What are the causes of painful ejaculation?

Causes of Painful Ejaculation

Painful ejaculation can be caused by various conditions including prostatitis, benign prostatic hyperplasia, ejaculatory duct obstruction, medication side effects, and psychological factors. Understanding these causes is essential for proper diagnosis and management of this distressing condition.

Common Causes of Painful Ejaculation

Genitourinary Causes

• Prostatitis and chronic pelvic pain syndrome: Inflammation or infection of the prostate is a leading cause 1
• Benign prostatic hyperplasia (BPH): Enlargement of the prostate can cause ejaculatory pain 2
• Ejaculatory duct obstruction: Blockage in the ejaculatory ducts can lead to painful ejaculation 2
• Urinary tract infection: Inflammation of the urethra or bladder can cause pain during ejaculation
• Prostate or seminal vesicle stones: Calcifications can cause mechanical irritation during ejaculation 2

Post-Surgical Causes

• Post-radical prostatectomy: Surgical intervention for prostate cancer can lead to painful ejaculation 2
• Post-inguinal hernioplasty: Nerve damage or scarring from hernia repair can cause pain 2

Medication-Related Causes

• Antidepressants: SSRIs, TCAs, MAOIs, and other antidepressants can cause painful ejaculation 3
• Alpha-blockers: Medications like tamsulosin can cause abnormal ejaculation, including ejaculation disorders and retrograde ejaculation 4

Neurological Causes

• Central neuropathic pain: Spinal cord injuries can lead to painful ejaculation 5
• Peripheral neuropathy: Nerve damage affecting genital sensation

Inflammatory/Infectious Causes

• Chronic pelvic pain syndrome: Non-bacterial inflammation of the prostate and surrounding structures 6
• Seminal vesiculitis: Inflammation of the seminal vesicles
• Epididymitis: Inflammation of the epididymis

Psychological Causes

• Psychosexual conflicts: Psychological issues can manifest as physical pain during ejaculation 2
• Sexual abuse history: Past trauma can lead to painful sexual experiences 1
• Depression and anxiety: Mental health conditions can contribute to sexual pain 1

Diagnostic Approach

The American Urological Association recommends the following diagnostic approach 1:

1. Detailed sexual history:

   • Onset and duration of symptoms
   • Relationship to specific partners or sexual activities
   • Location of pain (perineum, urethra, penis)
   • Timing of pain (during or after ejaculation)

2. Medical history:

   • Current medications (especially antidepressants)
   • Previous urological surgeries
   • History of psychological conditions

3. Physical examination:

   • Focused genital and prostate examination
   • Neurological assessment of genital area

4. Additional testing (for acquired painful ejaculation):

   • Urinalysis and urine culture
   • Expressed prostatic secretions
   • Hormonal assessment (testosterone levels)
   • Post-ejaculation urinalysis (to check for retrograde ejaculation)

Management Considerations

Treatment should be directed at the underlying cause:

• Prostatitis/pelvic pain: Antibiotics for bacterial causes; anti-inflammatories, alpha-blockers, and pelvic floor physical therapy for non-bacterial causes
• Medication-induced: Dose reduction, medication switching, or addition of tamsulosin may help resolve symptoms 3
• Neurological causes: Neuropathic pain medications like topiramate may be effective 5
• Psychological causes: Psychotherapy and sexual counseling
• Post-surgical: Pain management and time for healing

Clinical Pearls

• Painful ejaculation has a prevalence of 1-25% in the general population but is likely underreported due to embarrassment 7
• The condition significantly impacts quality of life and can lead to sexual avoidance and relationship problems 2
• For medication-induced painful ejaculation, tamsulosin has been reported to provide relief in some cases, though this is counterintuitive since tamsulosin itself can cause ejaculatory disorders 3
• Frequent ejaculation may exacerbate symptoms in some men with chronic pelvic pain syndrome due to accumulation of free radicals and lactic acid in the pelvic muscles 6

Understanding the diverse causes of painful ejaculation is crucial for proper diagnosis and management of this distressing condition that significantly impacts men's quality of life and sexual function.