PEDIATRICS Vol. 106 No. 4 October 2000, pp. 843

EXPERIENCE AND REASON:
"Blue Balls": A Diagnostic Consideration in Testiculoscrotal Pain in Young Adults: A Case Report and Discussion

"Blue balls" is a widely used colloquialism describing scrotal pain after high, sustained sexual arousal unrelieved because of lack of orgasm and ejaculation. It is remarkable that the medical literature completely lacks acknowledgment of this condition. The case reported here illustrates that a good history may help make the diagnosis, offer the possibility of prompt relief, and avoid any unnecessary evaluation. Clinicians should be aware of this condition and consider it in the differential diagnosis of scrotal pain.

	CASE REPORT

A 14-year-old male presented to the emergency department with a history of severe bilateral scrotal pain of 1.5 hours' duration. There was no associated nausea or vomiting. The patient denied fever, chills, or feeling systemically ill. He described the pain as sharp, stabbing, constant, and unaffected by position. There was no history of dysuria, urethral discharge, previous urinary tract infections, trauma, or any history of prior sexual intercourse. The patient was a reluctant historian.

On further history he noted that 1 week earlier he had experienced a milder form of this scrotal pain that had resolved slowly over 2 to 3 hours. In each instance the pain started when he had been "messing around," engaged in foreplay with his first girlfriend, kissing and fondling while fully clothed. In neither case did he ejaculate, and the pain began immediately after stopping foreplay.

On physical examination the patient was alert and nontoxic. He appeared uncomfortable and in moderately severe pain. Vital signs were normal, and physical examination was unremarkable except for diffuse testicular tenderness, increased over the epididymis bilaterally. Cremasteric reflex was present bilaterally. The urine analysis was normal. The patient's pain resolved spontaneously during 1 hour of observation in the emergency department. Telephone follow-up several weeks later revealed that the patient had begun to have sexual intercourse with his girlfriend, and no further episodes of testiculoscrotal pain had occurred.

	DISCUSSION

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A review of the literature was undertaken but no comment or reference to "blue balls" in any urologic, pediatric emergency medicine, general emergency medicine, or adolescent medicine textbooks could be found.^1-5 Medical librarians at 3 institutions conducted separate literature searches. Cross-references were made to articles in the sexuality literature, adolescent health literature, and to articles about scrotal pain. The one article found was from a human sexuality journal.⁶ The article is nonreferenced and the information came from "common knowledge and experience."

Specialists in urology and adolescent medicine were contacted, and although they all knew about "blue balls," their information was anecdotal and not related to medical training. The great majority of adult, pediatric, urologic, and emergency physicians, as well as nurses and nonmedical people informally surveyed, know of this condition, yet no one was aware of any medical references. Certainly the urologic and adolescent literature is full of subjects equally sensitive and potentially embarrassing. What is the pathophysiology of this condition? Sexual arousal produces pelvic venous dilatation. Perhaps if this persists and testicular venous drainage is slowed, pressure builds and causes pain. Is epididymal distention the cause of the pain? As with any disease entity, there is probably a spectrum of pain with "blue balls" varying from brief, mild discomfort to severe, sustained pain, as in the case described.

The treatment is sexual release, or perhaps straining to move a very heavy objectin essence doing a Valsalva maneuver. In the one article found, the author talks of straining to lift an immovable object such as a car bumper. He claims the pain often disappears within 15 to 30 seconds. Does this work?

How many young men have suffered unnecessary pain and anxiety if a simple maneuver could bring immediate relief? Is pain always bilateral? How many patients have had surgery to rule out testicular torsion or transient testicular torsion where the pain is episodic, when the true diagnosis was "blue balls"? Is the incidence of this condition high in age groups starting sexual exploration? The answer to these questions might easily be obtained with careful histories and further research. Patient education might be integrated with clinical research. It would seem logical to incorporate discussions of "blue balls" into age-appropriate sexual education.

	CONCLUSION

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In summary, "blue balls" is suspected to be common among young male adults and should be considered in the differential diagnosis of acute testiculoscrotal pain in such patients. A search of the medical literature shows a paucity of information for this condition and suggests that a greater awareness and discussion of this entity would benefit both physicians and their patients.

Jonathan M. Chalett, MD
Department of Pediatric Emergency Medicine
Mary Bridge Children's Hospital
Tacoma, WA 98415

Lewis T. Nerenberg, MD
The Permanente Medical Group
Kaiser San Francisco
Department of Pediatrics
Kaiser South San Francisco, CA 94080

	FOOTNOTES

Received for publication Jul 20, 1999; accepted Feb 14, 2000.

Reprint requests to (J.M.C.) Department of Pediatric Emergency Medicine, Mary Bridge Children's Hospital, 409 S J Street, Tacoma, WA 98415. E-mail:cerumen{at}u.washington.edu

	REFERENCES

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1. Campbell's Urology. 7th ed. Philadelphia, PA: WB Sanders Company; 1997
2. Fleisher GR, Ludwig S. Textbook of Pediatric Emergency Medicine. 3rd ed. Baltimore, MD: Williams & Wilkins; 1993
3. Barkin RM. Pediatric Emergency Medicine. 2nd ed. St Louis, MO: Mosby-Year Book; 1992
4. Tintinelli: Emergency Medicine; A Comprehensive Study Guide. 4th ed. New York, NY: McGraw Hill Text; 1995
5. Neinstein LS. Adolescent Health Care: A Practical Guide. 3rd ed. Baltimore, MD: Williams & Wilkins; 1996
6. McIntrye RV. Relieving male pelvic congestion. Med Aspects Hum Sexuality. 1989:51