There are certain topics in medicine that affect an enormous number of people, yet somehow remain almost invisible in everyday conversation. Male pelvic pain is one of them.
In this episode, I sat down with Dr. Susan MacDonald, a urologist who specializes in male pelvic pain, testicular pain, erectile dysfunction, penile implants, and the kinds of men’s health issues that many patients suffer with quietly for years before finding someone who actually understands what is happening.
And this conversation starts with a shocking idea: some men with chronic testicular pain are still being offered extreme solutions, including testicle removal, when the underlying problem may not be the testicle at all.
That is the first point Dr. MacDonald wants people to understand. Chronic testicular pain and chronic pelvic pain are often neuropathic pain problems. In simple terms, the pain may be coming from irritated nerves, overactive muscles, altered pain signaling, or pelvic floor dysfunction, not necessarily from infection, cancer, or a structural problem that can be “cut out.”
That matters because if the diagnosis is wrong, the treatment will be wrong too.
Many men are told they have prostatitis. They are given antibiotics again and again. Sometimes they feel temporarily better, which makes everyone think they are on the right track. Then the pain comes back. The cycle repeats. More antibiotics. More frustration. More scans. More normal results. More confusion.
And eventually, many men hear some version of: “Everything looks fine.”
But everything does not feel fine.
That is the gap this episode lives inside. The gap between what the scan shows and what the patient is experiencing. The gap between “nothing is wrong” and “I cannot work, train, have sex, sit comfortably, or play with my kids.” The gap between anatomy and suffering.
Dr. MacDonald’s message is clear: these men are not crazy. Their pain is real. But the framework we use to understand it is often incomplete.
The male pelvic floor exists, and medicine has not paid enough attention to it
Most women have heard of the pelvic floor. It comes up during pregnancy, childbirth, urinary leakage, pain with sex, postpartum recovery, and pelvic floor physical therapy. Women may not always get enough help, but at least the concept is culturally available.
Men, on the other hand, often have no idea they even have a pelvic floor.
But they do.
The pelvic floor is a group of muscles that acts like a hammock at the base of the pelvis. These muscles help support the organs, stabilize the pelvis, and allow humans to stand and move upright. In men, key structures pass through or near this muscular system, including the urethra, rectum, and spermatic cords.
That is why pelvic floor dysfunction in men can show up in so many confusing ways.
A man may come in with weak urinary flow and think he has a urethral stricture or a prostate problem. Another may have pain after ejaculation. Another may have testicular pain. Another may have constipation, pelvic pressure, perineal pain, erectile dysfunction, or pain that seems to radiate into the groin or leg.
From the outside, these symptoms can look unrelated.
But Dr. MacDonald’s point is that many of them can trace back to the same underlying issue: high-tone pelvic floor dysfunction.
This is the opposite of the pelvic floor issue many women hear about after childbirth. In that context, the problem is often weakness or loss of support. Kegels may be used to strengthen the muscles. But in many men with chronic pelvic pain, the issue is not that the muscles are too weak. It is that they are too tight.
Think about the person who carries stress in their shoulders. They are not consciously walking around all day saying, “I am going to contract my traps now.” It just happens. The body holds tension. The muscles tighten. Eventually the person gets neck pain, headaches, or referred pain somewhere else.
Dr. MacDonald sees a similar pattern in the pelvis.
For some men, stress, chronic guarding, trauma, constipation, prolonged sitting, injury, or some triggering event may create a situation where the pelvic floor becomes overactive. And once those muscles stay tight, they can start squeezing or irritating the structures running through them.
That can make urination feel obstructed even when the urethra is structurally normal. It can make ejaculation painful. It can contribute to constipation. It can create testicular pain that feels as if something is wrong with the testicle, when the actual problem may be muscular or nerve-related.
This is where the medical system often misses the mark.
A standard digital rectal exam is usually taught as a prostate exam. The clinician is looking at prostate size, shape, and texture. But Dr. MacDonald talks about the importance of also assessing the pelvic floor muscles themselves. If those muscles feel tight, tender, and rope-like, that can be a major diagnostic clue.
The problem is that many clinicians were never trained to think this way. And if doctors are not trained to look for male pelvic floor dysfunction, patients can spend years being treated for the wrong thing.
Chronic pain is real, even when the imaging is normal
One of the most important parts of this episode is the way Dr. MacDonald talks about chronic pain, because chronic pain patients are often invalidated.
They are told their scans are normal. Their labs are normal. Their anatomy looks normal. And because no one can point to a clear structural problem, the patient is sometimes treated as if the pain must be exaggerated, psychological, or medication-seeking.
That is a dangerous mistake.
Pain is not always visible on a scan. A CT, MRI, or ultrasound can show anatomy. It can show a mass, a stone, a blockage, or an obvious injury. But it cannot always show how the nervous system is processing pain.
This is especially important with neuropathic pain and chronic pain syndromes.
When someone is in pain long enough, the nervous system can become sensitized. The brain and spinal cord begin to process signals differently. A sensation that might register as mild discomfort in one person can register as severe pain in someone whose system has been primed by months or years of pain.
Dr. MacDonald compares this to other chronic pain syndromes like fibromyalgia or complex regional pain syndrome. These conditions were also misunderstood for a long time because they did not fit neatly into the old model of “find the structural damage, fix the structural damage, pain goes away.”
But the body is not that simple.
Pain is not just a signal from tissue. It is an experience created by the nervous system. It is influenced by inflammation, muscle tone, prior injury, fear, stress, trauma, sleep, anxiety, and the brain’s expectation of pain.
If a man has had severe testicular or pelvic pain for months, he may begin to fear the next flare. Then the first hint of pain arrives, and his nervous system reacts. He braces. He worries. His muscles tighten. The pain escalates. The fear of pain becomes part of the pain cycle.
This is one reason chronic pelvic pain can be so devastating. It is not just physical discomfort. It can disrupt work, training, sex, relationships, fatherhood, and identity. A 30-year-old man who cannot sit, lift, have sex, or get on the floor with his kids is not dealing with a minor inconvenience. He is dealing with something that can shrink his entire life.
And if every doctor keeps telling him everything is normal, the psychological burden gets even heavier.
That is why validation matters. Validation does not mean pretending to know the answer immediately. It means telling the truth: your pain is real, your symptoms matter, and we need to look beyond the obvious explanations.
The goal is often relaxation, not more tightening
One of the most practical takeaways from this conversation is that men with pelvic floor dysfunction usually do not need more tightening. They need to learn how to relax.
This is why generic advice can backfire. If a man with high-tone pelvic floor dysfunction searches online and finds pelvic floor advice centered around Kegels, he may think he needs to strengthen the area. But if his problem is already excessive tension, more contraction may make things worse.
The better target is downtraining.
That means teaching the pelvic floor to release, lengthen, and return to a healthier resting tone. This can involve specialized pelvic floor physical therapy, breathing work, stretching, relaxation techniques, myofascial release, and sometimes medications or procedures depending on the patient.
The word “specialized” matters here. Pelvic floor physical therapy is not the same thing as general physical therapy. A man with chronic pelvic pain should look for someone specifically trained in pelvic floor dysfunction. And yes, for men, that often involves internal work through the rectum because that is how the therapist can access and treat the pelvic floor muscles directly.
That can sound intimidating. It can also be the thing that finally helps.
Dr. MacDonald describes this like working on a knot in the shoulder. If someone has a tight, painful trigger point in the trapezius, a skilled therapist can work on that tissue and help it release. The same principle can apply to the pelvic floor, even if the anatomy is more private and the conversation is more uncomfortable.
This is also why trust-building is such a big part of her care.
Many patients have already seen multiple clinicians. They have already been told it is an infection, a prostate problem, or “nothing.” They may be skeptical, embarrassed, or exhausted. So Dr. MacDonald often starts with simple, low-risk interventions that can create a small improvement and begin rebuilding trust.
That may include addressing constipation, because a full rectum can increase pressure in the pelvis and worsen urinary or pelvic symptoms. It may include warm baths, short-term anti-inflammatories, medications that improve urinary flow, stretching, breathing, and education.
For some patients, neuropathic pain medications may be used, including options like duloxetine, gabapentin, pregabalin, or amitriptyline. Muscle relaxants, rectal suppositories, trigger point injections, Botox, acupuncture, and other approaches may also have a role depending on the case.
For chronic testicular pain specifically, Dr. MacDonald also discusses spermatic cord blocks and microsurgical denervation of the spermatic cord. The block can act like a dress rehearsal. If numbing the nerve supply provides meaningful temporary relief, that may help identify patients who could benefit from a nerve-targeting procedure.
The larger point is not that every man needs the same treatment.
The point is that there are options.
And “remove the testicle” should not be the default answer for pain that may be neuropathic, muscular, or nerve-mediated.
Men’s sexual health is changing faster than medicine can keep up
This episode also moves into another uncomfortable but important topic: erectile dysfunction in younger men.
Dr. MacDonald is seeing more adolescents and young adults coming in with concerns about erections. These are not the same patients as older men with diabetes, cardiovascular disease, long-term smoking history, or post-prostate cancer sexual dysfunction. These are young men, sometimes teenagers, who are struggling before they have even built much real-world sexual experience.
This is a very different clinical picture.
We cannot reduce every case to pornography, anxiety, cannabis, hormones, or relationship issues. But Dr. MacDonald raises an important concern: many young people are learning sex through high-stimulation pornography before they have any realistic experience of intimacy.
That can shape expectation, arousal, and conditioning.
If a young man repeatedly pairs sexual arousal with highly stimulating visual content and very specific self-touch, then real-life sex with another human being may not provide the same pattern of stimulation. Not because something is “wrong” with the partner. Not because the body is broken. But because the brain has been trained toward a different arousal template.
The brain learns what it repeats. And if the first sexual education many young people receive is extreme, performative, algorithm-driven content, we should not be shocked when real intimacy starts to feel confusing, under-stimulating, or anxiety-provoking.
This is not only a male issue either. It affects expectations for young women too. It changes what people think is normal, what they think sex should look like, and how they relate to their own bodies.
Dr. MacDonald also explains that sexual arousal is not just a plumbing problem. It is a brain-body event. The brain has to register desire, assign value to sensation, turn down distraction, and coordinate the body’s physiological response. If someone is anxious, distracted, ashamed, overstimulated by pornography, or mentally overloaded, sexual function can suffer even when the anatomy is normal.
That does not mean medical evaluation is unnecessary. Hormones, vascular health, medications, mental health, substance use, and relationship factors all matter. But it does mean we need a more mature conversation about sexual function.
And when erectile dysfunction is severe or persistent, medicine does have tools. PDE5 inhibitors like Viagra or Cialis can help many men. Testosterone evaluation may be appropriate in some cases. Injections and vacuum devices may be used. And for men with severe erectile dysfunction who have failed other options, penile implants can restore the ability to have penetrative sex.
This is another area where silence creates suffering. Many men do not know what is available. Many are embarrassed to ask. And many assume that if they are struggling sexually, it says something shameful about their masculinity. But it does not.
Action checklist
If you are a man dealing with chronic pelvic pain, testicular pain, painful ejaculation, weak urinary stream, constipation, unexplained groin pain, or erectile dysfunction, do not assume you just have to live with it. And do not assume that a normal scan means nothing is happening.
Start by seeing a qualified medical provider, ideally a urologist with experience in chronic pelvic pain, chronic testicular pain, pelvic floor dysfunction, or male sexual medicine. If you have been given multiple rounds of antibiotics for “prostatitis” without lasting improvement, ask whether pelvic floor dysfunction or neuropathic pain could be part of the picture.
Look for a pelvic floor physical therapist who specifically treats men. This is not the same as general physical therapy, and it is not simply doing Kegels. For high-tone pelvic floor dysfunction, the goal is often relaxation, downtraining, breathing, stretching, and myofascial release.
Pay attention to constipation. If you are not having regular bowel movements without straining, that can increase pelvic pressure and worsen symptoms. This is not glamorous medicine, but it matters.
Do not ignore stress, trauma, sleep, or anxiety. This does not mean your pain is “all in your head.” It means your nervous system and pelvic muscles are part of the same body. If your body is living in chronic fight-or-flight, your pelvic floor may be too.
If testicular pain is severe and persistent, ask about nerve-targeting approaches before considering irreversible surgery. In the right patients, spermatic cord blocks and microsurgical denervation may be discussed with a specialist.
If erectile dysfunction is happening at a young age, be honest about pornography, masturbation patterns, cannabis or other substances, anxiety, relationship dynamics, and sexual expectations. A good clinician should be able to discuss this without shaming you.
Most of all, do not let embarrassment keep you from getting help. Pelvic pain and sexual dysfunction can feel isolating, but they are medical issues, not character flaws. The right diagnosis can change everything.
