Most men who come to me about pain have been somewhere else with it first, often several times. Swabs, a urine sample, a scan, a course or two of antibiotics, and a conclusion that nothing is wrong. The pain carries on, and by then there is a second problem on top of the first, which is that nobody quite believes you.
A normal scan is not the same as no cause. Usually it means the cause is not the sort of thing a scan can see.
Persistent pain here is more often a problem of muscle, of nerve, and of how the nervous system has learned to behave than one of infection or structure. None of that shows up on the tests done first. It does not make the pain less real, and it does not make it untreatable. It makes it a different assessment.
Everything came back normal. So why does it still hurt?
Because those tests look for infection and structural damage, and neither is the commonest reason for pain that has lasted months. Muscle that has learned to grip, nerves that have become sensitised, and a nervous system that has turned the volume up on signals it once ignored are all invisible to a swab and a scan. A normal result is useful, because it rules things out. It is not an answer, and being told there is nothing wrong while you hurt every day is its own kind of harm.
01Where it hurts
Five patterns, and they overlap more than they look as though they should.
Pain during receptive sex
Anodyspareunia. Common, rarely discussed, usually a mix of muscle tension, something local, and anticipation.
Pelvic and perineal pain
The perineum, lower abdomen, bladder, or pain on sitting. Often labelled prostatitis and treated with antibiotics that change nothing.
Penile pain
The shaft, the tip or the foreskin, sometimes only after sex or after coming.
Testicular and scrotal pain
An ache or a sharp pain that has not settled, sometimes after surgery, often with a normal scan and no explanation.
Pain nobody has explained
Where everything is normal and you have been told there is nothing wrong. That is where most of this work starts.
Anodyspareunia is common, rarely discussed, and one of the things men most often cannot find anyone to ask about. The physical and psychological causes usually run together rather than being alternatives.
What tends to be involved:
A hypertonic pelvic floor, where the muscle has learned to grip rather than release
Something local: a fissure, haemorrhoids, or proctitis
Not enough lubrication, or going faster than the body is ready for
Anticipation. Once sex has hurt, the body braces before it starts, and the bracing hurts
Patterns that behave like vaginismus, where the muscle closes involuntarily
Some discomfort the first few times is common. Pain that persists, or that starts after a stretch of things being fine, is a signal rather than something to push through, and pushing through teaches the muscle to brace harder. That is a learned response, not a failure of technique or of wanting it enough, and it is the bracing that treatment aims at rather than your tolerance for it. Where muscle tension is doing most of the work I bring in a pelvic health physiotherapist. Where anticipation is, that is work I do here.
Pain in the perineum, the lower abdomen, the base of the penis, the testicles or the rectum, lasting months, often worse on sitting because sitting loads the pelvic floor, and often arriving with urinary symptoms. Whether it changes after opening your bowels, after sex, or across the day tells me more about what is generating it than the location does.
A course of antibiotics that changed nothing is information rather than a dead end.
Stress does not invent pain, and I would not tell you it is in your head. What it does is change how much muscle tension you carry and how loudly the nervous system reports what it picks up, and both of those are physical. Pain running for months generates its own anxiety, so by the time a man gets here the two are feeding each other. Both are worth treating, rather than arguing about which came first.
I've been told it's prostatitis. Is that right?
It may be the label rather than the diagnosis. Prostatitis is used broadly, and only a small part of what it covers turns out to be a bacterial infection of the prostate. Where an infection is found it gets treated. Where it is not, and the pain has gone on for months, what is usually driving it is muscular and neurological rather than infective, and that needs different treatment. It is worth knowing which of those you have, because the two get treated as one.
Sudden, severe testicular pain, particularly with swelling or feeling sick, needs A&E the same day rather than an appointment with me. Testicular torsion is time critical and it is the one thing here that cannot wait.
Everything else tends to get investigated for the obvious things and then, once those come back clear, left alone. There is almost always more to look at.
In penile pain:
Skin conditions such as lichen sclerosus, balanitis or dermatitis
A tight foreskin, or a frenulum that is short or has torn
Peyronie's disease, where scar tissue causes pain and curvature
Pain arriving only after ejaculation, which behaves differently and is worth separating out
Nerve pain, including the pudendal nerve
Pain referred from the pelvic floor, felt in the penis but generated elsewhere
In testicular and scrotal pain:
Epididymitis, and whether it is genuinely infective
A varicocele
Pain after a vasectomy or a hernia repair, which is recognised and often not warned about
Pain referred from the back, the hip or the pelvic floor
Chronic scrotal pain with normal imaging, which is common and has its own approach
A normal scan there has done its job, which was to exclude what a scan can see. The next step is an examination that includes the pelvic floor and the nerve supply, not a repeat of the same scan.
When it started, what it feels like, what makes it worse, what has been tried and what happened. Most of what is useful is there rather than in another scan.
Only the investigations that are indicated
Not the ones already done twice. I arrange what will change something and say plainly when a test would not.
Pelvic floor physiotherapy
Where muscle is doing the work, often the most effective thing available and badly underused. I work with a pelvic health physiotherapist.
Medication where it fits
The medications used for nerve pain, which work differently from ordinary painkillers. Ordinary painkillers rarely touch this.
The nervous system itself
Long-standing pain changes how the nervous system responds to everything. Working with that is treatment, not a consolation prize.
The sexual and relational part
Fear of pain, avoidance, and what it has done between you and a partner. As a psychosexual therapist I do that here rather than refer it on.
EMDR is emerging as a treatment for chronic pain in its own right, not only for the trauma that sometimes sits behind it. The adapted pain protocols take the pain itself as a target alongside the memory network it belongs to: the injury or the first episode, the investigations, the consultation that went badly. The working model is that experiences which were never fully processed stay stored with their original sensory and emotional charge, and a nervous system still holding that charge goes on generating the signal. So the work is aimed at the somatosensory memory rather than at the tissue. The evidence is early, mostly small trials in chronic back pain and phantom limb pain, and I would call it promising rather than established. I use it where there is something underneath the pain that talking about it has not reached.
A urologist is the right person for a structural problem, a stone or anything surgical, and I refer when there is a reason to. Where the tests are normal and the pain has lasted months, the answer is usually not surgical, and the risk is another loop of investigations that keep coming back clear.
Can this actually be fixed?
Often, substantially, and for some men completely. I would rather not put a figure on that, because the honest answer depends on what is driving it and the published numbers vary widely. What I will not do is promise a cure at the first appointment, because pain that has run a long time usually has more than one thing holding it up and they come apart at different speeds. Where the pelvic floor is the main driver, physiotherapy usually gives a reasonably clear signal within a few months. Where the nervous system side is doing more, it is slower and less linear. You should know inside the first few appointments whether we are on the right track, and I will say so if we are not.
An hour, and most of it is talking. Where the pain is, when it started, what it feels like, what makes it better or worse, and what you have already been through. Send anything you have had done already rather than starting again, because half the value of a first appointment about pain is in what has been ruled out. Then I tell you what I think is going on and how I got there, and we decide together what to do. No referral needed to book.
Is an examination necessary?
It is more useful in pain than in almost anything else I see, because a pelvic floor that is gripping is something I can feel and no scan will report. It is still optional. If you would rather not, say so and nothing follows from it. I explain what I am doing as I go, check in throughout, and you can stop at any point.
The clinic is at Central Health London, 23 Devonshire Place, Marylebone, a quiet and discreet address a short walk from Regent’s Park. Most men arrive anxious and leave relieved. You will be welcomed by reception, offered tea or coffee, and given time to settle before we start.
A first consultation is usually an hour. We go through your symptoms, your medical and family history, and your sexual experience, relationships and lifestyle: the medical, psychological and relational picture together rather than one at a time.
I will ask you a lot of questions. You do not have to answer any of them: saying "I would rather not answer that" is a complete answer and nothing follows from it. A physical examination is sometimes useful, particularly for erection problems, and it is always optional. You stay in control of the appointment throughout.
If you have had recent blood tests, send them ahead. If not I will arrange them, and I will tell you which ones need taking before 11am.
The waiting room at 23 Devonshire Place.
Who tends to benefit most from seeing me
Men in midlife who have not engaged much with healthcare
If you are in your fifties or sixties, have no GP you know well, do not much like going to the doctor, but recognise it is time to take your health seriously, this is a reasonable place to start. I often find things that matter and have been missed.
Gay, bisexual and queer men
If you want help but are wary of seeing someone who is not comfortable talking about gay or queer sex, you can come to someone who does not need it explained, and who will not judge or shame you.
Men who want a thoughtful, whole-person assessment
Men who have tried quick fixes, or had a purely medical or purely therapeutic approach that did not help. I see a lot of men for second opinions. And men of any age and in any kind of relationship who want to understand what is going on rather than be handed a prescription.
About Dr Ben Davis
I am a GP, a sexual medicine specialist and a COSRT-registered psychosexual therapist, working at 23 Devonshire Place, Marylebone, central London, alongside NHS general practice in Hackney.
Most men reading a page like this arrived from a search rather than my homepage, so this is probably the first you have heard of me. The short version: I hold the medical, the psychological and the relational picture together in one appointment, rather than sending you to three people who each see a third of it.
