PEDIATRICS Vol. 108 No. 5 November 2001, pp. 1233-1234

Blue Balls

To the Editor.

We read with interest the case report and discussion on "blue balls."¹ We agree with the authors' conclusions that "a greater awareness and discussion of this entity would benefit both physicians and their patients." The condition described, what the urologists often term "epididymal hypertension," and some have labeled "deadly sperm buildup" or "DSB," has many other manifestations of which physicians and their caretakers ought to be aware. Other common presentations of this condition include an altered sensorium, thought to be the result of increased cerebrospinal fluid turbidity levels; and decreased visual acuity secondary to cloudiness of the fluid in the anterior chamber of the eye. The latter condition can be diagnosed by the finding of an anterior chamber meniscus.

In the discussion of treatment, however, we wonder whether the authors' suggestion that "straining to move a very heavy object" is the first choice "simple maneuver [that] could bring immediate relief." As this condition is coming to light in a highly respected pediatric journal, perhaps we should resurrect the advice of former Surgeon General Jocelyn Elders and teach masturbation in the schools. This novel idea, which led to her removal from office, should have been implemented yesterday.

Randy Rockney, MD
Anthony J. Alario, MD
Department of Pediatrics
Brown University
Hasbro Children's Hospital
Providence, RI 02903

REFERENCE

1. Chalett JM, Nerenberg LT Blue balls: a diagnostic consideration in testiculoscrotal pain in young adults: a case report and discussion. Pediatrics. 2000; 106:843-844 [Abstract/Free Full Text]

To the Editor.

We read with great interest the case report of acute testiculoscrotal pain after unsatisfied sexual arousal.¹ The authors perform a great service for the field of adolescent medicine by exposing this condition for the true medical problem it is. Countless young men have, no doubt, suffered unnecessarily, as effective treatments are available. However, we believe that the report leaves some ambiguities unresolved:

1. The authors suggest that sexual release is an effective treatment. What are the ethical implications of such a statement? Will young men demand sexual satisfaction of their partners as essential medical therapy? Do the authors condone self-treatment? What about potential adverse effects of treatment, such as blindness and palmar hypertrichosis (personal communications, our mothers)?
2. What are the ethical and/or medical responsibilities for the health care team in treating young men in an urgent care setting? And if treatment is rendered, are there appropriate diagnostic and treatment codes for billing purposes?

We applaud the audacity of the authors to initiate a rational, scientific discussion on this subject that will, we fervently hope, put an end to this dreaded affliction. In the meantime, perhaps the old adage should be amended: "Abstinence makes the gems grow bluer."

Stuart A. Weinzimer, MD
Paul S. Thornton, MB, BCh, MRCPI
Department of Pediatrics
University of Pennsylvania
Children's Hospital of Philadelphia
Philadelphia, PA 19104

REFERENCE

1. Chalett JM, Nerenberg LT Blue balls: a diagnostic consideration in testiculoscrotal pain in young adults: a case report and discussion. Pediatrics 2000; 106:843-844

In Reply.

We thank Drs Rockney and Alario as well as Drs Weinzimer and Thornton for their insightful and amusing letters. It's clear to us that blue balls really exists, and that it is a humorous as well as legitimate topic for medical discussion. The News Tribune of Tacoma presented an article (October 2, 2000) about our case report and discussion that, like the letter-writers, balanced information and levity.

A 70-year-old retired college professor told us anecdotally that in Los Angeles public schools in the 1940s a practicing physician taught him and his fellow eighth-graders about sexuality, including "lover's nuts." The doctor told them that masturbation was at times a legitimate medical treatment. As Drs Rockney and Alario point out, Dr Jocelyn Elders lost her job for suggesting the same.

Dr Dean Edell received numerous live phone calls on his national radio program after the October issue of Pediatrics was published and later interviewed Dr Chalett on the air. He too stressed the relevance of teaching ourselves and our patients as much about everyday issues (nutrition, stress, human sexuality) as we do about exotic and complicated diseases. He too was candid about how many complaints he would receive for even saying "masturbation" on the air, even if he did not advocate it.

Blue balls is real, yet the condition has been overlooked in the medical literature, adding unnecessary mystique and charge to a common condition. In no way should the pain of blue balls be an excuse to inappropriately advance a sexual relationship. As part of sexual education, we might teach that sexual urges are natural, abstinence is a real choice, and sexual decisions ought never to be based on coercion or exploitation.

We are not advocating any particular treatment method but are proposing education and communication. Sexual release will alleviate the pain of blue balls, but if a Valsalva maneuver offers pain relief, this option must also be taught so another nonsexual choice is available.

Drs Weinzimer and Thornton ask about appropriate billing codes for diagnosis and treatment of this entity, and, of course, we must recommend code blue. They "fervently hope" for "an end to this dreaded condition"; about this we can offer assuranceblue balls is real, and a cure is coming.

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

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