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Also known as
Dysorgasmia, Odynorgasmia, Orgasmalgia, Post-orgasmic pain, Dysejaculation, Male dysorgasmia
Definition
Painful ejaculation is a condition in which a man feels mild discomfort to severe pain during or after ejaculation, and the pain can involve the penis, scrotum and perineum.1 It is also known as dysejaculation, odynorgasmia, post-orgasmic pain, dysorgasmia or orgasmalgia, and it is a common but poorly understood phenomenon associated with sexual dysfunction.2 Pain has been reported mainly in the penis, but also in the testes, rectum or lower abdomen.3 Reported duration varies. One review describes pain that commonly lasts 2 to 24 hours,2 another describes durations from a few seconds up to two days,3 and in a series of 98 men with orgasmic pain, 52% had pain for less than 5 minutes.4 Prevalence has been reported at 1-10% in the general population and may rise to 30-75% among men with chronic prostatitis/chronic pelvic pain syndrome. The EAU Guidelines caution that most of these studies were not scientifically sound and that the condition is probably under-reported.1
Clinical Context
Many medical conditions can cause painful ejaculation, but it can also be idiopathic. Reported associations include seminal vesicle calculi, sexually transmitted infections, prostatic inflammation, prostate cancer, benign prostatic hyperplasia (BPH), prostate surgery, pelvic radiation, herniorrhaphy and antidepressants. Psychological causes are possible, especially if the pain does not occur during masturbation.1 Among 3,700 sexually active men with lower urinary tract symptoms suggestive of BPH, 18.6% reported pain or discomfort on ejaculation, and 88% of them considered it a problem.5 After radical prostatectomy, 12% of 702 men assessed for sexual function complained of dysorgasmia. Symptoms decreased over time, with 26% and 7% of these men still reporting pain at 18 and 24 months.6
Assessment starts with a rigorous medical and sexual history, recording the type and location of the pain and what aggravates or relieves it.2 Examination includes the genitals and a digital rectal examination of the prostate. Investigations range from urinalysis, urine culture and blood tests including PSA to transrectal ultrasound to look for ejaculatory duct obstruction or calculi.3 A neurological and musculoskeletal examination may detect pudendal neuropathy, and magnetic resonance imaging may help in that setting. No obvious cause is found in a significant number of patients despite extensive investigation.2
Treatment is tailored to the underlying cause when one is found. Options include psychotherapy or relationship counselling, withdrawal of suspected agents (drugs, toxins or radiation), or medical treatment such as antibiotics, α-blockers or anti-inflammatory agents. If no cause is identified, behavioural therapy, muscle relaxants, antidepressants, anticonvulsants and/or opioids and pelvic floor exercises may be used.1 Evidence for α-blockers is mixed. In an uncontrolled pilot study, 77% of 98 men with orgasmic pain reported significant improvement with tamsulosin,4 whereas a randomised placebo-controlled trial in men with painful ejaculation as a sole entity found tamsulosin no better than placebo.7 If medical treatment fails, transurethral resection of the prostate, transurethral resection of the ejaculatory ducts and pudendal nerve neurolysis have been suggested. However, there is no strong evidence that surgery improves painful ejaculation, so it must be used with caution.1 Because of its sensitive nature, the symptom is best identified when clinicians ask about it specifically.3