Pelvic Pain in Men

• Epididymitis: Inflammation of the epididymis, often due to urinary tract infections or sexually transmitted infections.
• Orchitis: Testicular inflammation caused by bacterial or viral infections.
• Trauma: Physical injury to the testicles, which may lead to persistent pain.
• Inguinal Hernia: When abdominal tissues protrude into the groin, potentially causing referred pain to the testicles.
• Prostatitis: Inflammation of the prostate gland, which can radiate pain to the testicular region.
• Pelvic Floor Dysfunction: Tension or dysfunction in the pelvic floor muscles can lead to referred pain in the testicles.
• Post-Surgery Pain Syndrome: Persistent scrotal pain following a vasectomy or hernia surgery.
• Idiopathic Causes: In some cases, no clear underlying cause is identified.

Trauma, pelvic floor dysfunction, and post-surgery pain syndrome typically involve one of the nerves to the testicles. These are the genitofemoral, ilioinguinal, and pudendal nerves. Damage or entrapment of any of these nerves can lead to testicular pain.

The first step in diagnosing orchialgia (testicular pain) is to have a thorough examination with your urologist. Your doctor will look for other potential conditions that might be causing the pain and provide treatment for them first. If this doesn’t offer enough relief, the next step would be to see us for a more detailed neurological evaluation.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic exam and may include ultrasound imaging to identify any nerve-related issues. Combining the findings from your urologist’s examination with our neurological assessment helps us develop a personalized treatment plan to address your symptoms effectively.

• Wear supportive underwear.
• Avoid tight or constrictive clothing that can put excessive pressure on the affected nerve.
• Avoid activities that exacerbate the pain, such as heavy lifting or prolonged sitting.
• Discontinue any personal products (such as underarm deodorants, etc.) or foods that may cause irritation elsewhere in the body. This may include diet modification to avoid foods that can trigger flare ups.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or vaginal suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can release tension on the affected nerves and alleviate nerve irritation.
• Genitofemoral or ilioinguinal nerve blocks, and sympathetic nerve blocks: To decrease pain and alleviate irritated nerves.
• Neurostimulation: To decrease pain by blocking the pain signal to the brain.

Surgery can provide relief only if there is a well-defined area that is the source of the pain, but it comes with risks, including the possibility of developing a condition called deafferentation syndrome. This syndrome may lead to more widespread testicular or pelvic pain, which is why surgery is only considered carefully and on a case-by-case basis.

Pudendal neuralgia is a chronic nerve pain condition caused by irritation or damage to the pudendal nerve, which runs from the back of the pelvis to the genital area and anus. This nerve controls sensation and muscle function in the lower buttocks, perineum, penis, testicles, and around the anus and rectum. Patients with pudendal neuralgia often experience sharp, burning, or stabbing pain in these areas, which can worsen when sitting and improve when standing or lying down. Sometimes, the pain can be limited to the penis (which may be constant or only during ejaculation), posterior portion of the testicles, or anus but other patients report pain in multiple parts of the pelvis.

Pudendal neuralgia is caused by irritation, damage, or compression of the pudendal nerve, which runs through the pelvis and provides sensation and motor control to areas like the genitals, anus, and perineum (area between the penis and anus). Common causes include:

• Nerve entrapment: The pudendal nerve can become compressed or trapped due to anatomical structures or scar tissue.
• Prolonged sitting: Sitting for extended periods, especially on hard surfaces, can put pressure on the nerve.
• Trauma or injury: Pelvic fractures or surgical procedures can lead to nerve damage.
• Repetitive activities: Activities like cycling, squatting, or horseback riding can irritate the nerve over time.
• Infections or tumors: These can compress or irritate the nerve.

Nerve-related pain can be worsened by several factors, including hormonal changes, diabetes, hypothyroidism, obesity, chronic infections, interstitial cystitis (bladder pain syndrome), irritable bowel syndrome (IBS), endometriosis, post-surgical scarring, and pelvic trauma or injury. These issues can irritate the nerves further, leading to increased pain.

The first step in diagnosing pudendal neuralgia is to have a thorough examination with your urologist. Your doctor will look for other potential conditions that might be causing the pain and provide treatment for them first. If this doesn’t offer enough relief, the next step would be to see us for a more detailed neurological evaluation.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic exam and may include ultrasound imaging to identify any nerve-related issues. Combining the findings from your urologist’s examination with our neurological assessment helps us develop a personalized treatment plan to address your symptoms effectively.

• Avoid prolonged sitting. Using a cushion with a cutout or sitting on a soft surface can help reduce pressure on the nerve.
• Modify physical activities. Activities like cycling, squatting, or horseback riding can irritate the pudendal nerve. Consider adjusting or avoiding these activities to prevent flare-ups. Cyclists may need to use a custom seat to avoid putting pressure on the pudendal nerve.
• Use good posture. Maintaining proper posture can reduce strain on the pelvic area and help alleviate nerve irritation.
• Pelvic floor relaxation exercises. Learning techniques to relax the pelvic floor muscles, such as diaphragmatic breathing or gentle stretches, can ease tension and reduce pain.
• Stress management. Stress can exacerbate pain, so incorporating relaxation techniques can be beneficial.
• Dietary adjustments. If constipation is a concern, eating a fiber-rich diet and staying hydrated can help reduce strain during bowel movements, which may relieve pressure on the pudendal nerve.

Successful treatment usually consists of one or more of the following:

• Medications: oral and topical (such as creams or suppositories).
• Pelvic floor therapy: a specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: as an alternative or complement to medications.
• Acoustic wave therapy: another alternative or complement to medication that can release tension on the affected nerve and alleviate nerve irritation.
• Pudendal nerve blocks: to decrease pain and relieve pressure on the affected nerves.
• Neurostimulation: to decrease pain by blocking the pain signal to the brain.

Decompression of the pudendal nerve may be necessary to alleviate the pain. This is a major neurological surgery that is typically done once the area of pudendal nerve entrapment is identified with imaging (such as an MRI or ultrasound) and nerve blocks.

Men with Peyronie’s Disease may experience:

• The penis may curve upward, downward, or to the side.
• Pain during erections.
• Difficulty getting an erection.
• Difficulty with sexual activity because it is uncomfortable for their partner.
• Shortening of the penis.

Other factors that may contribute include:

• Age: As men get older, healing from injuries may become less effective.
• Health conditions: Certain conditions like diabetes, high blood pressure, or autoimmune disorders can increase the risk.
• Genetics: A family history of connective tissue disorders may make some men more prone to developing Peyronie’s Disease.

The first step in diagnosing Peyronie’s Disease is to have a thorough examination with your urologist. Your doctor will ask about your symptoms, such as pain, curvature, or changes in the shape of your penis as well as inquire about any history of injuries or other health conditions. In some cases, an ultrasound may be used to get a clearer picture of the scar tissue and blood flow in the penis. This is especially helpful for planning treatment.

• Quit Smoking or Vaping: These can affect blood flow and healing, so stopping can promote better circulation and reduce inflammation.
• Avoid activities that can cause trauma to the penis.
• Control any underlying medical conditions such that may be worsening circulation or promoting plaque formation.
• Eliminate foods that cause inflammation.

• Lifestyle changes: Very mild cases that do not cause significant discomfort or difficulty can be treated with lifestyle changes alone. If symptoms worsen, however, treatment should be started as soon as possible. Delaying treatment can make it more difficult to treat Peyronie’s.
• Medications: Oral medications or injections directly into the scar tissue can help reduce pain and improve curvature. Collagenase injections are commonly used to break down scar tissue.
• Traction therapy: Devices that gently stretch the penis can help reduce curvature and prevent shortening over time. These must be used carefully to avoid further trauma to the penis.
• Acoustic wave therapy: This can help break up the scar tissue to reduce the curvature, restore erections, and reduce pain. It is not painful and is often used in combination with the other treatments listed here.

In our practice, we have successfully treated many patients with Peyronie’s Disease using a combination of the treatments listed above.

• Plaque Incision or Excision with Grafting: The scar tissue is cut or removed, and a graft (often made from your own tissue or synthetic material) is used to repair the area. The goal is to help improve curvature and restore function.
• Plication Surgery: The surgeon adds stitches on the side opposite the curve to straighten the penis. This is typically used for less severe curvature and preserves most natural function.
• Penile Implant: If Peyronie’s has caused erectile dysfunction, a penile implant may be inserted. This option addresses both curvature and difficulty with erections.

Peyronie’s Disease can get worse over time, particularly if left untreated, with increased curvature of the penis and worsening pain. Because of this, surgery is usually is reserved for men who have had stable symptoms for at least 6-12 months. It’s important to talk with your urologist about the risks, benefits, and recovery process to decide if surgery is the right option for you.

Four Main Causes of Erectile Dysunction

• Neurogenic ED
• Arterial ED
• Venous ED
• Psychogenic ED

Once nerve damage occurs, starting penile rehabilitation as soon as possible can make a big difference. Many men think this is not necessary, but rehabilitation can make recovery faster and more complete. It requires commitment but it is effective, especially after prostate surgery or radiotherapy.

Arterial ED can be dangerous because the same condition blocking the arteries to the penis might also be blocking the arteries the heart, brain, or other parts of the body. This is why men who develop ED must discuss this with their primary care physician and urologist to determine the cause and treat any underlying conditions.

Sometimes, arterial disease partially blocks the arteries to the penis. This leads to partial erections that cannot provide enough support to close off the veins draining the penis and maintain the erection, so the blood simply leaks out and the erection is lost.

A very common cause is central obesity (obesity in the abdomen and pelvis) causing the valves in the larger veins that drain the penis to fail. Surgical attempts to treat the veins have not been very effective and this condition does not respond well to medications so venous leak tends to be particularly difficult to treat.

Treating any underlying arterial disease and losing weight helps control venous leak. Penile rehabilitation is also a very important part of treating this condition. Some men have been able to overcome venous ED with a regimen of weight loss (including adequate aerobic exercise), penile rehabilitation, and medications.

• Get adequate rest.
• Eat a well-balanced diet that provides good nutrition and avoid fad diets.
• Lose weight if you are overweight.
• Minimize stress as much as possible.
• Avoid pornography.
• Adjust your exercise regimen and seating position to avoid putting pressure on the nerves to the penis.

• Take medications as prescribed. These are usually oral medications for ED that can support blood flow and improve penile health.
• Vacuum Erection Devices (VED) are devices to help stimulate blood flow to the penis, prevente tissue atrophy, and promote vascular health.
• Acoustic Wave Therapy (AWT) uses sound waves to boost circulation and encourage tissue regeneration.
• Exercise – both Kegel exercises to improve penis function and aerobic exercises to maintain overall cardiovascular health.

Consistency and commitment are the keys to success. Like other forms of therapy, penile rehabilitation relies on regular, diligent use of these techniques as prescribed by your doctor.

Successfully treating ED usually consists of one or more of the following:

• Control any underlying conditions (such as diabetes, vascular disease, high blood pressure, etc.) that might be causing ED.
• Review whether any product or medication you are taking may be contributing to ED.
• Medications for ED – oral, transurethral, or injectable. Some men find oral medications stop working after a while and need to switch to another type of medication.
• Penile rehabilitation
• Vacuum Erection Device
• Counseling – note that some medications for depression or anxiety can cause ED
• Acoustic wave therapy can make the medications and rehabilitation more effective.
• Endovascular procedures to improve circulation or surgery if a mass is compressing an artery might also be necessary.
• Stem cell injections hold some promise but current techniques have not proven to be successful so far.

If other treatment options do not work adequately, men can always consider an implant. These have a proven track record of being effective and there are various types of implants on the market that might be suitable for each particular patient. Discussing this option with a urologist is always helpful when considering treatment for ED.

• Proctalgia fugax: This is characterized by sudden, brief spasms of the rectal muscles. The pain can be intense but typically resolves quickly.
• Levator ani syndrome: This involves persistent muscle spasms in the pelvic floor, leading to longer-lasting discomfort.

Rectal pain can arise from various causes, ranging from mild to serious. Some common causes include:

• Hemorrhoids: Swollen veins in the rectum or anus, often due to straining during bowel movements.
• Anal fissures: Small tears in the lining of the anus, typically caused by passing hard stools.
• Infections: Such as sexually transmitted infections or fungal infections.
• Inflammatory bowel diseases: Conditions like Crohn’s disease or ulcerative colitis.
• Trauma: From constipation, anal penetration, or other injuries.
• Abscesses or fistulas: Infected or abnormal channels near the rectum.
• Cancer: Rarely, rectal or anal cancer can cause pain.

• Sudden and Intense: It comes on abruptly and can feel sharp, stabbing, or like a cramp.
• Short-lived: Episodes usually last from a few seconds to a few minutes, though they may rarely persist longer.
• Localized: The pain is concentrated deep in the rectal area, without spreading to other parts of the body.
• Unpredictable: It often occurs without warning and may be triggered by stress, bowel movements, or no clear cause at all.

While the pain can be alarming due to its intensity, it typically resolves on its own without leaving lasting discomfort or damage.

Triggers:

• Bowel Movements: Straining during defecation or constipation can provoke spasms.
• Sexual Activity: Certain types of sexual activity may trigger episodes.
• Stress or Anxiety: Emotional stress is a known trigger for muscle spasms, including those in the pelvic region.
• Medical Procedures: Treatments like sclerotherapy for hemorrhoids or surgeries involving the pelvic area may lead to episodes.

These triggers vary from person to person, and not everyone with proctalgia fugax will experience pain due to all of these factors.

• Dull ache or pressure: The discomfort is often felt deep in the rectum or pelvis and may feel like sitting on a ball.
• Persistent or intermittent: The pain can last for hours or occur sporadically, sometimes worsening throughout the day.
• Triggered by sitting: Sitting for extended periods often exacerbates the pain, while standing or lying down may provide relief.
• Radiating pain: In some cases, the pain may spread to the buttocks, tailbone, or upper thighs.
• Unrelated to bowel movements: Unlike other rectal pain conditions, levator ani syndrome pain is not typically associated with defecation.

This condition can significantly impact quality of life, but it is not life-threatening.

Triggers:

• Prolonged Sitting: Sitting for extended periods, such as during long car rides or desk work, can strain the pelvic floor muscles and trigger spasms.
• Stress: Emotional or physical stress can lead to muscle tension, including in the pelvic floor.
• Sexual Activity: Certain types of sexual activity may provoke muscle spasms in the pelvic region.
• Pelvic Trauma or Surgery: Previous injuries or surgeries in the pelvic area may predispose individuals to muscle spasms.
• Heavy Lifting: Activities involving repetitive heavy lifting can strain the pelvic floor.

These triggers vary from person to person, and not everyone with levator ani syndrome will experience pain due to all of these factors.

The first step in diagnosing rectal pain is to have a thorough examination with your gastroenterologist or colorectal surgeon. Your doctor will look for other potential conditions that might be causing the pain and provide treatment for them first. If this doesn’t offer enough relief, the next step would be to see us for further evaluation and care.

At our practice, we take an additional step by performing a focused neurological examination of the lower back and pelvis. This is not the same as a standard pelvic or rectal exam and may include ultrasound imaging to identify any nerve-related issues. Combining the findings from your gastroenterologist or colorectal surgeon’s examination with our neurological assessment helps us develop a personalized treatment plan to address your symptoms effectively.

• Avoid prolonged sitting. Using a cushion with a cutout or sitting on a soft surface can help reduce pressure on the affected area.
• Modify physical activities. Activities like cycling, squatting, or horseback riding can make symptoms worse. Consider adjusting or avoiding these activities to prevent flare-ups. Cyclists may need to use a custom seat to avoid putting too much pressure on the affected nerves.
• Use good posture. Maintaining proper posture can reduce strain on the pelvic area and help alleviate nerve irritation.
• Pelvic floor relaxation exercises. Learning techniques to relax the pelvic floor muscles, such as diaphragmatic breathing or gentle stretches, can ease tension and reduce pain.
• Stress management. Stress can exacerbate pain, so incorporating relaxation techniques can be beneficial.
• Dietary adjustments. If constipation is a concern, eating a fiber-rich diet and staying hydrated can help reduce strain during bowel movements.
• Heat therapy with warm baths or heating pads to relax muscles and alleviate pain can also be helpful at times.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can help alleviate muscle tension of the pelvic floor muscles and reduce pressure on the nerves in the rectal area.
• Trigger point injections of the pelvic floor muscles: To reduce muscles spasms and tight muscles. This is sometimes combined with Botox® or similar medications to provide longer lasting relief.
• Pudendal nerve blocks: To decrease pain and relieve pressure on the affected nerves.
• Neurostimulation: To decrease pain by blocking the pain signal to the brain.

Surgery is typically not used to treat rectal pain unless there is a specific condition causing the pain or there is a clearly defined nerve entrapment identified with imaging (such as an MRI or ultrasound) and nerve blocks.

Symptoms include:

• Pain or tenderness at the base of the spine (the tailbone), especially when sitting.
• Discomfort that worsens with prolonged sitting, especially on hard surfaces, or leaning backward.
• Pain during activities that put pressure on the coccyx, such as cycling.
• Sharp pain during movements like standing up from a seated position.
• Pain during bowel movements due to pressure on the coccyx.
• Pain during sexual activity may occur in some cases.
• In severe cases, pain may spread to nearby areas like the lower back or hips.

The top causes of coccydynia (tailbone pain) include:

• Trauma or injury: Falls or direct impact can bruise, dislocate, or fracture the coccyx (tailbone).
• Repetitive strain: Activities like cycling or rowing that involve prolonged pressure on the tailbone.
• Prolonged sitting: Sitting on hard or narrow surfaces for extended periods.
• Poor posture: Slouching or improper alignment while sitting can strain the tailbone.
• Obesity: Excess weight can increase stress on the tailbone.
• Degenerative changes: Age-related wear and tear on the coccyx or surrounding structures.
• Infections or tumors: Rarely, nearby infections or tumors can cause tailbone pain.

Lifestyle changes can play a significant role in managing coccydynia (tailbone pain). Here are some helpful adjustments:

• Avoid prolonged sitting, especially on hard surfaces. Take frequent breaks to stand or walk during long sitting periods.
• Use a cushion with a cutout or sit on a soft surface to help reduce pressure on the affected area.
• Use good posture. Sit with proper alignment, avoiding slouching.
• Modify physical activities. Activities like cycling, squatting, or horseback riding can make symptoms worse. Consider adjusting or avoiding these activities to prevent flare-ups. Cyclists may need to use a custom seat to avoid putting too much pressure on the coccyx.
• Strengthen core muscles to support the spine and pelvis and focus on low-impact exercises like walking to avoid strain on the coccyx.
• Eat a high-fiber diet to prevent constipation and reduce strain during bowel movements.
• Maintain a healthy weight to reduce stress on the coccyx.
• Learn techniques to relax the pelvic floor muscles and reduce stress. Diaphragmatic breathing or gentle stretches can help ease tension and reduce pain.

Successful treatment usually consists of one or more of the following:

• Medications: Oral and topical (such as creams or suppositories).
• Pelvic floor therapy: A specialized type of physical therapy for treatment of pelvic conditions.
• Biofeedback and counseling: As an alternative or complement to medications.
• Acoustic wave therapy: Another alternative or complement to medication that can promote healing of the muscles, tendons, and ligaments around the coccyx.
• Injections along the sacrococcygeal ligaments and other soft tissue around the coccyx: To reduce inflammation and pain of the ligaments and tendons.
• Caudal epidural steroid injections: To reduce inflammation and pain at the coccyx.

Coccygectomy (removal of the coccyx), is considered only when all other treatments fail. This is a major surgery with a prolonged recovery time that is not always successful in controlling the pain.