Balls Hurt for No Reason? Here’s What It Might Mean — And What to Do

24:57And so I'm going to take a minute here and do a little plug for a pet project I'm doing. I thought about this problem because that time is maybe six months to a year where that patient could be helped because they're just seeing other providers who don't know about this. so I'm going to start an organization called cpain which stands for chronic pelvic pain providers and into this investigation network and it's going to be cpain.org and I'm going to get all of us pain people to self-identify so that around the country when you're looking for us you can find us okay that's one thing so that and there's going to be research we do and we're going to have message boards it's it's designed to have these people have a place to go a touchstone to get information.

25:40All right. So usually my patients struggle by the time they finally made it to me, they've tried multiple rounds of antibiotics, anywhere from like one to six. They've had multiple imaging studies. They've had multiple urine cultures and tests for STIs, and it's not an infection that much we know. But I'm the outlier who, when I say it's something different, like everyone else said, it's epididymal or chitus, that infection or prostatitis. that's where I get weird looks like I have literally cured chronic orcalgia with Miralax like I get the weirdest looks like you mean I just need to poop I'm like yeah bro you just need to poop I promise you you'll feel better yeah so here's here's the thing when I'm trying to figure out what it is the hallmark question I love to ask is I say does it hurt when you ejaculate oh I love If a man ejaculates and it hurts, if you boil it down to brass tacks, like there's some zebras, but like it can be two things, two things.

26:36So as a urethral specialist, let's say the man urethra is like, we're going to be generous, six inches. OK, somewhere in that tube, there is scar tissue that's blocking it. That's an anatomical tissue like a wall. So imagine that I'm sprinting through a doorway and someone closes the door, right? Like in our face plan into the door. hurts. So these people have what's called dysuria. It burns when they pee or they feel pressure or pain when they try to pee because they're peeing. Imagine, you know, a milkshake straw you're supposed to have and they have a coffee stir at that spot and it hurts. Okay, so that is an anatomic blockage of scar tissue, which I operate on and fix.

27:16But a lot of people have pain after ejaculation and a really common reason is pelvic floor dysfunction. We all carry stress in different places. People get like tension in their traps and referred headaches, migraines, etc. Some people carry tension in their pelvic muscles and none of us consciously tense our pelvic muscles. That's why we have to learn a Kegel if we want to or patients have to learn a Kegel because we don't consciously go, okay, like flex pelvis, relax pelvis. That's not how it works. So you have some resting tone and for these people, their resting tone is really high. And so the sphincter muscle, like everybody's got a urinary sphincter that keeps their pee in the ejaculatory ducts as you and I know are behind that okay so like the ejaculation has to come out and then it has to go through the open sphincter and pass into the urethra but here's the thing if your sphincter which is part of your pelvic floor the hammock of muscles that keeps you standing upright with all your guts not coming out if your sphincter is part of that muscle path you ejaculate forcefully boom and it runs into a wall again?

28:23It hurts. Same thing. Remember when I said same end result, different etiology? Okay, so same end result. It hurts, but that's because your muscle is clenched and you don't know you're clenching it. So a lot of times I'll try to get a flow rate on these patients. I'll have them pee in a machine that gives me a graph. That even doesn't differentiate it because sometimes the flow rates look very similar between someone who has a tight urinary sphincter and an actual stricture. The real test is, I hate to tell you, putting a camera in the urethro, which I don't need to do, but patients don't always believe me that they don't have a blockage.

28:58They have urinary symptoms like hesitancy, straining, weak stream, the same way a stricture patient does. So I call pelvic floor dysfunction testicle pain plus. Testicle pain plus is if you think about the things that go through the pelvic floor, there's the rectum. So these people have constipations, fissures hemorrhoids the urethra so they have urinary symptoms usually straining hesitancy like things that are obstructive and pain with ejaculation and or testicle pain and that constellation makes up pelvic floor dysfunction if they don't have all of that plus they just have pain in one testicle I'm going to think chronic orcalgia and if they have pain in that testicle but the other testicle their perineum their suprapubic area like it radiates in different places, or it's got a higher intensity and associated other chronic pain profiles, like they could have fibromyalgia, or, you know, central sensitization going along with this, then I start depression and anxiety, all that stuff, I start thinking more along the chronic pelvic pain syndrome path, or CPPS.

30:07Yeah, wow. So it sounds like you're saying, I mean, you can have both physiologic and anatomic obstruction which i think is critical for you to say that because usually we say like a physiologic obstruction is incredibly high pelvic tone which is going to be a very different treatment algorithm than a physiologic obstruction like a stricture or like a vasectomy you know and a guy that gets post-vasectomy pain syndrome that's the obstruction just like in that woody allen movie where he's dressed as a sperm you know you know i'm talking about jordan right which one was it everything thing you've ever wanted to know about sex but we're afraid that's right yeah they're all oh yeah that's a good one oh no yes they're gonna run into a wall or something other than what they thought yeah so that's obstructive pain but that's anatomic okay so then walk me through the treatment pathway you've you've got this down to it's not an infection it's bilateral he has some bowel issues as well going on so you're gonna probably just load him up full of drugs right No.

31:10Oh, what? I mean, yes and no. So firstly, I think anyone who treats pelvic floor dysfunction needs a pelvic floor physical therapist. Hell yeah. And also, if you remember that I'm on a time crunch in my office and I have, you know, X amount of minutes to see a patient, I think social media and YouTube is a great adjunct. So I refer them to YouTube videos first at the end of their visit to explain chronic male pelvic pain and pelvic floor dysfunction. head. They get out the models, they go through it longer form. I really like pelvic health and rehabilitation center and Stephanie Pendergast. She puts out some really good stuff.

31:46We should be friends. I don't know her yet. Yeah. We'll put that in the show notes too, Jordan. That's a great resource. Yeah. It's a great resource because it explains it because people really can't see it. And she gets out the models and like really shows them how it works. So in the first visit, I'm usually the first person to have said those words. And in the early days of my practice, like the first five years, I said, please don't Google it. Because if you Google it, you'll see vaginas, just vaginas, a wall of vaginas. No one really talked about it in men. And I went back and read the chapter and there was like one sentence.

32:16So I sort of just almost like an apprenticeship, just kept talking to people, talking to people, reading papers until I developed an algorithm. So my first visit with the patient is trust building because they do not believe what I'm saying to them. It is really only recently our guidelines on chronic pain came out last year there was nothing i could like refer patients to and say here this is legitimate i do know what i'm talking about so i'm glad to have that now and i would say okay if you have pelvic floor dysfunction let's start with something easy like flomax what we know about flomax is yeah it works with the prostate but if this like my little hands are the bladder and my wrists are the bladder neck it also works to open the bladder neck and so that works with the pelvic musculature, right?

32:59So those, um, alpha fibers at the bladder, neck relax, and they have less straining. So that helps them feel better. I tell them to take Miralax if there's any element of constipation, because if you look at a sideways view, like if you cut me like, but technically you Jesse down the middle and looked at you from the side, then if you think of, and this is that I'm going to steal Dr. Galloway's lecture. This is a really great lecture that I heard that like got you into this whole thing yeah okay so three passengers on a train the pelvis is a tight space it's the prostate and the rectum and the bladder okay so like they're all in there and if one gets too gigantic like the prostate's really gigantic the bladder and the rectum can't function and vice versa so if your rectum is really distended behind it's pushing on your bladder and prostate and making some very uncomfortable sensations for you so literally just pooping will help your pelvic floor, simmer down.

33:55So Miralax is an easy one. That's over the counter. If you're listening to this, go get yourself some Miralax. If you have some ball of pain, try it out and see what happens. So Miralax, Flomax, and I usually get them to do like a two week course of an NSAID ibuprofen to try and break that pine sacral because it's an anti-inflammatory. Not because I'm giving them the ibuprofen to reduce the pain. I'm reducing the inflammation and the inflammatory cytokines that are causing the pain, if that makes sense. So then when they come off of it, hopefully they're not having pain. Something in that, one of those three things, and then I say hot baths at night, and then I warn them it might lower their sperm count.

34:35I would not say that. But 20 minutes, hot bath. If you get out of that hot bath and your pain is gone, and they're all like, yeah, but it was only gone for like an hour. I'm like, yeah, but that was diagnostic. The fact that we relaxed your muscles and your pain went away, I know for sure without, you know, a rectal exam without an invasive cystoscopy. I know for sure. The other thing is I do rectal exams on any patients who will let me. And instead of just sticking your finger forward to feel the prostate, you swing your finger lateral. And this is described in the guidelines. And what you're doing is you're pressing on the levator ani muscles and it will elicit pain or tenderness.

35:16and like for the listeners if you're a clinician or a patient you want to know what we're feeling you just flex your bicep put your finger right in the crux of your elbow here and that's your bicep tendon that is what your muscle struts feel like on the inside they are like super tight and when we touch them you go yep guitar string tightness that's exactly it's a very good a very good finding a physical exam is that some guys have very relaxed levator and i and other guys yeah, it feels like a guitar string. And you know that that that is a heightened pelvic floor. And on cystoscopy, sometimes you see that high riding bladder neck where the guy's almost has a vertical instead of more of a horizontal neck because it's just so tight.

35:57And so, okay, yeah, so physical therapy. Okay, so that didn't work. So let's talk surgery. What do you do? Do you just go in and say, well, that's about all we can do for you, Jordan, is take your ball out. so different patients different things yeah okay so so pelvic floor patients it's non-surgical it's all about that muscle it's all about working with a pelvic floor physical therapist and once we get beyond that we're going to work with if if you know we're going to keep doing that then we're going to add on well what is causing that muscle tension and we need to think about stress we need to think about anxiety depression stress all of those things that are making you go like this without like like tense without consciously doing it and obviously that's a tough go in the male population because from like infancy you guys are conditioned to brush it off come on brush it off keep it going you're not that hurt you know so like the idea of going to a counselor because your muscles are tight that's a tough sell I I often start with a physical therapist.

37:02And then I just talk about like things they can do in their daily life to reduce stress. But if I can get them, if they have an anxiety depression history noted, or they are fidgeting like crazy in my office, like clearly anxious, I will say, if you want to feel better, that's why you came here, right? If you want to feel better, this is the fastest way. Go get that treated because that is driving your muscle tension. that's driving your pain. Now, I think if we're going to say surgery, where does surgery come in? Where surgery comes in, we have to back up and go to the other patient, chronic orcalgia.

37:38Let's go. Yeah. So chronic orcalgia, you just have testicle pain. You don't have any of those symptoms, but you have testicle pain. That's like a four out of 10 every day. And it reps to a seven out of 10 with an activity, whether that's sex or, you know, I'm military guys running with their pack on whatever. For that patient, there's kind of like two modalities. We think that's neuropathic pain. So it's a bit like a radio and there's stations. And then old school, somebody turned the dial and you're stuck between two stations and you don't hear music, you have static, right? So your brain is registering a pain signal without a pain stimulus from your testicle.

38:14And we don't know why that is, but the goal is to like stop the transmission. So what we do is we basically strip the testicle of its nerves okay so sejo pericotyl popularized it it was first invented by i think shell hammer in 1978 and and what we do is your you imagine your testicle hanging on a thread like a pendulum and a grandfather clock right so all this stuff in the cord that hangs down that's the stuff we go after and strip and it's three primary areas it's like the cremasteric muscles around the cord. It's the posterior lipomatous tissue, which is basically a lot of fat at the back of the cord and the perivasal sheath, which is like the stuff around your vas deferens, if it's still there or has been severed.

39:05And so when we do that, when we go and we make a very small cut about, you know, what, two inches on your inguinal canal and use a microscope, bring up the cord and lyse those structures in a day surgery, in and out, same day. I kid you not, I haven't published this yet, but my patients tell me they know and pack you. They wake up from surgery and they have pain, but they know it's not the pain they had before. It's different. It's like post-op pain. It's to do with their wound and the fact that they've been cut. But whatever that was previously, it's gone. The literature shows the success rates are, it's very tricky.

39:42It's a 80 to 90 % chance of being half better. But anecdotally, I will tell you, most of my patients are like completely better. And the ones that are half better, I look them in the eye and say, Hey, would you do this knowing what you know? And they all say, yeah, overwhelmingly. Yeah. So patient selection, probably important. Do you, if a guy is coming to a urologist and say, Hey, I heard this podcast, I want a spermatic cord de-innervation. what do you do ahead of time are there pre-op tests or you do you do spermatic cord blocks catalog injections walk me through how a guy gets to your operating room yeah so i'm still going to do a really thorough history physical and i'm gonna you know get the ultrasound and then rule out all the other things but assuming we've ruled out all the other things and we're just looking at okay you have chronic or calgen you're going to the operating room post probably i start with a spermatic cord block.

40:36And that is, and I explain very carefully that this is a dress rehearsal for the surgery. And I, I, you have to be careful because I understand that patients want to tell doctors what they want to hear, both not to make them disappointed. And also if you decide that that surgery is what's right for you, then you're going to be really fixated on that. And I say, don't lie to me because if you lie to me and you tell me it works great and it doesn't, your chances of the surgery working are nil. You're basically signing up for surgery that doesn't work okay there's no point to that we can it's not no point it's like 60 but that's right it's less it's less fruitful in my practice i really only take people who have a good cord block so the first cord block personally i use lidocaine and marcaine so short acting long acting i don't even put in catalog which is a steroid you can or can't it's personal choice i just literally do what we did in fellowship and it worked great so yeah shout out to ryan are lucky.

41:32Thanks. There you go. So yeah, I give them a cord block and I, you know, it's 10 cc's and we break it up. I try to hit three locations just to make sure I'm not missing. And I'm really bathing the cord in those structures. And the first time I asked them, and this is probably the most important thing I do. And no one taught me to do this. I say, you have homework. You need to three times a day, like stop what you're doing and write down a pain number and write it in your phone and a notepad or bring me homework, like a piece of paper. And literally, you could just look at the numbers and it tells a story.

42:04You can see where the pain was, where it came back, when it went away, all of that stuff. And then I repeat it. But when I repeat it, I say, okay, you seem like you're a good candidate. We're going to do a cord block the next time if it works. And then you're going to do the exact thing that exacerbates your pain. Right. Road test it. Same. I love that. Yeah. So if running five miles with your pack on is what makes your pain rev to a seven. And we know let's really put this principle to the test. Is it really going to work? And then I bring them back for an extensive counseling visit on the like, what if, what are we doing?

42:37What are the risks, all that stuff. And then we go to the OR. Right. OK. I mean, I love it.

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49:21so we've covered acute pain which basically we don't actually see very often as urologists because the er and urgent care handles it unless it's something like testicular torsion which we've also covered on previous podcast about when bad things happen to good testicles so we also do a segment we we like to call you're probably going to be okay and so i'm going to give you this case scenario and i want you to walk me through how this guy is going to well is he going to be okay or or is is he not i mean sometimes we'll have a case where the guy isn't okay so so 35 year old man is diagnosed with acute epididymitis which i'm sure you have opinions on what that diagnosis is even so you can certainly unpack that for us but severe doubling over pain he went to the er the ultrasound showed no torsion yay so he's not going to lose his testicle but he had this flaming hot epididymitis the ultrasound showed just raging blood flow into it kind of pathognomonic right no chlamydia all his stis came back negative he was given antibiotics and NSAIDs even though the urine test showed no infection or anything but uh but you know six weeks go by the guy is still in a lot of pain it's a little bit more dull and nagging and it hurts and i'm glad you brought this up this is a good callback for the audience un unprovoked too but uh but his main pain is with bouncing activities, ejaculation.

50:41So what are you gonna do for this guy? He's gone from acute now on chronic scrotal pain. Is he going to be okay there, Dr. McDonald? And how are you going to make him so? I'm a really good doctor and a really bad psychic. So I tell everybody in my office, I don't know. I don't know if this stuff is going to work for you. I don't know if you're going to be okay. I say, but I've been doing this a lot. And the patients I had who get better really seem a lot like your symptom profile. You seem a lot like them. I think you have a really good chance of getting better. And I give you my word that I am not going to get out of tricks until, you know, we'll just keep throwing pasta at the wall to see what sticks until I'm out.

51:19And I have a lot of tricks up these sleeves. So let's do this. A lot of pasta. Yeah, a lot of pasta. Probably homemade. Probably homemade. Well, that's my husband's territory. I make the tomato. I grow the tomatoes and he makes the pasta. There you go. Okay. So is this guy, is this a physical therapy candidate? Because he has that kind of physiology. I mean, can you see acute epididymitis then morph into pelvic pain once you understand the underlying cause? I would tell you that more likely, like it's possible. It's possible. But more often what I see is just the most random stories. Like one person told me their grandchild like rammed a Tonka truck into their scrotum, something like that.

52:00or like they get whacked or hit by their dog or they just wake up one day or they go rock climbing and they're at the gym and they have a muscle pull, blah, blah, blah. It's any number of innocuous, really benign, just random life stuff that would happen to all of us. And it takes a normal person who is functional and it makes them a chronic pain patient. So I have to say that is how I got into this particular thing. Can you imagine waking, like having a great life, the life you're having right now. And then tomorrow you wake up in pain. And every day thereafter you wake up in pain. Yeah, horrible.

52:38No, it's so empathetic. And you're right. I mean, that is a that is a huge thing that physicians I mean, I have to say we have we've been pretty good to our colleagues, because I think both of us do spend a good portion of our careers tailing dealing with chronic to secular and scrotal pain. But it is a lot of urologists say, you know another chronic ball pain guy and and i think i do the exact same thing you just said which is what if i woke up and my balls just started hurting for no reason at all and they never stopped getting better that's going to change you know your perspective and it should as a physician to realize that that this is a true suffering and that the number of men that are out there listening that that say yeah or have been marginalized or have or have been said, yeah, you know, it's not cancer.

53:24Take some ibuprofen, get on with your life, which is why I think I'm super pumped about you trying to make this network of providers where patients don't feel as if they're just done for and they can't do anything. And also often go, I mean, I tried to get you to bite on the orchiectomy, which you didn't. But, you know, a lot about it. Oh, can we? Can we? Well, yeah, of course we can. Because yeah, I mean, I think that's the thing is that a lot of times guys will, they, you know, when your toolbox is not as full of as much pasta as yours is, boy, that's a lot of metaphors you're mixing. Then you, you know, then you end up with, you end up with a guy with an orchiectomy that maybe still has pain because it was constipation or whatever.

54:07So yeah. So yeah. Okay. Talk to me now. Why shouldn't I do an orchiectomy on these guys or should I or when should I? No, you should not. So this is what I'm going to put it to you to anyone who has ever studied a look of the human body. When a diabetic's toes tingle, do we cut them off? When their fingers tingle? No, we don't go just chopping off body parts because of people's neuropathic pain. And that's what this is, is neuropathic pain. So stop doing it. So if you look in the guidelines and like the expanded version, the studies that it's based on the success rate of an orchiectomy varies from, and I kid you not, 20 to 75 percent, 20 to 75.

54:53That's the range. And it's based on, I don't even remember, something under 50 patients. Like you could sneeze and come up with this many patients. Whereas the denervation surgery has been studied in hundreds and hundreds and hundreds of patients. Reliably across different surgeons and centers produces good results. Now, the horrible thing is, and this isn't published, but I did a trinetics database thing, a research project to look at the rates and compare them for testicle pain. If you, and now there's a little bit of problem because, because the coding doesn't differentiate between acute and chronic.

55:30So we're, we took patients who had testicle pain and just assumed if they had had it more than three months. Okay. It had come up in the diagnosis codes. And we looked in those patients who went to surgery, the rates of orchiectomies were double, double the rates of these detervation surgeries that are evidence-based medicine, well-founded and work. And that lit a fire under me. Like, why are we still chopping off testicles in this day and age? Absolutely hard. No. Right. Yeah. Well, in detervations, we didn't talk about this, but really the downside, the side effects are minimal. You know, you have a little bit of medial thigh numbness and maybe a little bit less of a hot tub cold lake effect.

56:15In other words, a lot of guys will have a little. Yeah, the cremesteric messes don't pull it up anymore when you're cold. Exactly right. So yeah, it'll be, so Costanza won't have that problem. I don't think it was, I don't think it was a scrotum that got shrunken. No, it was not as, yeah, maybe it was some, it was that six inch urethra that you so generously endowed us with earlier in the, in the show. Okay. Well, anyhow, Jordan, what am I, what am I missing? the, you know, you're, you're still upright. You got good color. So we didn't quease you, but your, your balls are, are just happily dancing along for the ride.

56:49Talk to, uh, talk to me about what we missed the two doctors here. You know, I, I had prepped for this. I wrote all these really well thought, or at least for me, very well thought out questions in advance. I can't believe this is the one I'm going to pose to you that came up organically over the course of this episode. My job on the show is the voice of the every man posing what I know to you both are stupid questions and this is this is a doozy um i i love the analogy of the car the the car that i actually i i have is uh the same model has the world record of the most road miles and i would say it was a 1968 volvo 1800 and when they asked the guy what he did i think it hit something like three or four million miles he said took it in for regular checkups like i just did what it said when you got it changed the oil did took it in took care of it and that was i always thought of that especially after I went 10 years without going to a physician for a checkup and I started going again recently in the last couple of years and I was thinking of that analogy so I love that you said that prevention you mentioned feeling for lumps and I'm sorry there's a crude way to put this there's a comedian he said something like you're feeling for lumps in a bag of lumps I don't know what to do and so I guess I had that in my head as you were saying that and I guess I would like to put it to you to answer to me and anyone listening now who maybe just are not really sure what they're feeling for if, you know, just doing a self-check in advance of pain or maybe if there's pain present.

58:22I have a great answer for that, which is just that you're feeling for something different. Their testicles have been the same pretty much all your life. We could get into the structures of like the epididymis and the cord and like what you're feeling. But here's the thing same with breast exam like people's breasts are different people's testicles are different not we're all little snowflakes but if you start feeling it in your youth and then you just keep on keeping it up and have it then whatever you're feeling is your body and then when something's different that's what you need to notice when you feel something new yeah yeah there's no value add to the testicle not like one day you're like hey wow this is cool i didn't have this yesterday.

59:00Yeah, that's never cool. It's not a cool thing. New things are not good things. Hey, check this out. All right. Well, you, uh, you delivered on the mailroom, but you're coming back because this was way too much fun. And we haven't even begun to really get into know you as well as your story and what the hell you're doing with your life. And so Jordan, I'm going to, uh, I'm going to let long transit rip it out for us. And then we're going to have Dr. McDonald back, uh, a post-haste toot suite now that we have to speak in French since she's a new Canadian. Oh, yeah. Il faut qu 'on parle en français.

59:35Okay. No, Spanish. Oh, Spanish. As you remember. That's what we meant. Médicourette. Right outside. Slamis at SMSNA. That's right. All right, Jordan. Cool. Well, we'll bring her back. Thanks so much, Susan. And yeah.

59:56Let's talk about it. Let's talk about it in the mail room. Let's talk about it. Let's talk about it in the mail room. Let's talk about it. Let's talk about it in the mail room. The Mail Room with Dr. Jesse Mills was a production of iHeartRadio. It was executive produced by Jordan Runtog. It was edited, mixed, and mastered by Bahid Frazier. And the theme was provided by Long Transit. If you liked what you heard, please subscribe and leave a review. For more podcasts from iHeartRadio, check out the iHeartRadio app, Apple Podcasts, or wherever you listen to your favorite shows. This program is intended for educational and informational purposes only.

1:00:48It is not a substitute for professional medical advice, diagnosis, or treatment. Consult your health care provider for any medical or other related questions or concerns. The views and discussions aired on this podcast are those of Dr. Mills and do not represent the official positions of UCLA or UCLA Health.

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