How is painful ejaculation treated?

Treatment of Painful Ejaculation

The first step in treating painful ejaculation is identifying and addressing the underlying cause: treat infectious/inflammatory causes with antibiotics, discontinue or substitute offending medications, and consider alpha-blockers for prostatitis-like symptoms or BPH-related pain. 1, 2

Initial Diagnostic Approach

When evaluating painful ejaculation, focus your history on:

• Timing and location of pain (perineal, urethral, penile) to differentiate between prostatitis, urethritis, and other causes 1, 3
• Associated lower urinary tract symptoms (LUTS) - approximately 18-20% of men with BPH/LUTS report painful ejaculation, and these men have more severe symptoms than those without ejaculatory pain 2, 4
• Medication history - specifically tricyclic antidepressants, SSRIs, cyclobenzaprine, and alpha-blockers (tamsulosin/silodosin can cause ejaculatory dysfunction) 5, 6
• Recent surgical history - radical prostatectomy and inguinal hernioplasty are known causes 3
• Sexual dysfunction symptoms - men with painful ejaculation have higher rates of erectile dysfunction (72-75%) and reduced ejaculate volume (71-75%) compared to those without pain 4

Treatment Algorithm by Etiology

Infectious/Inflammatory Causes (Urethritis, Prostatitis)

For suspected urethritis or prostatitis, initiate empiric antibiotic therapy immediately:

• Azithromycin 1 g orally single dose OR doxycycline 100 mg twice daily for 7 days for chlamydial urethritis 1
• Add ceftriaxone 125 mg IM if gonococcal infection is suspected 1
• Add metronidazole 2 g orally once for broader coverage 1

For chronic prostatitis/chronic pelvic pain syndrome with persistent pain during or after ejaculation lasting >3 months, consider alpha-blocker therapy: 1

• Alfuzosin 10 mg once daily has demonstrated significant improvement in painful ejaculation, reducing weighted pain scores from 2.2 to 0.8 over 6 months, while also improving LUTS and erectile function 2
• This approach is particularly effective when painful ejaculation coexists with BPH/LUTS symptoms 2, 4

Medication-Induced Painful Ejaculation

If painful ejaculation is medication-related, discontinuation is typically curative:

• Tricyclic antidepressants and cyclobenzaprine are known culprits - symptoms resolve completely upon discontinuation 6
• Alpha-1 blockers (tamsulosin, silodosin) commonly cause ejaculatory dysfunction including retrograde ejaculation 5
• Consider dose reduction or medication substitution before adding additional therapies 1, 5

Post-Surgical Painful Ejaculation

For pain following radical prostatectomy or inguinal hernioplasty, referral to a mental health professional with sexual health expertise should be considered, as psychological factors often contribute 1, 3

BPH-Related Painful Ejaculation

When painful ejaculation occurs in the context of BPH/LUTS:

• Alpha-blocker therapy (alfuzosin 10 mg daily) addresses both LUTS and ejaculatory pain simultaneously 2
• These patients warrant more aggressive treatment as they have more severe symptoms and greater bother than men with LUTS alone 4

Concurrent Sexual Dysfunction Management

Screen for and address erectile dysfunction, as it is present in 72-75% of men with painful ejaculation: 4

• Some acquired premature ejaculation may be secondary to ED and should be treated according to AUA ED guidelines first 7
• Men with painful ejaculation also commonly report reduced ejaculate volume (71-75%), which may improve with alpha-blocker therapy 2, 4

Follow-Up and Monitoring

Patients should return for evaluation if symptoms persist after completing therapy: 1

• For infectious causes, test-of-cure is not routinely recommended unless symptoms persist or reinfection is suspected 1
• Repeat testing for chlamydia/gonorrhea is recommended 3-6 months after treatment due to high reinfection rates 1
• For chronic prostatitis symptoms, reassess at 3 months to determine if alpha-blocker therapy is providing benefit 1, 2

Common Pitfalls to Avoid

• Don't overlook medication history - painful ejaculation from tricyclic antidepressants and cyclobenzaprine is likely underreported but completely reversible 6
• Don't treat empirically without considering the underlying cause - the etiology determines the appropriate intervention 3, 8
• Don't ignore associated symptoms - men with painful ejaculation have significantly higher rates of ED and reduced ejaculate that also require attention 4
• Don't dismiss the impact on quality of life - 88-91% of men with painful ejaculation consider it a significant problem that profoundly affects their well-being 4, 8