Male Dyspareunia: Treatment Approach
For men experiencing painful intercourse, the primary step is to identify and treat underlying infectious or inflammatory causes, particularly epididymitis and urethritis in younger men, while addressing chronic pelvic pain syndrome and performance anxiety in those without acute infection. 1
Initial Diagnostic Evaluation
Age-Based Risk Stratification
Men <35 years: Sexually transmitted infections are the most common cause, particularly Chlamydia trachomatis and Neisseria gonorrhoeae causing epididymitis, which typically presents with unilateral testicular pain and is usually accompanied by urethritis (often asymptomatic) 1
Men >35 years: Non-sexually transmitted epididymitis from Gram-negative enteric organisms is more common, especially in those with recent urinary tract instrumentation, surgery, or anatomical abnormalities 1
Essential Testing
- Gram-stained smear of urethral exudate or intraurethral swab to diagnose urethritis (>5 polymorphonuclear leukocytes per oil immersion field) and presumptive gonococcal infection 1
- Nucleic acid amplification test (NAAT) on intraurethral swab or first-void urine for N. gonorrhoeae and C. trachomatis 1
- First-void uncentrifuged urine examination for leukocytes if urethral Gram stain is negative 1
- Syphilis serology and HIV testing with counseling 1
Treatment Algorithm
For Suspected STI-Related Pain (Age <35 or High-Risk)
Empirical treatment should be initiated before culture results are available 1:
- Ceftriaxone 250 mg intramuscularly as a single dose for gonorrhea coverage 2
- Doxycycline 100 mg orally twice daily for 7 days for chlamydia and broader coverage of non-gonococcal urethritis pathogens including Mycoplasma genitalium 1, 2
Critical partner management: All sexual partners within the preceding 60 days must be evaluated and treated with the same regimen regardless of symptoms 2. The patient must abstain from sexual intercourse until 7 days after completing therapy, and partners must also abstain until completing their own 7-day treatment course 2.
For Persistent Pain After Treatment
If pain persists after documented infection clearance:
- Confirm complete eradication with repeat testing if symptoms persist 3
- Rule out reinfection from untreated partners 3
- Consider concomitant infections like Mycoplasma genitalium or Ureaplasma urealyticum that may not respond to initial treatment 3
Do not initiate additional antibiotic therapy without objective evidence of persistent inflammation (documented signs or laboratory evidence) 3. Symptoms alone are insufficient justification for retreatment 3.
For Chronic Pelvic Pain Syndrome
When pain persists beyond 3 months without evidence of active infection 3:
- Performance anxiety is a significant predictor of sexual pain intensity and should be addressed through counseling 4
- Pelvic floor physical therapy may be beneficial for persistent pain and pelvic floor dysfunction 1
- Consider referral to pain management or urology specialists for comprehensive evaluation 5
Common Pitfalls to Avoid
Do not overlook asymptomatic urethritis: Sexually transmitted epididymitis is usually accompanied by urethritis, which is often asymptomatic but detectable on testing 1
Do not delay treatment in high-risk populations: When STD diagnosis in a partner is unknown or the patient may be difficult to locate for follow-up, empirical treatment is warranted 2
Do not continue antibiotics without objective findings: Persistent symptoms without documented inflammation should prompt evaluation for chronic pelvic pain syndrome rather than repeated antibiotic courses 3
Consider testicular torsion urgently: In cases with sudden onset of severe pain, especially in adolescents, testicular torsion must be ruled out immediately as it is a surgical emergency 1