What causes painful ejaculation?

Painful Ejaculation is not an uncommon condition and there are a number of causes including:

• Prostatitis, an inflammatory condition of the prostate gland which can make the prostate feel sore and irritated due to inflammation or infection. It is the most common urologic problem for men younger than 50 years old. For young gay men, this can also happen when they bottom (get fucked) hard and for a long time. Yes, anal sex is one of the risk factors for prostatitis.
  
  Most of the medical literature on painful ejaculation focuses on problems with the prostate. Prostatitis is one common cause.
  Men with prostatitis have swelling and inflammation of the prostate. This swelling is often due to a prostate infection. Prostatitis can also be caused by other issues, such as nerve damage or a urinary tract infection (UTI) that damages the prostate.
  Men with diabetes are more likely to experience nerve damage that causes prostatitis. A condition called benign prostatic hyperplasia (BPH), which causes the prostate to enlarge, may also affect ejaculation. Men with BPH may also experience painful or difficult urination or frequent urges to urinate.
• Infectious or inflammation: Conditions such as orchitis, epididymitis, prostatitis, or urethritis have been found to cause painful ejaculation [17-18]. Including Sexually transmitted infections that may inflame the area around the penis. A wide range of sexually transmitted infections (STIs) can make ejaculation painful. Men may notice a burning sensation when ejaculating, urinating, or both. Chlamydia and trichomoniasis are common culprits.
• Benign prostate hyperplasia: Litwin study showed patients with benign prostate hyperplasia (BPH) were more prone to have painful ejaculation than the normal population [19].
• Seminal vesicle problems The seminal vesicle is a gland where sperm mixes with other fluids to make semen. Problems with this gland, particularly hard growths called calculi, can make ejaculation painful. Seminal vesicle stone: The cause of seminal vesicle stones is still a mystery, but it is seen in patients with chronic infection, prostate cancer, reflux of urine, or diabetes mellitus. The majority of these patients present with painful ejaculation and hematospermia. Diagnosis is made by radiological assessment such as trans-rectal ultrasound and magnetic resonance imaging, MRI, or plain radiographs [21].
• Urethritis, swelling within the urethra which can be from infection or inflammation.
• Kidney stones, cysts and blockages in the ejaculatory duct: It’s possible to develop cysts or stones in the ejaculatory duct. They can block ejaculate, causing infertility and painful ejaculation.
• Nerve damage to the penis, Pudendal neuropathy is a condition in which there’s some damage to a nerve in the pelvis. That can lead to genital and rectal pain. Some things that can affect the pudendal nerve are injury, diabetes, and multiple sclerosis (MS).
  Chronic pelvic pain syndrome: Pudendal neuropathy has been mostly caused by nerve compression and can result in painful ejaculation [6]. Other areas of pain include the penile, scrotal, and peri-anal region. It is thought to be due to pelvic movements during intercourse. The damage mostly happens as the pudendal nerve passes between the sacrotuberous and sacrospinous ligaments [26]. Twenty-four percent of patients suffering from chronic pelvic pain syndrome (CPPS) were found to have ejaculatory pain regularly [27].
• Psychological problems. In some cases, the cause can’t be determined. If you don’t have pain when you masturbate, it could be emotionally based. Consider seeing a therapist to explore this further. Depression, anxiety, and stress can radically change a man’s sex life. Likewise, problems in a relationship may manifest as physical symptoms, including painful ejaculation. Men who experience no pain when they masturbate may have painful ejaculation because of emotional or relationship problems.
• Antidepressant drugs can cause sexual dysfunction, including painful ejaculation. It was noticed with imipramine, desipramine, clomipramine, protriptyline, amoxapine, fluoxetine, and venlafaxine [28]. Muscle relaxants such as cyclobenzaprine was also reported to cause painful ejaculation [29]. Stopping these medications have shown improvement in patient symptoms.

Painful ejaculation and urination

Some people who experience painful ejaculation may also experience painful urination. When this happens, the cause may be one of these underlying problems:

• prostatitis
• BPH
• trichomoniasis
• chlamydia

Many nerves and tissues are involved in both ejaculation and urination. As a result, any conditions, injuries, or procedures that affect this area of the body could result in painful ejaculation and urination.

How to take history diagnose painful ejaculation?

Complete medical history taking should consist of these questions;

• How long have you experienced pain with orgasm?
• How long does it last?
• Do you produce ejaculate or do you have dry orgasm?
• What other symptoms do you have?
• Does it hurt or burn when you urinate?
• Does your urine look normal?
• If you have anal sex are you top or bottom?
• If you're bottom, do you get fucked hard?
• Are you currently taking any medications?
• If you do chemsex, what are your favourite drugs such as weed, ice, E, ketamine, GHB?
• How much water do you drink during chemsex?
• Have you ever been treated for cancer?
• Is there a family history of prostate cancer?
• Do you have diabetes?

How to find the cause of painful ejaculation?

To find the causes of painful ejaculation, we follow the anatomy and physiology of male reproductive system.
The major organs responsible for ejaculation are prostate gland, urethra following the possible causes.

Diagnosing Prostatitis involves ruling out other conditions as the cause of your symptoms and determining what kind of prostatitis you have. Your doctor will ask about your medical history and your symptoms. He or she will also do a physical exam, which will likely include a digital rectal examination. A pelvic exam, including a prostate exam, can assess for prostatitis, BPH, and injuries.

Initial diagnostic tests might include:

• Urine tests. Your doctor might have a sample of your urine analyzed to look for signs of infection in your urine (urinalysis). Your doctor might also send a sample of your urine to a lab to determine if you have an infection.
• Blood tests. Your doctor might examine samples of your blood for signs of infection and other prostate problems.
• PSA. prostate-specific antigen test to assess for prostate problems. This substance tends to rise in men with certain prostate conditions, including prostate cancer.
• Post-prostatic massage. In rare cases, your doctor might massage your prostate and test the secretions.
• Imaging tests. In some cases, your doctor might order a CT scan of your urinary tract and prostate or a sonogram of your prostate. CT scan images provide more detailed information than plain X-rays do. A sonogram is the visual image produced by an ultrasound.

To look for signs of urethritis and/or kidney stones and urinary tract infeciton or STIs we perform:

• Urinalysis
• Urine PCR multiplex for gonococcal infection and non-gonococcal infections such as chlamydia, herpes, syphilis, ureaplasma, mycoplasma, trichomoniasis.
• A urethral swab may be taken to see if there is an infection, such as a sexually transmitted infection. But we don't need to do urethral swab anymore because urine PCR is a superior diagnostic test, non-invasive and painless.

How to treat painful ejaculation ?

All causes of painful ejaculation should be investigated by a doctor so the best treatment can be given.

If no physical cause is found, some behavioural techniques to relax the muscles in the pelvic area may help some men. When the cause is prostatitis the use of medications such as ‘alpha-blockers’, muscle relaxants, analgesics, and some anti-inflammatory drugs may help. Specific antiviral and antibiotic medications can be given if the cause of painful ejaculation is due to an infection.

If the cause is psychological, counselling may help deal with any underlying concerns.

Treatment will depend on the cause. Underlying diseases, such as diabetes and MS, must also be addressed.

Treatment for bacterial infection

• An extended course of oral antibiotics is usually necessary.
• Over-the-counter NSAIDs or prescription pain medications can help reduce swelling and ease pain.
• For serious infection, you may need intravenous antibiotics or even hospitalization.

Treatment for cysts or stones

• Blockages can be surgically removed in a procedure called transurethral resection of the ejaculatory ducts.

When the cause is antidepressant medications

• Don’t stop taking your medications without doctor supervision. Doing so can make your depression worsen.
• Work with your doctor to find an alternative drug. It may take some time to find the right drug and dosage.

Treatment for pudendal neuropathy

• Nerve blockers, numbing agents, and steroids can help control pain.
• A physical therapist can instruct you on how to strengthen your pelvic floor muscles.
• In some cases, surgery can be performed on the compressed nerve.

Treatment for prostate cancer

• Treatment options depend on type, stage, and aggressiveness of the cancer.
• Some prostate cancers are very slow growing, requiring minimal treatment along with active surveillance.
• Prostate cancer can be treated with radiation therapy, hormone therapy, vaccine treatment, and chemotherapy.
• Surgery may be needed to remove part or all of the prostate.

Treatment for trichomoniasis

• Treatment with antibiotics is usually all that’s needed.
• Because trichomoniasis is an STD, sexual partners should be checked and treated.

When it’s caused by emotional or psychological issues

If there’s an emotional or psychological reason behind painful ejaculation, therapy may prove beneficial.

When treatment fails, or a doctor cannot figure out the cause, a man can try some alternative strategies that may reduce the pain. Some options include:

• sex therapy
• pelvic floor exercises to strengthen the muscles involved in ejaculation
• pain medication
• muscle-relaxant medications
• anticonvulsant medications