Male pelvic pain: the role of psychological factors and sexual dysfunction in a young sample

Methods

The current study is based on cross-sectional data from a research project on psychological and sexual health in younger men. Data was collected through a survey consisting of self-report scales and questions which was distributed online. Participants had to be men between 18 and 40 years old, and were self-recruited via an advertisement in social media. The study was regarded as ethically sound by the Regional Ethical Committee in Uppsala (2018/152).

Demographic data was collected on age, place of birth, highest level of education, as well as information on relationship status, sexual orientation, and gender.

Pelvic pain was defined as pain in the penis (shaft, glans, and foreskin), testicles, perineum, groin, and/or lower abdomen. The presence of pelvic pain was assessed with the binary question “Have you during the last 6 months experienced any pain in the pelvic region?.” If participants indicated pain, pain intensity was measured on a 10-point scale (1 = Low; 10 = High). Pain duration was estimated by four pre-fixed options: “0–3 months,” “3–6 months,” 6–12 months,” and “Over a year.”

Anxiety and depressive symptoms were measured using the Hospital Anxiety and Depression Scale (HADS) [28]. It contains two subscales, each subscale ranging from 0 to 21. The Swedish version of HADS has shown good psychometric properties [29].

To measure catastrophic thinking, the catastrophizing subscale was used from the Safety Behaviors and Catastrophizing Scale [30], with scores ranging from 5 to 30. The subscale has been shown to have good psychometric properties [30].

Premature ejaculation was measured using the Premature Ejaculation Diagnostic Tool (PEDT) [31]. The scores of the PEDT can range from 0 to 20. PEDT has shown acceptable internal consistency [31].

To measure erectile dysfunction, the International Index of Erectile Function-5 (IIEF-5) [32] was used. This is an abbreviated version of the original 15-item questionnaire, which has shown good psychometric properties [33]. The scores of the IIEF-5 can range from 1 to 25.

Sexual satisfaction was measured using the Global Measure of Sexual Satisfaction scale (GMSEX) [34], which was modified to also include respondents not currently in a relationship. The scores of the GMSEX can range from 5 to 35. GMSEX has shown good psychometric properties [34].

Six independent t-tests were then conducted to compare those who reported pelvic pain and those who did not. Effect sizes were calculated using Hedges’ g. The pain group was then divided into two groups of high and low pain intensity using the first and fourth quartile of the pain intensity measure, and compared using six independent t-tests. Effect sizes were calculated using Cohen’s d. A Bonferroni correction was used to control for the risk of family-wise error, and the alpha level was accordingly set to 0.008.

A hierarchical multiple regression was conducted (n=369) to investigate the association between depressive symptoms, anxiety, and catastrophizing and pain intensity. The order of which the psychological factors were inserted in to the model was chosen dependent on the strength of their correlation with pain intensity.

All analyses were made with IBM SPSS Statistics 25.

Results

Discussion

This study shows that psychological factors are important in the experience of male pelvic pain. Men with pelvic pain reported higher levels of catastrophizing and anxiety than men without pelvic pain. They also suffered from premature ejaculation to a greater extent. Furthermore, men with higher levels of pain expressed more anxiety, catastrophizing and symptoms of depression compared to men with lower levels of pain. Finally, catastrophizing and depressive symptoms significantly predicted pain intensity in men with pelvic pain, explaining approximately one tenth of the variance.

While this is not a study of prevalence due to the self-selected sample, it is interesting to note that 14% reported pelvic pain within the last 6 months. This may reflect a possible selection bias of the sample, but it also underscores the fact that the study includes non-clinical levels of pain (mean pain intensity = 3.42). Despite the participants young age, a large portion of the men suffering from pelvic pain reported a duration of more than 3 months, classifying it as a chronic condition [35], yet with low intensity. This would indicate that the majority do not suffer from easy-to-treat conditions of a clear medical origin. This emphasizes that male pelvic pain is a fairly common, yet still ignored, problem within a young population.

The major findings of this study correspond with the fear-avoidance model of pain, which was originally designed to explain the role of psychological factors in the development and maintenance of chronic back pain [36] but has since then gained support in other pain populations (e.g., Refs. [37, 38]). In line with this model, our results show that men with pelvic pain display elevated levels of catastrophizing and that it is a significant predictor of heightened pain levels. Out of the included psychological factors, catastrophizing had the strongest association with pain intensity, replicating the central role of catastrophizing found in other pain populations [16, 39]. Anxiety levels were also found to be increased in our sample. It is however surprising that depressive symptoms were not significantly different between men with and without pelvic pain, contradicting earlier studies (e.g., Refs. [40, 41]). This is further complicated by the fact that depressive symptoms and not anxiety was found to predict pain intensity. Still, these findings are understandable in the context of the fear avoidance model. Considering the participants young age, it is reasonable to believe they are in an earlier phase of the pain process, not yet reaching the depressive stage. As such, the regression model may represent the fact that anxiety is more prominent in the early development of pain, while depression maintains or worsens pain at later stages. It should however be noted that the two subscales of HADS were highly correlated within our sample. In fact, more recent studies on the HADS-scale indicate that anxiety and depression subscales do not represent two distinct constructs [42]. Nevertheless, the current findings point to a need for further testing the importance of fear-avoidance variables in male pelvic pain.

Premature ejaculation was the only sexual variable that differed between men with and without pelvic pain. Premature ejaculation is more common in younger men as compared to erectile dysfunction, which might explain this finding. Anxiety about sexual performance is believed to be a cause of premature ejaculation [43] and is likely to increase with pelvic pain, potentially explaining the link between these factors. While premature ejaculation was more common in the pelvic pain group, sexual satisfaction was not significantly different. This could be due to the non-clinical levels of premature ejaculation, or perhaps because these men find alternative ways of being intimate with a partner, which has been suggested to sustain sexual satisfaction in women with genital pain [44].

The role of psychological factors is crystalized when comparing the high and low pain group, as the differences in sexual well-being diminishes from the first analysis while all psychological factors become more pronounced. This suggests that sexual variables may play a limited role in male pelvic pain, while psychological factors are present during each stage of the pain development.

The greatest strength of this study is its large and heterogenous sample, which offers large statistical power and generalizability. Furthermore, the focus on men in family-forming ages is a unique contribution to the pelvic pain literature, which has mainly covered older populations. This study applies a broad definition of pain based on self-report, which is a strength given that it increases external validity. However, it is difficult to compare our results to other studies which usually focus on older clinical populations. The cross-sectional nature of the data is a prominent limitation as it does not allow for causal explanations. Additionally, although our results show that psychological factors matter, they only explain of a small portion of the variance. Lastly, the sample in this study is not a representative sample of Swedish men and the generalizability of these results is therefore unknown.

More research on male pelvic pain is direly needed. Firstly, prospective longitudinal studies are required to gain knowledge of the development and maintenance of male pelvic pain. Secondly, we encourage the use of theoretical models derived from the pain psychology field to further the understanding of this complex issue. Lastly, more research is needed to tease apart the heterogenous group of men suffering from pelvic pain. The phenotype of male pelvic pain varies widely [45] and a further understanding of possible subgroups together with longitudinal and theoretical work would inform treatment development.

In conclusion, in this large sample of younger pelvic pain sufferers, elevated levels of psychological distress, and to some extent sexual dysfunction, were found. These findings indicate that non-medical variables are important in understanding the pain experience and should be further investigated as driving forces in the development and maintenance of male pelvic pain. Theoretical models such as the fear-avoidance model may guide research and bridge the current gap between male pelvic pain and other advances in the chronic pain literature.