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)

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