Painful Ejaculation

Painful ejaculation is pain during or immediately after ejaculation. It is felt in the penis tip, perineum, testes, suprapubic area or lower back, and may be burning, aching or colicky.

It is reported by about 1 to 10% of men attending sexual health and urology clinics.

Most causes are inflammatory or obstructive, and many are treatable.

Pathophysiology. Pain arises from contraction of inflamed, obstructed or hypertonic structures during ejaculation.

Causes:

• Prostatitis (acute, chronic bacterial, chronic pelvic pain syndrome), seminal vesiculitis, epididymitis and urethritis.
• Sexually transmitted infection (chlamydia, gonorrhoea, Mycoplasma genitalium), tuberculosis and schistosomiasis of the genital tract.
• Ejaculatory duct obstruction from cysts, calculi or fibrosis.
• Pelvic floor muscle hypertonia and pudendal neuralgia.
• Medications: selective serotonin reuptake inhibitors, serotonin and noradrenaline reuptake inhibitors, and alpha blockers.
• Prostate surgery, brachytherapy and pelvic radiotherapy.
• Bladder neck spasm, benign prostatic enlargement, Peyronie disease and psychogenic causes.

Pain timing (during or after), location, character and duration. Associated lower urinary tract symptoms, perineal pain, penile discharge, fever, haemospermia, reduced semen volume and sexual avoidance. Examination may show a tender prostate or seminal vesicles, epididymal tenderness, or tight pelvic floor muscles.

Fever with perineal pain, urinary retention, or an abscess or fluctuant prostate needs urgent treatment.

• Urinalysis and midstream culture, and first void and midstream urine nucleic acid testing for Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium.
• Semen culture and analysis, including volume.
• Digital rectal examination for prostate tenderness, nodularity and seminal vesicle fullness. Do not massage an acutely inflamed prostate.
• Chronic Prostatitis Symptom Index to grade symptoms.
• PSA only when indicated by age and risk, and not during acute infection.
• Transrectal ultrasound or pelvic MRI for ejaculatory duct obstruction (dilated seminal vesicles over 1.5 cm, cysts, calculi).
• Urine or semen microscopy for Schistosoma eggs in endemic areas, and tuberculosis tests when suggested.
• Pelvic floor assessment by a specialist physiotherapist.

Differential diagnosis.

• Acute and chronic bacterial prostatitis
• Chronic pelvic pain syndrome
• Epididymo orchitis
• Ejaculatory duct obstruction
• Pelvic floor myalgia and pudendal neuralgia
• Urethritis from sexually transmitted infection
• Drug induced painful ejaculation
• Prostate cancer (rare)

• Treat the cause.
• Sexually transmitted infection: ceftriaxone 1 g intramuscularly once for gonorrhoea, plus doxycycline 100 mg orally twice daily for 7 days for chlamydia. Mycoplasma genitalium needs resistance directed treatment. Treat partners and avoid sex until treatment is completed.
• Acute bacterial prostatitis: ciprofloxacin 500 mg orally twice daily for 14 days, or culture directed therapy, with the dose reduced when eGFR is under 50. Admit with intravenous antibiotics for sepsis or retention. Cautions with fluoroquinolones: tendon rupture, QT prolongation, dysglycaemia and neuropsychiatric effects.
• Chronic bacterial prostatitis: culture directed antibiotic with good prostatic penetration, usually ciprofloxacin 500 mg twice daily for 4 weeks or longer, or doxycycline.
• Schistosomiasis: praziquantel 40 mg/kg orally on one day. Tuberculosis: a 6-month antituberculous regimen.
• Chronic pelvic pain syndrome and pain without infection:
  • Tamsulosin 400 micrograms orally once daily after a meal for 6 to 12 weeks.
  • NSAID for short courses (ibuprofen 400 mg every 8 hours for up to 2 weeks).
  • Neuropathic agents: amitriptyline 10 mg at night, increased to 50 mg, gabapentin 300 mg at night, titrated to 900 to 1800 mg daily, or pregabalin 75 mg twice daily, titrated to 150 mg twice daily, reduced when eGFR is under 60.
  • Pelvic floor physiotherapy, 6 to 12 sessions, with relaxation training and avoidance of prolonged sitting.
• Drug related: reduce the dose or switch the antidepressant or alpha blocker with the prescriber.
• Ejaculatory duct obstruction: transurethral resection of the ejaculatory ducts, or drainage of a cyst.
• Post-radiotherapy or brachytherapy: alpha blocker, NSAID and pelvic floor therapy, with urology review.
• Psychosexual therapy when pain persists without a cause.

Monitoring. Review at 4 to 6 weeks for response, culture result and sexual function. Repeat semen analysis if volume was low.

Referral and escalation. Refer to urology for persistent pain, abnormal prostate examination, suspected obstruction, or failure of 3 months of treatment. Urgent referral for sepsis, retention, prostatic abscess or a suspicious prostate nodule.