Thousands of men are being left to suffer an embarrassing and debilitating condition – even though treatment could be as simple as a few minutes of daily exercises. Nearly one in ten men endure chronic testicular and penis pain at some point in their lives, which can make getting dressed uncomfortable and moving around an agony.
Experts say the condition is often mistaken for a sexually transmitted disease or dismissed as a symptom of depression or anxiety.
Growing research suggests these men could effectively be cured using a regime of pelvic floor exercises, similar to those recommended for women to combat urinary incontinence after childbirth.
But specialists have told The Mail on Sunday the NHS has a ‘blind spot’ for this area of men’s health – meaning the condition, known as chronic pelvic pain syndrome (CPPS), often goes undiagnosed and untreated.
Jose Gonzalez Martinez began experiencing agonising pain after recovering from a prostate infection. Doctors and scans could find little clarity, until he was referred to Dr Boylan
Patients are sometimes forced to pay for private treatment because some NHS physiotherapists do not treat men for pelvic floor issues.
Instead, experts say, it is viewed as a ‘women’s issue’.
‘Thousands of men suffer with these painful spasms in their pelvic area, but are repeatedly told there is nothing wrong,’ says Dr Johnny Boylan, a genitourinary consultant who runs the CPPS clinic at Liverpool University Hospitals NHS Foundation Trust. ‘Or they are given antibiotics for a potential infection or painkillers.
‘But pain relief won’t solve the problem unless you treat the underlying issue, which we know is rarely happening.
‘Physiotherapy or simple daily exercises they can learn themselves could change the lives of many of these men but, too often, they cannot get this on the NHS. That needs to change.’
It is unclear how many men suffer from CPPS, but research published in the British Medical Journal this year suggested that as many as one in 12 men have been affected at some point.
The long-term pain often occurs in the testicles, the perineum (the area between the testicles and the anus) and the tip of the penis.
The sensation is often likened to a burning feeling or electric shocks that ripple through the affected area.
Patients report that the sensation can be so uncomfortable that putting on pants or trousers becomes unbearable because the pressure leads to flare-ups.
Pain in the genitals can also be a symptom of serious conditions such as sexually transmitted diseases, kidney stones, and even cancer.
This is why experts say it is important that patients who experience these issues always visit their GP.
However, many GPs are unaware of the symptoms of CPPS and are often unable to help men affected by it.
Studies suggest that, for some men, the condition can be triggered by an infection.
The pelvic floor is a group of muscles that support the spine, bladder and bowels
Other patients believe their CPPS was brought on by stress.
Doctors are also often unsure what causes the condition – or why it affects certain areas of the genitals but not others.
However, experts say that is becoming increasingly clear that CPPS is caused by a tightening of the pelvic floor muscles. Stretched like a hammock from the pubic bone at the front to the tailbone at the back, the pelvic floor is a group of muscles that support the spine, bladder and bowels.
It also allows us to control urine and bowel movements.
For women, it can be weakened by childbirth, leading to stress incontinence – peeing or pooing involuntarily when laughing, sneezing or exercising.
According to the NHS, one in three women experiences urinary incontinence in the first year after having a baby – and many continue to suffer for years afterwards. Women are advised to strengthen their pelvic floor by doing Kegel exercises – named after the 20th- century US gynaecologist Dr Arnold Kegel – which involve tightening the pelvic floor muscles for three to five seconds, then relaxing for three to five seconds, and repeating.
In June 2021, NHS England announced it was setting up specialist pelvic health clinics, staffed by physiotherapists, to treat tens of thousands of pregnant women and new mums with pelvic floor issues.
It is thought that men with CPPS have the opposite problem to women with stress incontinence. While, for these women, the muscles become too loose, for men, the muscles become constricted, and cannot relax.
Overtime, this leads to muscle spasms. Experts say CPPS patients should be offered ‘reverse Kegel’ exercises that loosen the muscles (see below for details).
However, there are no specialist pelvic health clinics available for men. In fact, experts say that many physiotherapists outright refuse to treat men for pelvic floor problems.
‘Huge numbers of men suffer from chronic testicular pain,’ says Bill Taylor, an Edinburgh-based physio, and a member of the Pelvic, Obstetric and Gynaecological Physiotherapy group, which campaigns for greater awareness around CPPS.
‘It can be incredibly debilitating, can really impact their lives, even make them feel life isn’t worth living.
‘But when you’re speaking to people about men’s pelvic health, they tend to ask: ‘Do men even have a pelvic floor?’
‘There’s this idea that only women have a pelvic floor, which even trickles down through GPs and doctors.
‘Historically, if you worked in pelvic health you were working in women’s health.
‘Most of the research has focused on women – there’s really not been much research done on men.
‘We need to educate doctors – GPs, sexual health consultants, urologists, incontinence specialists – so they understand the problem better and know what we as physiotherapists can offer, especially for men with chronic testicular pain.’
Dr Johnny Boylan says that, frequently, he has been unable to find NHS physiotherapists who will take on patients with CPPS.
‘I’ve had to give them the names of a private physio who would help them instead,’ he says.
One man who knows the agony of CPPS – and the frustration of trying to find treatment – is Jose Gonzalez Martinez, 37, a hotel worker, from Liverpool.
In October 2022, he developed an infection of the prostate, the gland that controls flow of urine.
Although a two-month course of antibiotics treated the infection, Mr Gonzalez Martinez was left with relentless pain in his testicles.
He said: ‘It just kept getting worse. At first I thought it was a reaction to the infection or to the antibiotics.
‘It was there all the time, although it was worse some days, and would get worse if I was moving around a lot.
‘At times it would spread up into my groin and into my belly.’
Assuming the pain was caused by another infection, Mr Gonzalez Martinez’s GP referred him to a sexual health clinic, where he was tested for sexually transmitted diseases including chlamydia, gonorrhoea and HIV.
Although he explained he was happily married and unlikely to have an STI, they repeated the tests a few weeks later.
He said: ‘I don’t think they believed me – even when all the tests, for both me and my wife, came back clear.’
An ultrasound failed to find any sign of physical damage, leaving Mr Gonzalez Martinez to struggle on.
He said: ‘No one knew where the pain was coming from. I was still able to work. But it was constantly tiring and annoying. People told me they could see the pain in my face.’
Eventually he was referred to Dr Boylan.
Realising the problem was caused by over-tight muscles of the pelvic floor as result of the prostate infection, he prescribed daily exercises to release the tension – plus nortriptyline, an antidepressant also used for pain relief. Starting on 10mg a day, he later increased the dose to 20mg.
Mr Gonzalez Martinez said: ‘There was an improvement, quite quickly. I was going two or three days without pain.
‘For a time, if I was moving around a lot in my job, it was still sometimes painful. But with the exercises alongside the medication, the pain has completely disappeared.
‘The exercises are very easy to do: just make the pelvic floor tense then relax. I do between one and three minutes and make sure I do it every day.’
Dr Boylan say it is crucial that more funding is made available for physiotherapists to take on men with CPPS and that GPs and specialists are educated about the symptoms so they can diagnose patients more speedily.
‘It’s a shame that it is so difficult to get diagnosed and treated for a condition that is so common,’ he says.
‘We are doing a disservice to these men by not providing that important part of their treatment.’
Simple seated exercise to help treat genital pain
Relaxing and loosening the pelvic muscles regularly will teach the muscles how to move normally again and reduce muscle tension – and pain – according to Dr Johnny Boylan, a genitourinary consultant who runs the Chronic Pelvic Pain Syndrome clinic at Liverpool University Hospitals NHS Foundation Trust.
One pelvic exercise – known as ‘down-training’ – involves sitting in a chair and takes no longer than one minute.
It can be done at home, on public transport or at work.
Patients are told to uncross their knees and place their feet apart on the floor.
Then, let the jaw hang loose and teeth separate.
The belly is supposed to relax and the buttocks loosen.
Patients should then breathe deeply, gently expanding the stomach. This should be repeated five times in one sitting. Another option is to stand in front of a mirror without underwear and lift the testicles up towards the body by tightening the pelvic muscles. These are the muscles tightened or loosened to go to the toilet. When the pelvic floor is tightened, the anus should feel clenched.
Then, patients are told to relax again and let the testicles hang loose. Letting the belly hang loose will help the pelvic floor muscles relax too.
It is the loosening part of this exercise that is important. Regular practice makes it easier. So it is important patients do these exercises for several minutes every day. However, it is vital not to strain while tightening the pelvic muscles, as this can exacerbate pain.
