What causes pain after ejaculation in adult males?

Pain After Ejaculation in Adult Males

Pain after ejaculation is most commonly caused by chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), though other etiologies including ejaculatory duct obstruction, medication side effects, post-surgical complications, and rarely post-orgasmic illness syndrome must be systematically excluded. 1, 2, 3

Primary Differential Diagnosis

Chronic Prostatitis/Chronic Pelvic Pain Syndrome

• CP/CPPS is the leading cause of post-ejaculatory pain, characterized by pain in the perineum, suprapubic region, testicles, or penile tip that is specifically exacerbated by ejaculation 1, 4
• Pain may be perceived throughout the pelvis including the urethra, and can radiate to the lower abdomen and back 1
• This condition overlaps significantly with interstitial cystitis/bladder pain syndrome in men, particularly when bladder-related pain predominates 1
• Prevalence of painful ejaculation ranges from 1-25% in the general male population, though it remains underdiagnosed due to patient reluctance to report 2, 3

Post-Orgasmic Illness Syndrome (POIS)

• POIS presents with systemic flu-like symptoms occurring within minutes to hours after ejaculation, lasting 3-7 days 5
• This is an auto-immune condition triggered by specific cytokines released in response to seminal fluid antigens from prostatic tissue 5
• Distinguished from localized pain syndromes by its systemic manifestations including fatigue, cognitive impairment, and flu-like symptoms 5

Structural and Obstructive Causes

• Ejaculatory duct obstruction causes pain by creating back-pressure during emission 2, 3
• Seminal vesicle stones or pathology can produce sharp, localized pain with ejaculation 2
• Lower urinary tract symptoms (LUTS) and benign prostatic hyperplasia (BPH) are associated with ejaculatory pain 2, 3

Post-Surgical Etiologies

• Radical prostatectomy can result in painful ejaculation or orgasm-associated pain even without ejaculate 2, 3
• Inguinal hernioplasty has been reported as a cause of post-ejaculatory pain 2

Pharmacologic Causes

• Antidepressants, particularly SSRIs, are associated with ejaculatory pain as a side effect 2, 3
• This should be distinguished from other SSRI-related sexual side effects like delayed ejaculation 1

Psychogenic Causes

• Involuntary spasm of genital muscles triggered by psychosexual conflicts can produce post-ejaculatory pain 6
• History of sexual abuse or unresolved psychosexual issues may manifest as ejaculatory pain 2, 6
• This represents the mildest form on a continuum of psychogenic ejaculatory disorders 6

Clinical Assessment Algorithm

History Taking

• Specifically ask about ejaculatory pain, as patients rarely volunteer this information due to embarrassment 3, 7
• Determine timing: pain during ejaculation versus post-ejaculatory pain versus systemic symptoms hours later 5, 3
• Assess pain location: perineal, urethral, penile tip, testicular, suprapubic, or diffuse pelvic 1, 2
• Evaluate associated urinary symptoms: frequency, urgency, dysuria, incomplete emptying 1, 3
• Review medication history, particularly antidepressants 2, 3
• Document surgical history including prostate surgery and hernia repairs 2, 3
• Screen for psychological health issues including anxiety, depression, and sexual trauma 1, 2

Physical Examination

• Perform focused genital and digital rectal examination to assess prostate tenderness, nodularity, or asymmetry 1
• Palpate for inguinal hernias or surgical complications 2
• Assess for urethral discharge or meatal abnormalities 3

Diagnostic Workup

• Urinalysis and urine culture to exclude infection 3
• Post-void residual if obstructive symptoms present 3
• Consider transrectal ultrasound if ejaculatory duct obstruction suspected (dilated seminal vesicles, midline prostatic cysts) 2, 3
• Semen analysis if fertility concerns or to document ejaculatory duct obstruction 2
• Cystoscopy is not routinely indicated unless hematuria or other concerning features present 1

Treatment Approach

For CP/CPPS-Related Pain

• Treat according to chronic prostatitis protocols, recognizing that pain exacerbated by ejaculation is a defining characteristic 1, 4
• Alpha-1 adrenergic antagonists may provide benefit for associated LUTS and potentially ejaculatory pain 1
• Multimodal therapy including pelvic floor physical therapy, anti-inflammatory agents, and neuromodulators 1

For Ejaculatory Duct Obstruction

• Transurethral resection of ejaculatory ducts (TURED) for documented obstruction with dilated seminal vesicles 2, 3

For Medication-Induced Pain

• Consider switching or discontinuing offending antidepressants if clinically appropriate 2, 3
• Coordinate with prescribing psychiatrist for medication adjustments 1

For Psychogenic Pain

• Referral to mental health professional with expertise in sexual disorders 1, 6
• Sex therapy may address underlying psychosexual conflicts 6
• Pelvic floor physical therapy for muscle spasm component 6

For POIS

• Hyposensitization protocols using autologous semen have shown promise in case reports 5
• Antihistamines and NSAIDs may reduce symptom severity 5

Critical Pitfalls to Avoid

• Do not dismiss the complaint - this symptom profoundly impacts quality of life and sexual function, yet is frequently minimized by clinicians 2, 3, 7
• Do not assume infection without evidence - chronic prostatitis/CPPS is typically non-bacterial and antibiotics are not indicated without documented infection 1, 4
• Do not overlook medication review - antidepressants are a common iatrogenic cause that is easily modifiable 2, 3
• Do not confuse with premature ejaculation - these are distinct conditions, though they may coexist 1
• Do not ignore partner involvement - shared decision-making and partner inclusion improves outcomes in ejaculatory disorders 1