Barry R. Komisaruk, PhDHealth Blog - Sexual Health

What causes “blue balls?”

Published on 2011-01-05 by Barry R. Komisaruk, PhD

It is rare to find intentional humor in the normally staid professional medical journals.  A recent dialog on “Blue balls” was an exception. While humorous, the dialog actually raised serious medical, social, and ethical issues – an altogether unusual and thoughtful mix.

It started with a case report in the major medical journal, “Pediatrics” in 2000.

The authors, medical doctors Chalett and Nerenberg, started by stating, “’Blue balls’ is a widely used colloquialism describing testicular and 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 authors describe a case of a 14-year old who came to the emergency room with testicular-scrotal pain that was persisting for more than an hour.

It had also happened previously when he was petting with his girlfriend; in neither case did he ejaculate and in both cases, the pain started immediately after stopping foreplay. He had no current or prior relevant pathology, and the pain subsided after an hour in the emergency room.  On subsequent telephone followup, he revealed that he started having sexual intercourse with his girlfriend with no further episodes of testicular-scrotal pain.

The authors suggested that the pain may result from the lack of orgasmic resolution, which could lead to insufficient draining of blood from the genitalia and/or increased pressure in the epididymal tubes, through which the sperm and fluid are normally transported away from the testicles.  They state, “The treatment is sexual release, or perhaps straining to move a very heavy object.…[the ‘Valsalva Maneuver’].”

Their publication stimulated physicians Rockney and Alario to reply in a letter to the editor of “Pediatrics”: “…we wonder whether the authors’ suggestion that ‘straining to move a very heavy object’ is the first choice….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.” [Editor’s note: Jocelyn Elders, MD, was appointed Surgeon General by President Bill Clinton and served for 15 months in his Administration until she was forced to resign in 1994 as a direct result of suggesting that schools should consider teaching masturbation to students as a means to prevent sexually transmitted diseases]. 

In response to the above authors’ suggestion that sexual release is an effective treatment for blue balls, physician Weinzimer and colleague Thornton wrote in a letter to the editor of Pediatrics: “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 [hairiness] (personal communications, our mothers)?  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?”

To these funny but ethically serious concerns, the authors of the original article, physicians Chalett and Nerenberg, responded in another letter to the editor of Pediatrics: “A 70-year-old retired college professor told us…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.”  They continue, “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.  They conclude with the droll pun, “blue balls is real, and a cure is coming.”

In a subsequent commentary on the dialog, an engineer, L.N. Ludovici, wrote, “I have had a vasectomy and noticed that I no longer get blue balls with prolonged sexual excitement if there is no release by ejaculation. Instead, I feel pain along the path of the vas deferens down to the point where it is sealed off. Indeed, with palpation of the vas deferens, it feels swollen. If blue balls were caused by blood engorgement in the testicles I would still get it since the vasectomy did not cut the blood vessels. I conclude that blue balls is caused not by blood engorgement, but by seminal fluid engorgement.  I theorize that since the fraction of the seminal fluid that is produced outside of the testicles has nowhere to go, it backs down the vas deferens into the normally connected testes and swells the whole system to the point of pain.

Here is another case in which further research is called for.


Rockney, R., & Alario, A.J. 2001. Blue Balls. Pediatrics, 108:1233-1234.

Weinzimer, S.A., & Thornton, P.S.  2001.  To the Editor.  Pediatrics, 108: 1234.

Chalett, J.M., & Nerenberg, L.T.  2001.  In Reply.  Pediatrics, 108: 1234-1235.

Ludovici, L.N. & Arndt, J. 2005. The true cause of blue balls.


This article was written and based on the book "The Orgasm Answer Guide" by Barry R. Komisaruk, Beverly Whipple, Sara Nasserzadeh, and Carlos Beyer-Flores. Baltimore: The Johns Hopkins University Press.  2010.

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