What causes painful orgasms and how are they treated?

Painful Orgasm: Causes and Treatment

Painful orgasm requires a systematic evaluation to identify the underlying cause, with treatment directed at the specific etiology—whether urogenital pathology, medication-induced, pelvic floor dysfunction, or psychogenic factors. 1, 2

Causes of Painful Orgasm

In Men

Painful ejaculation/orgasm affects 1-9.7% of men and has profound quality of life impacts. 2 The primary causes include:

• Prostate and seminal vesicle pathology: Lower urinary tract symptoms/BPH, prostatitis, ejaculatory duct obstruction, and seminal vesicle stones 2
• Post-surgical complications: Radical prostatectomy and inguinal hernioplasty 2
• Medication-induced: Antidepressants (particularly SSRIs) are common culprits 1, 2
• Psychogenic factors: Psychosexual conflicts and history of sexual abuse 2

In Women

Painful orgasm in women is part of the broader spectrum of female sexual dysfunction affecting 40-50% of women. 3 Key causes include:

• Pelvic floor dysfunction: Associated with pelvic pain, urinary/bowel incontinence, and sexual dysfunction 1
• Vaginal/vulvar pathology: Vaginal atrophy, scarring from radiation or surgery, vestibular gland dysfunction 1
• Hormonal deficiency: Low estrogen causing vaginal dryness, reduced lubrication, and altered nitric oxide regulation 1
• Interstitial cystitis/bladder pain syndrome: Pain throughout pelvis including urethra, vulva, vagina, and rectum that worsens with bladder filling 1
• Medication effects: SSRIs, narcotics, and hormone therapies 1, 4
• Psychological factors: Anxiety, depression, body image concerns, and relationship issues 1, 4

Treatment Approach

For Men

First-line management involves identifying and modifying contributing medications, particularly antidepressants. 1

• Medication adjustment: Replace, adjust dose, or stage cessation of medications contributing to delayed/painful ejaculation 1
• Testosterone evaluation: Check morning testosterone levels, as low testosterone correlates with ejaculatory dysfunction; consider replacement if biochemically low 1
• Behavioral modifications: Modify sexual positions or practices to increase arousal 1
• Mental health referral: Refer men with lifelong or acquired delayed ejaculation to a mental health professional with sexual health expertise 1

For Women

Treatment must be directed to the specific type of dysfunction identified during evaluation. 1, 4

For Pain-Related Symptoms:

• Pelvic floor physical therapy: First-line treatment for genito-pelvic pain disorders, improving sexual pain, arousal, lubrication, orgasm, and satisfaction 1, 3
• Vaginal lubricants and moisturizers: Water-, oil-, or silicone-based products for vaginal dryness and sexual pain 1
• Topical anesthetics: Lidocaine applied to vulvar vestibule before penetration for dyspareunia 1
• Vaginal estrogen: Most effective treatment for vaginal dryness-related dysfunction in postmenopausal women (pills, rings, or creams) 1
• Vaginal DHEA (prasterone): FDA-approved for vaginal symptoms; improves sexual desire, arousal, pain, and overall function 1, 4
• Vaginal dilators: For pain with sexual activity or vaginal stenosis from radiation/surgery 1

For Orgasmic Difficulties:

• Cognitive behavioral therapy: Strong evidence for improving sexual function, particularly effective in cancer survivors 1, 3
• Sex therapy: Combined with CBT for orgasmic disorders 3
• Sexual aids: Vibrators or clitoral stimulatory devices for orgasmic difficulties 1, 4

Pharmacological Options:

• DHEA: 10-50mg daily for sexual desire and function 4
• Other medications for low desire: Androgens, bupropion, buspirone, flibanserin, or bremelanotide 1, 4

Critical Evaluation Steps

Identify prescription medications that may contribute, particularly hormone therapy, narcotics, beta blockers, and SSRIs. 1, 4

Assess traditional risk factors including cardiovascular disease, diabetes, obesity, smoking, and alcohol use. 1, 4

Evaluate menopausal status and symptoms, as vaginal dryness significantly impacts sexual function. 1, 4

Screen for psychological factors including anxiety, depression, body image concerns, and relationship issues. 4

Important Caveats

Avoid hormonal treatments in survivors of hormone-sensitive cancers without careful consideration of risks and benefits. 1, 4 For these patients, non-hormonal options like vaginal moisturizers, pelvic floor therapy, and CBT should be prioritized. 1

Do not use PDE5 inhibitors (sildenafil) for female sexual dysfunction due to lack of evidence for effectiveness. 1, 4

Recognize that painful orgasm carries high personal distress and represents a legitimate request for medical help requiring competent interpretation and appropriate management. 2