What causes pain inside the penis and head pain after sexual activity?

Pain Inside Penis and Headache After Sexual Activity

You need urgent evaluation to rule out serious causes, but this presentation most likely represents two distinct conditions: urethritis or chronic prostatitis/chronic pelvic pain syndrome causing penile pain, and primary headache associated with sexual activity (PHASA) causing the head pain.

Immediate Evaluation Required

Seek medical attention within 24-48 hours to exclude emergent conditions, particularly if this is the first occurrence or if symptoms are severe 1, 2.

Red Flags Requiring Emergency Evaluation

• Sudden, severe "thunderclap" headache (worst headache of your life) - may indicate subarachnoid hemorrhage, reversible cerebral vasoconstrictive syndrome (RCVS), or arterial dissection 3
• Sudden onset of severe penile pain - may indicate testicular torsion, priapism, or penile fracture 1, 4
• Inability to urinate or blood in urine 5
• Fever, chills, or systemic symptoms suggesting infection 5

Understanding Your Penile Pain

Most Likely Causes

Urethritis (inflammation of the urethra) is the most common cause of internal penile pain after sexual activity 5. This can be caused by:

• Chlamydia trachomatis or Neisseria gonorrhoeae (sexually transmitted infections) 5
• Non-gonococcal organisms including Mycoplasma genitalium, Ureaplasma urealyticum, or Trichomonas vaginalis 5

Chronic prostatitis/chronic pelvic pain syndrome should be considered if pain persists beyond 3 months, especially if accompanied by perineal, pelvic, or ejaculatory pain 5.

Diagnostic Workup Needed

• Urethral swab or first-void urine for nucleic acid amplification testing (NAAT) for gonorrhea and chlamydia 5
• Urinalysis to check for white blood cells and signs of infection 5
• HIV and syphilis testing as part of comprehensive STD screening 5

Treatment Approach

Empiric antibiotic therapy should be initiated immediately after testing, without waiting for results 5:

• Azithromycin 1 g orally as a single dose (preferred for compliance and effectiveness against Mycoplasma genitalium) 5
• OR Doxycycline 100 mg orally twice daily for 7 days 5

Abstain from sexual intercourse for 7 days after single-dose therapy or until completion of 7-day regimen AND until all partners are treated 5.

Understanding Your Headache

Primary Headache Associated with Sexual Activity (PHASA)

PHASA is a benign headache disorder that occurs during or immediately after sexual activity, with a lifetime prevalence of 1-1.6% in the general population 6, 7.

Characteristic Features

• Typically bilateral and occipital (back of head) or diffuse 6, 7, 3
• Can present as either:
  • Dull headache that progressively worsens with sexual excitement 3
  • OR explosive "thunderclap" headache at or around orgasm (more common) 7, 3
• Duration typically 2 hours to several hours 6, 7
• More common in males, usually starting in the third decade of life 7
• Often associated with history of migraine, tension-type headache, or hypertension 7, 3

Critical Distinction: Primary vs Secondary Headache

First-time occurrence of severe headache during sexual activity requires neuroimaging (CT or MRI) to exclude life-threatening causes 3:

• Subarachnoid hemorrhage
• Reversible cerebral vasoconstrictive syndrome (RCVS)
• Arterial dissection
• Vasospasm

Treatment Options for PHASA

Prophylactic treatment with propranolol 40 mg daily is highly effective and should be first-line therapy 6:

• Dramatic improvement typically seen within 2 weeks 6
• Treatment maintained for 6 months, then reassessed 6
• Alternative prophylactic options include topiramate and calcium channel blockers 3

Preemptive treatment (taken 30-60 minutes before sexual activity) 3:

• Indomethacin 25-50 mg
• Triptans (sumatriptan, rizatriptan)

Follow-Up and Partner Management

For Penile Pain

• Return for evaluation if symptoms persist after completing antibiotic therapy - this is not sufficient basis for retreatment without objective evidence of ongoing urethritis 5
• All sexual partners within the preceding 60 days must be evaluated and treated empirically 5
• Repeat testing recommended 3-6 months after treatment due to high reinfection rates 5

For Headache

• If headaches continue despite treatment, consider referral to neurology 3
• Maintain regular follow-up to monitor for recurrence 6

Common Pitfalls to Avoid

• Do not assume penile pain is "just trauma" without STD testing - asymptomatic infections are common 5
• Do not dismiss first-time severe headache during sex as benign without imaging - secondary causes can be life-threatening 3
• Do not resume sexual activity before completing treatment and ensuring partner treatment - this leads to reinfection 5
• Do not ignore persistent symptoms - chronic prostatitis/chronic pelvic pain syndrome may develop if initial treatment is inadequate 5