Dear Dr G,

I am a 52-year-old-man having some trouble in the sac for nearly two years.

I recalled having this pain in my groin and my testicles when I got “sexcited” with my wife even with just some foreplay. The pain persisted even up to the point of ejaculation.

My pain is predominantly in the left testis and area pressing on the groin.

I have consulted Dr Google, who has kindly informed me (free of charge, of course!) that the pain could be because of accumulation of trapped blood in the sac caused by the malfunction of two “check valves” of the blood vessels.

The pain is generally tolerable when I lie down compared with being upright. I think that is due to blood elevation while standing up. On ejaculation, the pain disappears.

In the spirit of Christmas, I am hoping to put Dr G on the spot to resolve the mystery of my “nut crackers”.

What are the causes of my trouble below the waist? Can this be dangerous? What are the do’s and don’ts to avoid this pain?

Many thanks and wishing you Merry Christmas and a Happy New Year!

Man At Work

Most men would agree their testicles are very sensitive, that even minor injury can cause severe pain and discomfort that would send chills down the spine. Testicular pain is peculiar, as the pain can arise from within the testis and its supporting structures, or originated from another organ due to its innervation.

Sometimes, what seems like testicular pain is actually caused by pathology in other region such as the groin (inguinal hernia) or kidney (kidney stones), and such pain is often lingering with nauseating sensation. The etiology of pain in the sac can range from minor trauma to serious conditions such as cancers.

The common medical problem that can cause testicular pain includes damage to the nerve due to diabetes (diabetic neuropathy), sexually transmitted infections (chlamydia and gonorrhea), mumps, intermittent twisting of the balls (testicular torsion) or an abnormally dilated vein in the scrotal sac (varicocele).

Discomfort in the sac for most men is usually mild, transient and short-lived. However, when the pain in the testicles persist for more than three months, it is commonly referred as chronic orchalgia. In general, the complaint is described as squeezing deep ache in the balls. This is often associated with abdominal and pain discomfort, with or without the symptoms of nausea.
The onset of the pain is commonly associated with activities such as exercise and sexual intercourse. The cause of the pain is often idiopathic and the origin of the problem unknown.

Virtually, all urologists will encounter men with the complaint of chronic testicular pain, which can be frustrating for both the patients and the physician, as the symptoms are often vague and variable between individuals.

One of the most common causes of pain in the sac is varicocele. A complex vasculature provides the blood supply of the testicular system of pampiniform plexus, allowing the entry and departure of the blood into the scrotum, controlled by a
network of valves. As men get older, the defective valves of the plexus will result in the dilated veins, causing compression and pain in the testicles.

Varicoceles are common. The condition is found in 15% of adult man, and 20% of adolescent population. It is more pronounce in the left due to differences in the venous returns of testicles. Although the “nut-cracking” effect of the veins is causing significant weight and strain on the testicles, most men are completely symptomless and oblivious to the “nutcrackers” in the sac.

Men who experience pain in the sac usually find relief by lying flat, especially during sex. Medications are for symptom relief, and the only intervention to eradicate the varicocele is through an operation. Many great philosophers and academics have given their thoughts on the strategies to cope with pain.

The famous American Professor of Literature who worked on comparative mythology and religion, Joseph Campbell once said: “Find a place inside where there is joy, and the joy will burn out the pain.” The pain in sac literally caused by the “nut-cracking” effects of the dilated veins can be a nuisance for many men, but may even be a complete “nut-cracker” that is off putting for sex.

When Dr G is put on the spot, his advice is to “lie down and find the place during sex where there is joy, as the pleasure will often drown out the pain!”

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