Dr. Susie Gronski


Male Pelvic Pain

Some things work better when they come in 2’s or pairs.

Noah certainly believed this when he populated his arc after some very unseasonable downpours way back when. Batman and Robin, gin and tonic, thunder and lightning, bacon and eggs, yin and yang, Thelma and Louise, left and right testicles! Bet you didn’t have that in your top ten duets did you?! Since the Autumn of 2004 I have been flying solo, there is no Chewy to my Han. I lost a testicle due to a potent bacterial infection in my testicle and epididymis (the network of tubes that passes the sperm from the testicle into the vas deferens which then travel up into the body cavity) and had been unbalanced ever since. Although there were a few rumblings beforehand, this was the birth of my pelvic pain. But here’s the thing, aches and pains are common places, right? We ALL get them, ALL the time. If I focused I could probably count 2-3 right now (and my pelvic pain is currently clear). I ran this morning, so my legs are a little achy, and my cat found it highly amusing to claw my forehead last night (don’t ask), so I have a minor cut there. But these sensations are fleeting, they are transient (like my cat's affections). Long-standing, persistent pain gnaws right to your core. It alters your behavior, your confidence, your ability to cope with even the most mundane of tasks. It is life changing. Chronic pain needs to be life changing for you to get through it (more on this later).

As a 26-year-old male, my life was turned on its head. I quit my job, moved out of the flat I was living in with my best mate and moved back in with my folks with the one remaining testicle I had. I can’t thank my parents enough for the support during this period. 

During my time at the flat (9 months), I had a couple of fleeting relationships, nothing serious, just a bit of fun. After that fateful weekend, my interest in sex, relationships, and intimacy simply went flaccid. How could I enter into a relationship with deformed genitals? I was broken. I was never going to be the same again. The infection ate away at the tissue of my testicle and epididymis, eventually leaving a void in the scrotum. Let’s sit on the honesty step a second; the male genitals are pretty hideous looking at the best of times. I now had the wrinkliest, loosest hanging ball sack in the world (or so I thought). The thing is when aroused the cremaster muscle elevates the testes and irons out these wrinkles. Apart from the odd Dr, the only other times my genitals were being examined, juggled or otherwise by others would be when I was aroused, and therefore they would be smooth. I can rationalize this now, but back then it felt like the end of my world. 

Painful ejaculation is the biggest quandary in the world. How could something that should be so pleasurable cause SO much pain!? What foul temptress created this horrible affliction and why was a hot poker being repeatedly rammed down my urethra for what could turn out to be hours on end?! Did I still have a bacterial infection (my original infection was nonSTD, but your mind boggles when you are in excruciating pain)? Did I get this from one of those causal relationships? Could I pass this on to someone else? Clearly, sex was off the cards; even masturbation was now debatable! Is this how my life is going to be from now on? How could I face having to explain to any potential partner about my pain (after ejaculation and urination and the deep ache where my ball used to be), about the absence of a significant part of my male anatomy and my possible infertility (I couldn’t stomach having the tests done at the time)?

My pain is very much under control. Am I cured? Good question, what does that even mean? Do I still get aches and pains in my pelvis? The answer is yes. Do I get aches and pains elsewhere in my body? The answer is also yes! Is this ‘normal’? It is not ‘abnormal’ (just consider that for a second...) Can I rationalize this pelvic pain now? Yes, very much so. My pelvic pain is an indicator of my health, an early warning signal if you like. My last major flare was a precursor for a bout of shingles and round of 7 styes across both of my eyes over the following nine months! The flare up (burning on urination and ejaculation alongside a general heaviness in my groin) came off the back of an intense period of high stress and anxiety. My awareness, my ability to reflect and my studies have taught me not to catastrophize (not easy in the early days at all!) my situation. Pain is a warning system that is key to our survival as human beings. Without pain, we would not be here as a species! 

There is hope out there; you are not alone (this is not an ad for the X-files). Current research indicates that a multidisciplinary approach is by far the most successful strategy for managing and reducing pelvic pain.

It had taken the best part of 9 months before my pain subsided and I felt confident enough even to consider a sexual relationship. Moving out of the flat, quitting my job and remodeling my lifestyle were all key to my recovery. Central to this and a message I preach to all of my patients is going back to basics. Doing things in moderation, gradually building things up until I felt strong or robust enough to take on more. It is rehab, plain and simple. Instead of juggling three jobs, working seven days a week, partying too hard and eating crap I looked after myself and did things that were kind to myself.  I practiced mindfulness and meditation daily (I still do!), I got regular massages specific to my legs, back, and abdomen (there were no treatments available at the time for pelvic pain). I started gentle exercise including yoga (I quit a demanding tennis coaching role). I ate a variety of good food at the right times of a day. I balanced my work, learning to give myself a time out, taking breaks and holidays. In essence, I learned to switch off and pay attention to what my body was telling me (this is so central to recovery). I spent time EVERYDAY doing something that was just for me, something that benefited my health.     

I have now been married to my beautiful wife for four years and have a little one coming this Christmas. Every couple of years I get some pelvic pain to remind me to calm down, switch off and look at my lifestyle (I am a human after all). It has taught me a lot about myself and my limitations. It reminds me of what I lost and will never get back again, but it reminds me of what I have gained and all that I am grateful for in life. 

What is male pelvic pain? The National Institute of Health (NIH) classifies male pelvic pain into four primary categories:

  • Acute bacterial prostatitis

  • Chronic bacterial prostatitis

  • Chronic prostatitis (CP)/Chronic Pelvic Pain Syndrome (CPPS)

  • Inflammatory

  • Noninflammatory

  • Asymptomatic inflammatory prostatitis

With international findings indicating that only 5-10% of all cases are bacterium related (2) the majority of male pelvic pain cases fall into the type III Chronic Prostatitis (CP)/Chronic Pelvic Pain Syndrome (CPPS) category. Symptoms are widespread and unique to the individual, often making it a poorly understood condition to treat. They include but are not exclusive to the following.

Some patients have a plethora of the below, others just one or two:

  • Pain in the testicles, scrotum, penis, bladder, prostate, rectum, perineum, coccyx (tailbone), lower back, pubic bone, lower abdomen, inner thighs

  • Urinary Symptoms including increased frequency, increased urgency, nocturnal urination, hesitation, dribbling, sensation the bladder is not emptied, poor stream

  • Sexual dysfunction including painful ejaculation, premature ejaculation, erectile dysfunction (inability to achieve and maintain an erection), low libido

  • CP/CPPS is a condition that affects up to 16% of the male population globally (3-6) across all ages and races. It is the most common urological diagnosis in men under 50 years old and the third most common in males over 50 years old (7-9). It has been suggested that almost one-third of all men during their lifetime will experience symptoms consistent with CP/CPPS (10). Greater emphasis is being placed on the pelvic floor musculature and its associated structures as a primary cause of male pelvic pain (11), even though it is still commonly treated as a bacterial infection with prolonged use of antibiotics over many, many months.

Karl Monahan is the owner of The Pelvic Pain Clinic, London. He has been successfully treating male pelvic pain since 2010. His depth of knowledge and personal experience on the subject provides his patients with a compassionate approach that is rarely found. His holistic approach to treating male pelvic pain addresses, lifestyle, diet, exercise, stress management, and therapeutic movement. The clinic's approach is very much aimed at empowering the patient, teaching them the tools and techniques to manage and reduce their symptoms allowing them to be the driver in their recovery and not just a passenger. To learn more about Karl please visit www.thepelvicpainclinic.co.uk

1. C. P Smith “Male chronic pelvic pain: An update,” Indian J Urol. 2016 Jan-Mar; 32(1): 34–39.
2. Mazzoli s (2007) Conventional bacteriology in prostatitis patients: microbiological bias, problems, and epidemiology on 1686 microbial isolates. Archivio Italiano di Urologia e Andrologia 79(2):71-75
3. R. O. Roberts, M. M. Lieber, T. Rhodes, C. J. Girman, D. G. Bostwick, and S. J. Jacobsen, “Prevalence of a physician-assigned diagnosis of prostatitis: the Olmsted County study of urinary symptoms and health status among men,” Urology, vol. 51, no. 4, pp. 578–584, 1998. 
4. C.-Z. Liang, H.-J. Li, Z.-P. Wang et al., “The prevalence of prostatitis-like symptoms in China,” The Journal of Urology, vol. 182, no. 2, pp. 558–563, 2009. 
5. C. E. C. C. Ejike and L. U. S. Ezeanyika, “Prevalence of chronic prostatitis symptoms in a randomly surveyed adult population of urban-community-dwelling Nigerian males,” International Journal of Urology, vol. 15, no. 4, pp. 340–343, 2008. 
6. J. Q. Clemens, R. T. Meenan, M. C. O'Keeffe Rosetti, T. Kimes, and E. A. Calhoun, The Journal of Urology, vol. 178, no. 4, part 1, pp. 1333–1337, 2007.
7. Wagenlehner F et al. (2013) Bacterial Prostatitis. World Journal of Urology 31:711-716
8. Collins MM et al. (1988) How common is prostatitis? A national survey of physician visits. Journal of Urology 159:1224-1228
9. Nickel JC (1998) Prostatitis; myths and realities Urology 51:362-366
10. Nguyen CT and Shoskes DA, in Chronic Prostatitis / Chronic Pelvic Pain Syndrome, Humana Press, 2008. Shoskes, DA, ed.
11. Hetrick D et al. (2003) Musculoskeletal Dysfunction in Men With Chronic Pelvic Pain Syndrome Type III: A Case-control Study.  The Journal of Urology 170(3):828-31

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