What causes pain after sexual activity?

Pain the Day After Sexual Activity

The most important first step is to determine whether this represents a cardiac warning sign, as fatigue the day after sexual activity can indicate inadequate cardiac reserve and should prompt immediate cardiovascular evaluation. 1

Immediate Cardiovascular Assessment

Fatigue or pain the day after sexual activity is a recognized warning sign of cardiovascular disease and requires medical evaluation. 1 This symptom pattern suggests that the cardiac workload during sexual activity (typically 3-5 METs) exceeded the patient's functional capacity. 1

Red Flag Symptoms Requiring Urgent Evaluation

• Fatigue persisting the day after sexual activity 1
• Chest pain during or after sexual activity 1
• Shortness of breath 1
• Rapid or irregular heart rate 1
• Dizziness 1
• Insomnia after sexual activity 1

Patients experiencing any of these symptoms should be evaluated with exercise testing to assess whether they can achieve 5-6 METs without symptoms. 1 Sexual activity is generally safe only for patients who can exercise at 5 METs without angina, excessive dyspnea, ischemic changes, or arrhythmia. 1

Gender-Specific Considerations

In Women

If cardiovascular causes are excluded, pain after sexual activity in women most commonly represents dyspareunia or related sexual pain disorders, which affect approximately 15% of women and have multifactorial etiologies. 2

Common causes include:

• Hormonally associated vestibulodynia 2
• Inflammation-associated vestibulodynia 2
• Overactive pelvic floor muscle dysfunction 2
• Vulvar dysesthesia 2
• Painful bladder syndrome 2

Treatment must address the specific underlying cause identified through examination, as sexual pain disorders are heterogeneous conditions. 2, 3

In Men

In sexually active men under 35 years, post-coital pain should raise suspicion for epididymitis, particularly if accompanied by testicular tenderness or swelling. 1, 4

Diagnostic Evaluation for Epididymitis

• Gram-stained smear of urethral exudate (≥5 polymorphonuclear leukocytes per oil immersion field) 1, 4
• Nucleic acid amplification test for N. gonorrhoeae and C. trachomatis 1, 4
• First-void urine examination for leukocytes 1, 4
• Syphilis serology and HIV testing 1, 4

If epididymitis is suspected, empiric treatment with ceftriaxone 250 mg IM once PLUS doxycycline 100 mg orally twice daily for 10 days should be initiated before culture results. 1, 4

Testicular torsion must be ruled out emergently, especially in younger patients, as this is a surgical emergency. 1, 4 Emergency consultation is indicated when pain onset is sudden and severe. 4

Critical Pitfalls to Avoid

Never dismiss next-day fatigue or pain as simply "overdoing it" without cardiovascular assessment. 1 This symptom pattern specifically indicates that the patient's cardiac reserve was inadequate for the activity level. 1

Do not assume sexual pain is purely psychological or relationship-based. 2, 5 These are legitimate pain conditions with biological, psychological, and social components that require systematic evaluation. 5

In men with testicular or scrotal pain, failure to consider testicular torsion can result in loss of testicular viability. 1, 4 When the diagnosis is uncertain, immediate specialist consultation is mandatory. 1

Management Algorithm

1. First: Screen for cardiovascular warning signs (fatigue, chest pain, dyspnea, palpitations) 1

   • If present → Cardiology referral and exercise testing 1
   • If patient cannot achieve 5-6 METs → Sexual activity may not be safe 1

2. Second: Assess for infectious/inflammatory causes in men 1, 4

   • Unilateral testicular pain/tenderness → Rule out torsion, then treat for epididymitis 1, 4
   • Urethral symptoms → Test for STIs 1, 4

3. Third: Evaluate for sexual pain disorders in women 2

   • Detailed pain characterization (location, timing, quality) 2
   • Examination for vestibulodynia, pelvic floor dysfunction 2
   • Treatment targeted to specific diagnosis 2

Patients should avoid sexual activity until evaluation is complete and any identified conditions are treated. 1, 4