The First In-Depth Study on ‘Blue Balls’ Reveals a Lot about Sex

published a paper in Sexual Medicine on the first in-depth study investigating epididymal hypertension—a sometimes uncomfortable state of engorged genitals that is commonly known as “blue balls.”Previous research on this acute condition is practically nonexistent. To investigate whether blue balls are a real phenomenon and, if so, how they affect sexual behavior, Pukall and her colleagues at Queen’s University in Ontario teamed up with journalists at Science Vs to solicit survey responses from people with a penis and people with a vagina—2,621 in all. Among the takeaways: testicles are not a prerequisite for what Pukall prefers to call “throbbing crotch syndrome.” Scientific American talked with Pukall about the pervasive myth that arousal without orgasm is dangerous and why people still use it to pressure a partner into having sex.[An edited transcript of the interview follows.]

Why is excess blood in the genitals potentially uncomfortable?

There’s a whole bunch of things that go on in the process of being turned on sexually. One of the main body-related phenomena that occurs is something called engorgement, where blood rushes to those erogenous zones. That will be responsible for things such as clitoral enlargement and penile erection.

Orgasm is almost like a quick-release valve for all of these body-related processes to come back to the regular resting state, when genitals return to their normal size and blood stops pooling in those erogenous areas. But let’s say there’s a lot of foreplay happening. It’s more like a very slow release valve where there’s no explosion to let those processes come back to that nonaroused state.

Are blue balls a legitimate phenomenon?

Yes, absolutely. Now, what does it mean to have blue balls? It could range from feeling a bit uncomfortable to feeling frustrated that this arousal response hasn’t been completed. It could be throbbing, it could be achy, but in terms of intense pain or frequent pain, that is exceptionally rare. Is it something that requires immediate medical attention? No. But the experience of that pain is absolutely real. Anyone who has genitals and is capable, physically, of that physiological sexual response can experience this ache. [This study] legitimizes this condition for all people, whether it’s blue balls or blue vulva or blue genitals. I’ve started to call it “throbbing crotch syndrome.”

Throbbing crotch syndrome is a much better name. Do the testicles and the vulva actually turn blue?

[In our study], some people reported that their genitals do take on a slightly blue tinge. But we couldn’t find any papers showing that this phenomenon leads to a bluish tinge in the genitals. There’s [no research] out there that gives solid proof that there is hypertension in the scrotal area or in the genitals. Everything that we could find around how it occurs are just ideas. There is only a survey of college students from the 1950s and a case study of a 14-year-old from 2001.

Were you surprised that 40 percent of people with a vulva reported that they experience throbbing crotch syndrome?

I was actually expecting quite a high number simply because I don’t see it as the domain of the frat boys and of people with a penis. If you think about the way the process works, it doesn’t matter what your accoutrements are. It’s not like the blood flow knows that it is going into the scrotal area. Or if no scrotal area exists, it’s not like the blood flow is going to be acting, well, nicer.

Were you expecting severe pain levels to be low—less than 7 percent in people with a penis?

I actually expected [the level of severe pain] to be higher. I’ve worked in genital pelvic pain, so I’m used to always validating [people’s experiences]. This is an acute pain condition that is typically easily resolvable, relatively infrequent and mild. It isn’t on the radar of medical professionals simply because it isn’t dangerous in any way. If the pain is chronic and extremely distressing, that’s when you need to see a medical professional to get some tests done and to have a thorough assessment. In all likelihood, something else is going on.

Scientists have been studying pain for centuries, yet this survey was the first serious inquiry into blue balls. Considering society’s love affair with penises, why do you think this topic has been overlooked?

It’s interesting, right? Usually pain related to penises is taken super seriously, whereas pain related to vulvas or other sorts of configurations of genitals is not. I was really stumped. But I think one explanation could be the narrative that blue balls happens mainly to younger men who are sexually frustrated, so it’s kind of treated like a joke and almost like a rite of passage.

It sounds like scientists haven’t studied it because it isn’t a big deal medically. Yet more than 40 percent of the survey respondents with a vagina said that they’ve felt pressured to “engage sexually due to a partner’s fear of getting blue balls/vulva.”

Yes, as did some people [3.7 percent] with a penis. In our qualitative analysis, we included a section where respondents could add comments, and many people wrote that blue balls shouldn’t be used as an excuse to sexually coerce somebody. This was one of the most prominent themes that came up in our analyses: even though people know that it shouldn’t be used as an excuse, it’s still happening.

The good news is that there are many ways for a person to resolve their uncomfortable sensations. We found from the study that you can wait it out, do distracting activities, exercise or masturbate. These are all things that don’t implicate a partner. It’s important to have masturbation as an option, but I think people are just so uncomfortable with the idea of it. Automatically, it’s like, “Oh, someone else needs to take care of this for me.” No way. You’ve got to take the problem in your own hands.

Why do you think the myth that blue balls is dangerous is so pervasive?

I think it has a lot to do with gendered scripts that people have internalized. In many cases, there’s this emphasis placed on penile pleasure in sexual situations—the patriarchy inside the bedroom. Men are seen as the sexual go-getters and as proactive; women are seen as the gatekeepers to sex and more passive. This sexual script places a huge emphasis on the performance of men and their penis. Cisgender women who are having sexual activity with cisgender men tend not to benefit from this at all. This [dynamic] is also manifested in something called the orgasm gap: men are reporting lots and lots of orgasms, whereas women who are having sex with men report the lowest frequencies of orgasm.

How does an undue focus on orgasm contribute to the pressure to engage sexually that many respondents reported feeling?

Some people really feel that they’re not having real sex unless they have an orgasm, that they are entitled to it. People talk about “achieving” orgasm, right? It sounds like you’re hiking to the top of Kilimanjaro or something. [Orgasm] is wonderful! It’s like icing on the cake! But you don’t have to have the icing on the cake because the cake itself is delicious.

We want to ensure that people have the knowledge to say no—to feel confident in their rejection of continuing an activity if it’s not something they truly want.

Are you going to do more research on throbbing crotch syndrome?

We are planning a more in-depth study where we will take more into account the genders of people’s sexual partners. [In the recent study] we only talked about bodies. We also want to take a look at the context: Are there differences [in the frequency or intensity of the phenomenon] if it’s more of a casual encounter versus an encounter with a committed partner?

It would be cool to do research on how [throbbing crotch syndrome] happens and if there are ways we can prevent it. I have some pretty cool devices in my lab, but I don’t know if it would fly with my ethics board to have people come in and masturbate to almost orgasm and then, like, scan their genitals.

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