Painful Ejaculation (Male Dysorgasmia)

Symptoms of Painful Ejaculation

Painful ejaculation, although common, is usually not reported by people with penises. The discomfort can happen during one or both phases of ejaculation:

• Emission phase: During this stage, sperm and fluids are released simultaneously from the prostate gland, testicles, and seminal vesicles to form semen.
• Expulsion phase: Here, the muscles within the pelvic floor contract recurrently to drive semen through the urethra, which is a tube that also expels urine from the body.

Generally, dysorgasmia implies discomfort in the penis and urethra. However, the pain can affect (or sometimes remain confined to) the scrotum, testicles, rectum, lower abdomen, or perineum (the area between the genitals and anus). Apart from the pain, there might be the presence of blood in the semen, a condition known as hematospermia. What sets dysorgasmia apart from other kinds of pain in the male reproductive system is that the discomfort directly results from ejaculation and orgasm.

Causes of Painful Ejaculation

Many factors contribute to painful ejaculation, and sometimes the cause remains unidentified (idiopathic). Even though the causes are rarely life-threatening, the condition can severely affect one’s quality of life, sexual function, and self-esteem. These are the six potential causes that doctors often look at when symptoms of male dysorgasmia are present:

1. Lower Urinary Tract Infections Lower urinary tract infections affect the bladder, bladder neck, prostate gland, urethra, and urinary sphincters, which are muscles regulating urine flow. Many cases of urinary tract infections (UTIs) result from bacteria called Escherichia coli (E. coli), which naturally exists in the body, particularly in the intestinal tract. Other forms of bacteria can also cause UTIs. Risk factors among males are diabetes, the use of a urinary catheter, or an enlarged prostate.
2. Inflammatory Conditions Inflammatory conditions triggered by viral, bacterial, or fungal infections can impact the male reproductive system, such as the testicles, urethra, prostate, and epididymis (the tiny tubes carrying sperm out of the testicles). These comprise sexually transmitted infections (STIs) such as chlamydia, syphilis, gonorrhoea, and trichomoniasis. Moreover, bacteria may be found in the semen or seminal fluid. Semen infections are likely to cause symptoms of painful ejaculation and prostatitis. The infections can also contribute to inflammation in various reproductive organs, resulting in:
• Orchitis: Testicular inflammation
• Prostatitis: Inflammation of the prostate gland
• Epididymitis: Inflammation of the epididymis
• Urethritis: Inflammation of the urethra

These conditions also have noninfectious causes, such as chemical irritants, previous urinary tract surgery, and prolonged horse riding or cycling. Regardless of the contributing factors, inflammation occurring in these reproductive organs can easily lead to pain during ejaculation.

1. Enlarged Prostate An enlarged prostate, sometimes referred to as benign prostatic hyperplasia (BPH), is a disorder that mostly affects older males. It can lead to symptoms such as frequent urination, painful urination, and nighttime urination, among other urinary problems. According to the National Institute of Diabetes and Digestive and Kidney Diseases, prostate enlargement (benign prostatic hyperplasia) can also result in pain after ejaculation.
2. Obstructive Conditions Some conditions can obstruct the path of sperm and seminal fluid from the body. Flow obstruction during ejaculation increases the pressure and can result in severe shooting pain and sometimes urethral bleeding. Possible obstruction contributing factors are:
• Urethral stricture: Narrowing of the urethra due to an injury, infection, or inflammatory disease.
• Ejaculatory duct obstruction: Obstruction of the ejaculatory duct carrying sperm to the urethra can happen due to urinary tract infections, epididymitis, or cysts.
• Seminal vesicle calculi: These are hardened mineral deposits resembling kidney stones, which can block the seminal vesicles (glands producing seminal fluid).
• Inguinal hernia repair: Sometimes, hernia repair in the groin area can lead to nerve compression or scarring/kinking of the vas deferens.
• Vasectomy: This is a surgical birth control method that blocks sperm flow by sealing or cutting the vas deferens, which is the vessel receiving sperm from the epididymis.
• Radical prostatectomy: This is the surgery to remove the seminal vesicles, prostate gland, and sections of the vas deferens. It is often performed in individuals with prostate cancer.
• Pelvic radiation: Radiation therapy mostly used for prostate cancer treatment can result in ducts and vessels scarring and narrowing in the male reproductive tract.
3. Pudendal Neuropathy Also referred to as pudendal neuralgia, pudendal neuropathy is chronic pain that results from damage to the pudendal nerve that serves the pelvis. Nerve compression or entrapment is usually the main cause of this condition. The contraction of ejaculatory muscles can trigger pain during orgasm, particularly in the perineum and lower buttocks. About one out of four males with pudendal neuropathy report painful ejaculation. Pudendal neuropathy causes involve prolonged cycling, sitting, and horse riding, normally over several months or years. Pelvic fractures and chronic constipation can also contribute to the occurrence of pudendal neuropathy.
4. Medications Male dysorgasmia is often associated with particular groups of antidepressant medicines for depression and chronic pain. Discontinuing these medications usually alleviates the symptoms. Antidepressants that can contribute to male dysorgasmia are:
• Anafranil (clomipramine)
• Effexor XR (venlafaxine)
• Asendin (amoxapine)
• Norpramin (desipramine)
• Tofranil (imipramine)
• Prozac (fluoxetine)
• Vivactil (protriptyline)

Also, muscle relaxants with a chemical structure similar to tricyclic antidepressants, like Flexeril (cyclobenzaprine), have been reported to trigger painful ejaculation.

Diagnosis

Since male dysorgasmia is nonspecific with a number of causes, diagnosis often begins with a physical exam and a review of your medical history. The doctor will also ask about the symptoms you have and any medicines you are taking. The physical exam will likely include an examination of your genitals, and probably a digital rectal exam (DRE). DRE involves inserting a gloved finger into the rectum to assess the prostate gland.

Additional common diagnostic tests and procedures are:

• Prostate-specific antigen (PSA) test: The provider can use this blood test to check for a protein known as prostate-specific antigen, which rises when the prostate gland gets inflamed.
• Urinalysis: This involves the evaluation of the urine sample for signs of infection, high blood sugar, bleeding, or kidney disease.
• Urine culture: This uses a urine sample to grow a particular bacteria, virus, or fungus in order to identify and isolate them.
• Pelvic ultrasound: This is a non-invasive imaging method that creates detailed pictures of inner organs like the testicles and epididymis using reflected sound waves.
• Transrectal ultrasound: This form of ultrasound is placed inside the rectum to view the prostate gland or look for blockage of the seminal vesicles or ejaculatory duct.
• Cystoscopy: Involves inserting a tiny, flexible scope (cystoscope) into the urethra to examine if there is urethral stricture or an injury.
• Urethrogram: This specialised type of X-ray involves administering contrast dye through a urinary catheter to better view the urethra and nearby structures.

Depending on the outcomes, more tests may be required.

Who diagnoses painful ejaculation?

Painful ejaculation diagnosis is usually done by a urologist, who is an expert specialising in diseases and conditions of the urinary tract and male reproductive system.

Treatment

How to treat painful ejaculation Painful ejaculation treatment often varies depending on its triggering factors. Addressing the root cause usually improves the symptoms, and sometimes, no further treatment is required apart from time. There are limited direct treatments for male dysorgasmia that consistently provide positive results. However, if the cause is unknown, the doctor might recommend muscle relaxants, anticonvulsant drugs, pelvic floor muscle exercises, or opioid medicines to help alleviate the symptoms.

The table below outlines the available treatments used to address the underlying causes of male dysorgasmia:

Underlying Cause	Type	Treatment Options
Lower urinary tract infections	Bacterial (most common)	Oral antibiotics such as ceftriaxone or penicillin
	Viral	Oral antivirals such as Zovirax (acyclovir)
	Fungal	Oral antifungals such as Diflucan (fluconazole)
Inflammatory conditions	Orchitis	-Oral antibiotics. -Oral NSAIDs to ease swelling and pain. -Cold compress to testicles to minimize swelling. -Supporting the testicles with a jockstrap.
	Prostatitis	-Oral antibiotics. -Oral alpha-blocker medicines such as Flomax (tamsulosin) to ease the bladder neck. -Oral NSAIDs or Tylenol (acetaminophen) to reduce pain and swelling.
	Urethritis	-Orally antibiotics. -Drinking enough fluids
	Epididymitis	Oral antibiotics. -Cold compress to the testicles. -Oral NSAIDs to ease pain and swelling. -Using a jockstrap
Enlarged prostate		-Oral 5-alpha reductase inhibitors like Proscar (finasteride). -Flomax (tamsulosin). -Minimally invasive procedures includingtransurethral resection of the prostate (TURP). - Prostatectomy (surgery to reduce the size of the prostate).
Obstructive conditions	Urethral stricture	-Urinary catheters. -Urethral stents. -Minimally invasive procedures including urethral dilation (urethrotomy). -Urethroplasty (surgical reconstruction of the urethra).
	Ejaculatory duct obstruction	-Minimally invasive procedures such as transurethral resection of the ejaculatory ducts (TURED)
	Seminal vesicle stones	-Minimally invasive procedures such as transurethral seminal vesiculoscopy (TRU-SVS) to eliminate the stone
	Surgical factors such as vasectomy or inguinal hernia repair	-Mostly watching and waiting, as pain often gets better with time. -Oral NSAIDs or Tylenol (acetaminophen) to help with longer-lasting pain.
Pudendal neuropathy		-Oral pain relievers such as NSAIDs and opioids. -Pelvic floor muscle exercises. -Cortisone injections around the pudendal nerve to ease nerve inflammation. -Botox (botulinum) injections to ease muscles near the pudendal nerve. -Surgical decompression of the pudendal nerve
Medicines	Antidepressants	Stopping the medication often improves the symptoms.

When to See a Healthcare Provider

While male dysorgasmia is a worrying problem, it usually does not necessitate emergency care. However, a lower urinary tract infection can become serious if it spreads to the upper urinary tract organs (such as the ureters and kidneys). If not treated, these infections can result in kidney damage, acute kidney failure, or sepsis (a possibly life-threatening inflammatory response to infection).

Seek a doctor as soon as possible if the urinary tract infectionsymptoms occur along with more severe signs like:

• High fever with chills
• Nausea or vomiting
• Uncontrollable shaking
• Serious back or side (flank) pain
• Blood in urine

A Note from MD

Painful ejaculation is generally an indication of a bigger problem requiring treatment. Although you might hesitate to discuss the issue with a doctor or assume it isn’t serious, evading a diagnosis can result in complications if the underlying disorder is untreated. For instance, untreated STIs can cause male infertility in some cases.

Even when the cause is unidentified, symptom management under a urologist’s care can enhance a person’s sex life as well as overall well-being.