healthline.com/health/mens-health/blue-balls

Fischer, N., Graham, C. A., Træen, B., & Hald, G. M. (2021). Prevalence of masturbation and associated factors among older adults in four European countries. Archives of Sexual Behavior, 51(3), 1385–1396. https://doi.org/10.1007/s10508-021-02071-z

Kaestle, C. E., & Allen, K. R. (2011). The role of masturbation in healthy sexual development: Perceptions of young adults. Archives of Sexual Behavior, 40(5), 983–994. https://doi.org/10.1007/s10508-010-9722-0

Kobola, F. (2021, November 2). What is blue balls? Cosmopolitan. Retrieved March 15, 2022, from https://www.cosmopolitan.com/sex-love/q-and-a/a815/blue-balls/

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Endometriosis: The One in Ten

It’s March, which means it is officially Endometriosis Awareness Month! Endometriosis Awareness Month takes place across the globe every March, with a mission to raise the profile of endometriosis. I know what you’re probably thinking – Endometri-What?

Let’s break it down: Endometriosis is a painful, chronic inflammatory condition, which is characterised by the presence of tissue similar to the lining of the uterus growing outside of the uterus, often on the pelvic organs and tissues (Carbone et al., 2021; O’Hara et al., 2021). Endometriosis is commonly characterized by life-altering pain (Culley et al., 2013). Endometriosis has been associated with a wide variety of pain symptoms, including severe pelvic pain, pain with menstruation, pain with vaginal penetration during sexual activity, pain with urination, pain with defecation, pain with ovulation, and lower back pain (Kennedy et al., 2005; van Poll et al., 2020). Other symptoms of endometriosis may include prolonged menstrual bleeding, gastrointestinal symptoms (e.g., bloating, nausea, diarrhea), subfertility (reduced fertility with prolonged period of unwanted non-conception) or infertility (inability to conceive after a year or longer of unprotected sex), and chronic fatigue (Dunselman et al., 2014; Ek et al., 2015; Kennedy et al., 2005).

So, how many people ‘have’ endometriosis? Prevalence data on endometriosis are limited due to many factors, including needing to have tissue surgically removed and sent to the lab for special analyses, the existence of microscopic (tiny) endometriotic tissues that are rarely diagnosed, and the barriers faced by those looking for a diagnosis (Carbone et al., 2021). With these limitations in mind, endometriosis affects approximately 10% of women of reproductive age (1 in 10), and up to 50% of women with chronic pelvic pain (CPP) or fertility problems; global estimates suggest a prevalence of approximately 200 million women (Adamson et al., 2010; As-Sanie et al., 2019; Dunselman et al., 2014).

I just listed statistics for women, so that must be the Endometri-Who, right? Nope! While most individuals diagnosed with endometriosis are adult women, there is evidence of endometriosis in cisgender males (Makiyan, 2017; Rei et al., 2018), the human fetus (Schuster & Mackeen, 2015; Signorile et al., 2010, 2012), gender diverse people (Cook & Hopton, 2017; Yergens, 2016), and females (pre- and post-puberty) who have never menstruated (Gogacz et al., 2012; Houston, 1984; Marsh & Laufer, 2005; Suginami, 1991).

You’re probably thinking, if there is evidence of endometriosis in individuals other than adult women, why do we only have prevalence rates for this subgroup? The answer is two-fold: first, not much is known about the pathophysiological mechanisms which cause or put individuals at risk for developing endometriosis. Many theories have been proposed, however, many hypotheses regarding how endometriosis develops are highly debated (Guidone, 2020). This leads me to my next point: In the past, endometriosis was known as the “career woman’s disease” based on the assumption that the disease predominantly affected childless, white, affluent, educated women (Carpan, 2003; Nezhat et al., 2012). This assumption still holds today despite increasing evidence of the existence of endometriosis in people of various genders, ages, menstrual status, and social locations.  

 
So, Endometri-Why?

Traditionally, the field of medicine tended to center men as the gender-neutral ‘standard’, while women were viewed as gender specific. Thus, (white) male bodies were viewed as the norm, and all other bodies were pathologized. The field of medicine also tended to view bodies through the lens of essentialism (that certain attributes—an “essence”—characterize people and objects); from this perspective, people who menstruated were automatically defined as ‘women’ and were assigned a primary function of reproduction. This, in turn, has caused medical professionals to attribute reproductive bodies with endometriosis, and only offer treatment options that revolve around the reproductive system, neglecting other areas of impairment. In a nutshell, sexism distorted scientific knowledge (Guidone, 2020). However, issues such as menstruation, pregnancy, childbirth, and menopause are not inherent, nor confined, to women—individuals who are not women can and do experience these processes. Hence, using the term ‘gendered’ to indicate that endometriosis can occur in all genders, rather than ‘gynecological’ or ‘reproductive’ to describe endometriosis is important—endometriosis is a gendered, whole-body, condition.

Now that you know the Endometri-What, the Endometri-Who, and the Endometri-Why, let’s move onto the Endometri-How.

Endometri-How do I get a Diagnosis?

Unfortunately, receiving a diagnosis of endometriosis can be a lengthy and non-linear process. The average length of time worldwide from the onset of symptoms to a diagnosis of endometriosis is estimated to be around 7.5 years (Bullo, 2020). Delayed diagnosis is a huge source of stress for people with endometriosis, and can result in large psychological impacts (Guidone, 2020). But, why is there such a long delay?

There are many reasons for diagnostic delays; for example, the invisibility of endometriosis requires invasive surgical procedures such as laparoscopic surgery, rather than identification in a more straightforward, non-invasive fashion (Hsu et al., 2010). Moreover, worldwide, people with minimal access to resources, or limited health coverage, may experience significant barriers to diagnosis (Cromeens et al., 2021). Furthermore, misinformation about endometriosis continues to be pervasive, permeating the healthcare and public sectors (Guidone, 2020). For example, in the healthcare sector, healthcare practitioners frequently dismiss and normalize women’s pain as part of their menstrual cycles (Bullo, 2018). In addition, a general lack of public education regarding pelvic pain persists (Guidone, 2020). For example, women with endometriosis have delayed seeking help for their symptoms due to the belief that their symptoms are a part of ‘normal’ menstruation experiences, with the assumption that clinicians may dismiss their pain as ‘all in their heads’ (Bloski & Pierson, 2008). Thus, this dismissal and normalization of pain may prolong referrals for diagnostic treatments (Bullo, 2020).

Transgender and gender non-conforming individuals may face additional barriers. On top of the experience of being misgendered and discriminated against, trans men and nonbinary individuals often face ignorance and hostility from clinicians (Jones, 2020). In addition, lesbian health has been historically subsumed under heterosexual women’s health (LaVaccare et al., 2018). Very few self-help resources for endometriosis mention LGBTQ+ issues; when they do, inclusion is framed around barriers to conceiving. Indeed, lesbians postpone accessing gynecologic care in order to avoid heterosexist microaggressions, such as pressuring them about birth control, or asking about sexual practices in heteronormative ways (Sabin et al., 2015). For example, the standard yearly gynecological exam is derived from premarital examinations done to ‘prepare’ (heterosexual) women for penetrative sex with their spouses. Given the fact that pain with sex, clinically stipulated as “recurrent or persistent genital pain upon penile penetration” (Olive, 2005, p. 135) and infertility are the hallmark symptoms of the endometriosis, lesbian women are likely underdiagnosed. Thus, due to historical biases and an abundance of misinformation in the medical sector, many individuals who may have endometriosis are not receiving appropriate medical care.

The spread of misinformation about endometriosis has recently made it into the media-sphere as well; in season 18, episode 10 of Grey’s Anatomy (aired March 3, 2022), many inaccuracies about endometriosis were reported. For example, in the show, endometriosis was reported to be composed of cells that line the inside of the uterus and it was also reported that it was treatable. Unfortunately, endometriosis is an incurable disease, and while there is a ‘gold standard treatment’, it’s notoriously hard to access.

What is this ‘gold standard treatment’, you ask?

Being that there is no known cure for endometriosis, treatment commonly consists of managing chronic pain (Arafah et al., 2021). When pain medication and/or hormonal therapy are not producing sufficient relief for individuals with endometriosis, laparoscopic excision surgery, the gold standard, becomes an option (National Health Service, 2017). However, a recent meta-analysis found no significant difference in pain relief in women who underwent surgery or medical treatment in the form of analgesics and/or hormones (Chaichian et al., 2017). Thus, further research is needed to understand the etiology, presentation, and treatment of endometriosis (Arafah et al., 2021).

The Endo-Effects

Although further research is needed, we do know that endometriosis and the associated symptoms have a substantially negative social and psychological impact (Missmer et al., 2021). Affected aspects of life include self-esteem, affective and emotional stability, private and professional relationships, sexuality, and the social and working functioning of affected people. The large burden of the symptoms causes distress and a substantial lowering of quality of life, and lowering of sexual quality of life (Friggi Sebe Petrelluzzi et al., 2012). Moreover, gender norms categorizing who does and doesn’t get or have endometriosis impedes abundant opportunities to detect endometriosis in individuals who do not menstruate (Guidone, 2020). Studying individuals who do not menstruate, as well as sexual and gender/sex minorities, and emphasizing endometriosis as a whole-body condition, could radically transform and improve medical knowledge about endometriosis.

What Can I Do?

            Now that you know more about this condition, you may be asking, what can I do to help? First, you can help spread (accurate) information, and increase awareness about this condition. Second, you can advocate for others in your life who may have endometriosis—remember, 1 in 10 – which is most likely an underestimate! Third, if you have endometriosis, you can participate in the study (click HERE and if you decide to not participate, please share it; the study examines resilience and vulnerability factors associated with sexual outcomes in individuals who have been diagnosed with, or believe they may have, endometriosis. At SexLab, we are passionate about raising awareness and bettering the quality of life of those who are affected by endometriosis.

One lab, one blog, one month, one in ten.

We will fight with you, Endo Warriors.

Sam Levang (she, her, hers)
M.Sc. Student, Clinical Psychology, Sexual Health Research Lab, Queen's University

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