Painful Ejaculation: Is This Normal?

Ejaculation that is painful can be debilitating and distressing. This is the unbearable sensation that happens during orgasm. Painful ejaculation, also medically termed dysorgasmia, dysejaculation, odynorgasmia, is quite a common medical condition that can affect up to 25% of male. The pain that is experienced during ejaculation can last for seconds to minutes, or in some cases last up to days. The pain intensity can vary from mild dull pain to severe excruciating sharp pain. 

This is a medical symptom that are under-diagnosed as patients may not openly discuss such embarrassing symptom and also due to the sensitive nature of the clinical presentation (present during orgasm). Despite the fact that most cases of painful ejaculation are not life- threatening, it can significantly affect a man's quality of life, leading to low self-esteem and sexual dysfunction.

This article strives to increase awareness of this medical condition that can affect men, and encourages patients with such symptom to reach out for medical evaluation and treatment.

Normal Physiology of Ejaculation

There are 2 phases for a man to ejaculate:

1. The Emission phase, where the sperm are produced by the testicles, travelled through the vas deferens, together with semen fluid that are produced along the way by the prostate and seminal vesicles.
   
2. The Expulsion phase, where the pelvic floor muscle contracts to facilitate the expulsion of semen and sperm through the urethra and out of the body.

Painful ejaculatory disorders may arise when pain occurs anywhere along this pathway of ejaculation.

What are the symptoms that can also be associated with painful ejaculation?

The pain during ejaculation is being described as pain that occurs in the urethra that may extend to the scrotum, abdomen or the lower perineum. It can range from being a dull ache to an intense great pain that potentially last a few seconds to a few days long. Some men may also notice the presence of blood in the semen while experiencing painful ejaculation.

You should see your health care providers if you have above symptoms for further checkup and treatment.

What are the possible causes of painful ejaculation?

While a painful ejaculation is usually not a dangerous symptom, it can have a negative impact in a person’s sexual wellbeing and esteem. Hence, understanding the cause of a person’s painful ejaculation symptoms can be the first step in regaining a man’s quality of life.

Possible causes include:

1. Infections
   • Lower urinary tract bacterial infection such as E coli spp infection
   • STDs bacterial infections such as Chlamydia Trachomatis, Neisseria Gonorrhoeae, trichomoniasis, Mycoplasma Genetalium, syphilis and etc

2. Inflammation of lower urinary tract structures- inflammation of the prostate, seminal vesicles and testicles
   • Infection causes such as discussed in (1)
   • Non-infectious causes such as irritant, urinary tract surgery/procedure, chronic trauma or irritation from physical activities such as cycling and horse riding.

3. Prostate disorders - Enlargement of prostate or cancer of prostate

4. Obstruction of the lower urinary/ejaculatory tract passage ways
   • Narrowing of the lower urinary connection tubes/urethra
   • Small calcified stones in the seminal vesicle
   • Scarring following abdominal or lower urinary tract surgery, vasectomy surgery, prostate surgery or even localized radiotherapy

5. Nerve disorders due to damage or compression of the nerve
   • Underlying medical condition such as diabetes
   • Trauma following pelvic fracture leading to nerve damage or chronic irritation    from physical activities such as horse riding and cycling 

6. Psychiatry medications such as tricyclic antidepressants (TCAs) or selective serotonin reuptake inhibitors (SSRIs) 

When should I consider seeing my doctor if I experience painful ejaculation?

Although painful ejaculation is not a life-threatening condition, leaving the symptoms unattended can greatly impair a man's quality of life, sexual wellbeing and self-esteem. In some cases, it can also lead to infertility eventually.

You should consider consulting your doctor if you have:

• Painful ejaculation and it affects your quality of life and sexual wellbeing
• Painful urination
• Blood in your semen
• Abnormal urinary flow
• Erectile dysfunction

What do I expect my doctor will do if I have painful ejaculation?

Your doctor will obtain a history of your symptoms and physically examine your genital and perineum region. Sometimes your doctor may also offer a rectal physical examination to palpate the prostate. Depending on individual circumstances, your doctor may offer further tests including: 

• Urine tests to screen for infection, 
  
• Blood tests to screen for prostate cancer and other medical conditions such as diabetes, 
  
• Imagings such as ultrasound and MRI of the prostate or urinary system to rule out structural causes,
  
• In more challenging cases, scopes of the urinary system may be offered to investigate further on the cause of painful ejaculation.

What are the treatments for painful ejaculation?

The treatment of painful ejaculation is dependent on the underlying cause of the symptom. 

• Antibiotics and anti-inflammatory drugs are commonly offered to eradicate underlying infection and alleviate inflammation. 

• Offending medications that potentially exacerbate ejaculation symptoms may be withheld.

• Symptoms of painful ejaculation secondary to prostate enlargement can be treated with medications such as alpha-blockers.

• In more severe cases, surgical intervention may be required to treat underlying structural cause of the condition.

• Lifestyle modification maybe required to avoid exacerbation of symptoms due to recurring irritation of the groin or perineum. Pelvic floor strengthening exercises may be beneficial in alleviating the pain during ejaculation.

In some cases, the underlying cause of painful ejaculation may not be determined. Psychological counselling and cognitive behavioural therapy may be offered in managing the pain. 

What have I learnt today?

• Painful ejaculation can affect men’s quality of life profoundly. It can impair a person’s sexual relationship, causing distress, anxiety, low self-esteem. In some cases, the symptoms may even lead to infertility.
  
• Painful ejaculation can be due to unattended medical conditions.

• Understanding the potential causes of painful ejaculation is key in managing the symptoms.

• Infections such as bacterial urinary infections and STDs are reversible causes of painful ejaculation. 

• Prostate screening and management of prostate disorders are important to manage painful ejaculation.

• In more severe and less common cases, surgical intervention may be required to explore and manage underlying structural cause of painful ejaculation.

Reference

1. Waqar M, Omar K, Moubasher A, Brunckhorst O, Ahmed K. Painful Ejaculation - An Ignored Symptom. Cureus. 2020 Oct 30;12(10):e11253.
2. Illie CP, Mischianu DL, Pemberton RJ. Painful ejaculation. BJU Int. 2007 Jun;99(6):1335-9.
3. Pescatori ES, Farina FP. Painful Ejaculation: A Review. Urologia Journal. 2009;76(4):230-235.