Chronic pelvic pain in men: why it persists and what helps

Most men do not arrive at a sex therapist's clinic with pelvic pain as their first port of call. They have been to their GP. They have been referred into urology. They have had scans, blood tests, ultrasounds, sometimes cystoscopies. They have tried antibiotics, sometimes for months, sometimes for years. They have been through pelvic floor physiotherapy. They have tried pain medication. They have looked online. By the time they reach me, they have usually been at this for a long time, and they are usually reluctant. Coming to psychological therapy for what feels like a physical problem is not the obvious next step. For many of them, I am the last person they have come to see.

The experience of living with pelvic or genital pain is one of the most distressing things I see in the men I work with. It is also one of the most under-researched. Pelvic pain in men is a territory that medicine still does not have clear answers for. The symptoms can be wide-ranging. The origins are often unclear. The treatment paths are contradictory. And the men I see have usually been carrying it, often alone, for years.

In over ten years working in NHS sexual health services, and across the outcomes we have now published in peer-reviewed work, what I have come to think is that psychological therapy has a real place in this work, but not the place men sometimes imagine when they first arrive. This piece is about what that place actually is, and what helps for the men whose pelvic pain has not resolved through everything else they have tried.

The shape of pelvic pain in men

Pelvic pain in men comes in many forms. The symptoms can include pain in the genitals or penis specifically, pain across the pelvic floor or abdomen, discomfort in the area of the bladder, the bowel, or the perineum. For some men, the experience is constant. The pain or the discomfort is there every day. It does not move into the background. For others, it comes in flare-ups, with periods where things feel manageable and periods where the symptoms become much worse.

The quality of the pain varies too. Some men describe it as sharp, stabbing, discrete pain. Others describe persistent aching. Others describe it more as a background noise, an uncomfortable feeling that is not always acute, but is distracting, persistent, and a constant reminder that something does not feel right.

The origins are not always clear either. Sometimes pelvic pain is linked to a specific injury. Sometimes it is related to another medical condition. Often it is not fully medically explained. The investigations come back without a clear cause, and the men I see are left holding a problem that medicine has not been able to name precisely, often for a long time.

That uncertainty matters. Living alongside pain you have not had explained, alongside discomfort that has not resolved, generates a particular kind of psychological distress that is different from acute pain with a clear cause. It produces high levels of anxiety. It erodes confidence. It begins to affect how men relate to their bodies in ways that go well beyond the local symptoms.

What pelvic pain does to a man's sexual life

For most of the men I see, pelvic pain has a substantial impact on their sexual life. The mechanism is different for different men.

For some, the pain itself is part of sexual function. Getting an erection induces pain. Maintaining one is uncomfortable. Ejaculation triggers a flare-up of symptoms that can last for hours or days afterwards. The body is delivering pain signals exactly when arousal is happening, and that is a profoundly disorienting experience for a man who has previously thought of his sexual body as something that worked without him having to think about it.

For other men, sex is not directly painful, but the underlying discomfort in the pelvis or genitals has steadily eroded their confidence to be sexual at all. They have lost the sense of being relaxed in their own body. They have lost the ease of moving into a sexual encounter without anticipation of what might go wrong. They have lost something that is hard to name but that they know they used to have.

For many men, the pattern that develops is a cycle. They have a sexual experience. The pain or the discomfort flares afterwards. They feel anxiety, shame, and worry about what they have done to themselves. They become abstinent for a period. The body settles. They try again. The pain returns. The cycle restarts. Over time, sex itself begins to feel dangerous, or difficult, or like something they are doing wrong. The pain has become a constant reminder that this part of life cannot be trusted.

Why this kind of pain carries so much shame

One of the most consistent things I hear, from the men who arrive in clinic with pelvic pain, is that the location of the pain itself carries a particular weight. Pain in the genitals, in the pelvic floor, in this part of the body, feels deeply shameful. It feels like something is broken. It feels like something that cannot really be talked about or explained. Men carry it for months or years without telling their partners, their friends, or sometimes even their doctors in plain terms.

Pain in this part of the body feels deeply shameful. It feels like something is broken.

There is a second layer of shame for a particular proportion of the men I see. Not all pelvic pain has clear causes, but for some men, the pattern that preceded their pain involved masturbation, or sex, in ways that may have put strain on the body. Frequent or hard masturbation, especially during a stressful period of life. Sex at times when arousal was not fully established. Patterns that, in retrospect, the man can connect to the symptoms that followed. For those men, there is a particular and painful belief that they did this to themselves. That the pain is, in some way, a punishment.

That is the position many of them are in when they walk into the room. They are carrying a body that does not work the way it used to, a story about themselves that says they caused it, and an exhaustion from the medical journey that has not given them the resolution they were looking for.

What psychological therapy actually does, and what it does not do

The first thing I am usually doing in the room with these men, in the first session, is making clear what psychological therapy is here to do, and what it is not here to do.

It is not here to replace medical investigation. It is not the end of the road for medical or physiotherapy work. I will often actively encourage men to continue with both. We know that psychological therapy, in combination with physiotherapy, produces significantly better outcomes than either alone. The work happens alongside, not instead of, the other parts of the picture.

It is also not here, as a primary aim, to remove the pain. That is a long-term hope. It does sometimes happen. But it is rarely the first thing the work delivers, and framing it that way at the start tends to make the work feel like another disappointment when it does not produce instant results.

What psychological therapy can do, often relatively early in the work, is change the relationship a man has with the pain he is experiencing. That sounds like a small claim. It is not. The relationship to the pain, more than the pain itself, is often what is keeping it as distressing and as dominant as it has become.

Change the relationship a man has with the pain. That sounds like a small claim. It is not.

The relationship to the pain, more than the pain itself, is often what is keeping it as distressing and as dominant as it has become.

The brain, attention, and the feedback loop

When a man is in pain, the threat detection systems of his brain go into action. This is appropriate. Pain signals exist to tell us that something might be wrong, that something has harmed the body or could harm it further. The brain places attention on the painful area, so that we can seek help, protect the area, and respond to the threat.

That system works well for acute pain with a clear cause. You cut your hand. The brain alerts you. You attend to it. The cut heals. The signal switches off. The attention moves elsewhere.

The challenge for chronic pain, and particularly for chronic pelvic pain, is that the signal does not switch off. The brain has been alerted, again and again, to a problem that has not been resolved by any of the conventional routes. The attention keeps going back to the affected area. The man is already aware of the pain. He does not need his brain to keep telling him about it. But the system was not designed to know that.

What happens next is the feedback loop. The more attention is placed on a part of the body, the more the brain amplifies the pain signals coming from that area. The amplification increases the subjective experience of pain. The increased pain produces more anxiety and stress. The anxiety and stress increase attention to the area. The loop tightens.

By the time men arrive in psychological therapy, this loop has usually been running for a long time. The pain is real, the underlying source is real, and the loop is amplifying both. What therapy does is intervene in the loop. Not by ignoring the pain or denying it, but by changing the kind of attention being placed on it, and by changing the relationship the man has with his own threat response.

This is not a quick or simple piece of work. It requires understanding what the brain is doing, recognising the pattern as it shows up minute to minute, and beginning to develop a different set of responses to pain signals. But for most of the men I see, this work begins to turn the dial down on the experience within weeks. The pain has not been removed. The relationship to it has changed. And for many men, that change is itself experienced as a meaningful reduction in how much pain is shaping their day.

Resetting the relationship to sex

The second strand of the work, once the threat response has begun to settle, is to rebuild the relationship to sexuality. This is where pelvic pain work meets sex therapy properly.

For many of the men I see, they have arrived having either stopped being sexual altogether, or having entered the cycle of trying, flaring, abstaining, and trying again. Neither of those is sustainable. The work involves opening up the question of what being sexual can look like, with this body, as it is now.

What this often looks like in the room first is sitting with a man through the recognition that the way he used to use his own body is not coming back in the same shape. The masturbation he was doing in his twenties. The sex that used to happen automatically. The body that did not need to be thought about. The recognition usually arrives quietly, not catastrophically. But there is grief in it, and we sit with that, sometimes for several sessions, before the work can move forward.

From there, the work becomes about what is possible now. What kinds of touch and pressure can be built without strain. What pleasure is available that does not depend on the parts of the body that are most affected. How to recognise the early signals of a flare-up, and how to pause or change course before the pain becomes acute. The detail varies man to man. The principle is the same: a different relationship to the body, built honestly, in this body as it is now.

This often involves a different kind of conversation with sexual partners. For men in relationships, that can mean explaining the pain in a way they have not before, asking for changes in how sex happens, building the kind of communication that allows sexual connection to continue without each encounter becoming a test of whether the body can cope. For men dating, it can mean some form of disclosure to new partners, in a way that is honest but does not become the only thing the relationship is about.

This can take time. For the men who stay with it, what tends to emerge is not a return to how things were before. It is a different relationship to the sexual self, often a more honest one, that is not built on the assumption that the body will always perform without thought.

A man I have been thinking about

To make this concrete, one man I worked with arrived in his early thirties, with persistent pelvic and penile pain. The pain was there most days. It was significantly worse during sexual arousal. He had been through extensive medical investigation, with no clear physical cause identified. He had been attending pelvic floor physiotherapy, which had been useful in some ways but had not changed the pain during sexual arousal. Pain medications had been of limited use. Urological examinations had not found a specific cause.

The pain had started, he could trace, after a difficult period in his life. A series of relationship breakdowns had been very stressful. He had been struggling to find new sexual partners. He had spent a lot of time, in that period, masturbating, often heavily, often when he was already feeling low. He could see, in retrospect, a pattern that linked the masturbation to the onset of his symptoms, although the medical investigations could not confirm it.

He arrived with very high levels of shame, frustration, and anxiety about whether anything would help. Almost in the first session, he said:

> "My body is broken, and I've done it to myself."

He followed that, a little later, with this:

> "I don't think there'll ever be a way of me getting out of this. This is going to be it for the rest of my life."

That hopelessness is common in men who arrive at psychological therapy this far down the road. It is part of what they bring into the room.

The work began, as it usually does, with the relationship between his attention and the pain. We mapped his experiences of pain in detail and found, almost immediately, that the pain was not uniform. There were periods, even days, when it was less. That alone began to give a small amount of hope. We then spent time understanding what his brain was doing in the periods when the pain was at its worst. The attention it was placing on the painful area. The anxiety and stress that was being driven by the threat response. The way the loop was perpetuating itself.

The early work was frustrating for him, because part of it involved stepping back from being sexual at all for a period. That included a period of stopping masturbation. For a man who had been using masturbation to cope with stress and isolation for years, that was extremely difficult. But he stayed with the early work.

Some weeks in, he came into a session and said this:

> "I feel lighter."

He looked it, too. The pain had not gone. But it was not dominating him in the way it had been when he first arrived. The minute-to-minute weight of it had reduced. He was sleeping better. He was less preoccupied. The dial had begun to turn down.

The pain had not gone. But it was not dominating him in the way it had been when he first arrived.

From that point, we could move into the second strand of the work. Together, we thought about what masturbation could look like in a way that did not put pressure on his body. We thought about what sexual experiences could look like, what kinds of touch and arousal were possible without straining the affected area. We thought about how he would approach future partners, what he would and would not say, how he would communicate during sex if the pain was returning.

Over time, his confidence began to rebuild. His masturbation looked different than it had before. He had developed strategies for pausing if pain was emerging. He had begun some form of light disclosure to new partners, framed not as an apology but as a normal piece of information about how his body worked. By the end of the work, the pain had diminished but had not fully resolved. He was being sexual again, in a different shape than before, and with more knowledge about his body than he had had at any point.

He was also still engaged with urology and with his physiotherapist. The investigation had not stopped. The point was that he now had a way of living alongside the pain, and a way of being sexual within it, that he had not had when he walked in.

What the change actually feels like

One thing a man in this work said to me, late in his own course, has stayed with me. He said it felt like the roadworks had cleared from in front of his house. I asked him what he meant.

> "For so long it felt like there had been this noise, this uncomfortable thing that was right in front of me, that I couldn't move past and was there every single day. Now I feel like I can see the road again. I'm aware there are still roadworks by the side, but I can see what's ahead. It means I can focus on other things. Day to day life feels easier. I'm able to get on with things that feel important. Even if the noise sometimes is in the background."

That is, as well as anything I have heard a patient describe, what the change in this work actually looks like. Not the symptoms or the pain disappearing completely. The dial gets turned down. The experience changes. It impacts less. It is less in the way. There is a possibility to move forward and to see a future again.

What this means in practice for men with pelvic pain

A few things follow from this for men who are sitting in this territory and trying to work out what to do.

The first is to not give up on the medical and physio routes. They matter. Psychological therapy is most effective in combination with them, not as a replacement. If you are reading this and you have been told you should consider psychological therapy as the next step, that is not the system giving up on the medical side. It is the system recognising that the picture is more layered than any single discipline can address.

The second is that the goal of the psychological work is not, in the first instance, to remove the pain. It is to change the relationship you have with the pain. That sounds like a smaller goal. It is actually the thing that, for most men, allows the rest of the picture to begin to shift, often including the subjective experience of how much pain is present day to day.

The third is that the shame around pelvic pain, and especially the shame around feeling that you may have caused your own pain through how you have used your body, deserves to be looked at directly. It is not your fault. Pain like this can happen in a way that looks like a lottery. Some men develop it after patterns that many other men also follow without consequence. Holding on to a story that says this is a punishment will not help the work. Letting go of that story, slowly, with someone who can hold both the medical reality and the emotional weight of it, often does.

The fourth is that the work takes time. The journey is rarely linear. There are periods where things feel better and periods where the symptoms flare. The men I see who do well tend to be the ones who allow themselves the time the work needs, and who are willing to stay engaged across multiple disciplines, rather than looking for one route that will solve it.

The fifth, and this matters, is that the relationship you have with your own sexual body is part of the work. Pelvic pain pulls many men into a particular kind of disconnection from their own sexuality. The work involves a slow and patient reconnection, not a return to what was before, but the building of a relationship with the body that can hold the pain and still allow for pleasure, intimacy, and presence with a partner.

Where the work has to start

Psychological therapy is not a magic answer for pelvic pain. It is not a replacement for medical investigation or physiotherapy. It is not a guaranteed route to resolution.

Psychological therapy is not a magic answer for pelvic pain. It is not a replacement for medical investigation or physiotherapy.

But ignoring the psychological component of pelvic pain, as a system and as a man trying to live with it, leaves out one of the main things that maintains and amplifies the problem. Pain that is not engaged with psychologically tends to last longer, feel worse, occupy more of the day, and cause more secondary damage to sex, relationships, and confidence than pain that is being met by a combined approach.

For most of the men I work with, the work over time produces three kinds of change. The first is that the day-to-day experience of pain becomes less dominant. The dial turns down. The pain does not necessarily go, but it does not run the day in the way it did. The second is that the relationship to the body, and particularly to the sexual body, begins to be rebuilt. Men start being sexual again, in modified shapes, with new strategies, with more honest communication. The third, less often but real, is that for some men the symptoms themselves eventually resolve, through the combination of psychological work, physiotherapy, and continued medical engagement.

We cannot always explain why pelvic pain stops when it stops. We cannot always predict who it will resolve for. But the men who give themselves the best chance are usually the men who pursue multiple parts of the picture together, over time, and who are willing to look at the psychological territory alongside the physical one.

It is not a quick journey. It is rarely a clean one. But there is a way through, and the work, when it is done well, is worth doing.

It is not a quick journey. It is rarely a clean one. But there is a way through.

Dr Michael Yates is a Clinical Psychologist, EFS-ESSM Certified Psychosexologist and COSRT-registered Sex and Relationship Therapist. He is Lead Clinician and Psychology Service Lead at 56 Dean Street, part of Chelsea and Westminster Hospital NHS Foundation Trust.