Male dyspareunia

INTRODUCTION — The term “dyspareunia” refers to pain associated with sexual intercourse, which can affect men as well as women and cause significant psychologic distress. Male dyspareunia is defined as recurrent or persistent genital or pelvic pain with sexual activity or sexual dysfunction that is present for three months or longer [1]. The condition often leads to embarrassment and may be difficult for the patient and clinician to discuss openly.

Most studies describing male dyspareunia are small case reports. Few long-term studies have been published, with the majority of reports on associated conditions such as chronic prostatitis or Peyronie's disease.

This topic will focus on the epidemiology, etiology, classification, diagnosis, and management of male dyspareunia that is not the result of infectious conditions (eg, acute urethritis, acute cystitis, acute prostatitis), which are discussed elsewhere. (See "Urethritis in adult males" and "Acute simple cystitis in adult and adolescent males" and "Acute bacterial prostatitis".)

A general overview of male sexual dysfunction, chronic prostatitis/pelvic pain in men, and dyspareunia in women are also discussed separately. (See "Epidemiology and etiologies of male sexual dysfunction" and "Chronic prostatitis and chronic pelvic pain syndrome" and "Female sexual pain: Evaluation".)

EPIDEMIOLOGY — Studies have reported that approximately 1 to 5 percent of male patients suffer from pain with sexual intercourse [2-4]. However, because of the social stigma associated with male sexual disorders, underreporting appears to be common. It is not known whether the low reported incidence of dyspareunia in males represents a lack of disclosure or reflects the true infrequency of this condition. In the absence of an identifiable genitourinary abnormality, uncircumcised men are more likely than circumcised men to report dyspareunia [5]. This association is not entirely explained by greater physical trauma associated with sexual intercourse in uncircumcised men.

ETIOLOGY AND CLASSIFICATION — The male patient complaining of pelvic pain during sexual activity presents a challenge for the primary care practitioner because of the lack of a uniformly accepted classification system. In general, male dyspareunia can be divided into four broad categories based upon the underlying etiology (table 1) [1]:

●Isolated ejaculatory pain

●Chronic prostatitis/chronic pelvic pain

●Medical causes

●Other causes of sexual pain

Isolated ejaculatory pain — Painful ejaculation is a common type of ejaculatory dysfunction [6] (see "Epidemiology and etiologies of male sexual dysfunction", section on 'Ejaculatory disorders'). The incidence of painful ejaculation in men age 50 years and older ranges from 1.0 to 6.7 percent. The incidence increases in men with other lower urinary tract symptoms [7,8].

There are multiple causes of painful ejaculation (table 2). Painful ejaculation sometimes results from ejaculatory duct obstruction [9]. Common presentations of painful ejaculation can include penile pain, perineal ache, or suprapubic discomfort occurring during or after the ejaculatory period. Pain is sometimes experienced in the testicular or glans area of the penis immediately after ejaculation or may result from perineal muscle spasm. Atypical pain with ejaculation can also occur in the abdomen, urethral meatus, or rectum. Intense perineal discomfort immediately after ejaculation can occur without evidence of infection or trauma [10].

Painful ejaculation can have a significant impact on quality of life, negatively affecting patient self-esteem and reducing his desire for sexual intercourse [11]. Among men who report painful ejaculation, 90 percent considered this condition to be a serious problem [8,12].

Chronic prostatitis/chronic pelvic pain syndrome — The chronic prostatitis/chronic pelvic pain syndrome, characterized by urologic symptoms and/or pain in the pelvic region without an identifiable cause, is frequently associated with male dyspareunia, but research in this area is limited. This topic is discussed separately. (See "Chronic prostatitis and chronic pelvic pain syndrome".)

Medical causes — Several medical causes of male dyspareunia have been described in case reports and small cohort studies.

●Peyronie's disease – Peyronie’s disease is the formation of an inelastic scar or plaque of the tunica albuginea that may cause a pathological curvature of the penis and painful erection. It is a common cause of chronic dyspareunia in men [13]. (See "Peyronie's disease: Diagnosis and medical management".)

●Phimosis – Phimosis is an abnormal constriction of the opening in the foreskin which leads to inability to retract the foreskin in the uncircumcised male and can cause discomfort with intercourse [14]. (See "Balanitis in adults", section on 'Phimosis'.)

●Frenulum breve – Frenulum breve is a shortened frenulum, which may restrict the glans in the erect state and cause pain with erection and intercourse.

●Herniorrhaphy sequelae – Approximately 3 percent of males age 18 to 40 years of age reported moderate to severe pain-related sexual dysfunction (largely related to pain with ejaculation) following groin hernia repair in a nationwide Danish survey [15]. Among patients with dyspareunia, 8.5 percent wanted to talk to a clinician about their problem, but only 1.8 percent did so. (See "Post-herniorrhaphy groin pain".)

●Pudendal nerve entrapment – Compression of the pudendal nerve within Alcock's canal or surrounding ligaments may cause pain and sexual dysfunction. It can also result in penile pain being present even without sexual activity [16].

●Ejaculatory duct obstruction/cyst/calculus – Obstruction of the ejaculatory duct or seminal vesicles is an uncommon cause of discomfort with ejaculation.

●Genitourinary infections – Genitourinary infections (eg, urethra, prostate, seminal vesicles, or bladder) can lead to intense burning or itching sensations following ejaculation. Sexually transmitted infections (eg, gonorrhea, chlamydia) may cause urethral discharge as well as penile pain or burning associated with ejaculation. (See "Treatment of Chlamydia trachomatis infection" and "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)

●Interstitial cystitis (painful bladder syndrome) – This refers to chronic bladder pain in the absence of an identifiable cause. Patients may experience intense pain at the moment of ejaculation and with intercourse. Compression of the bladder during intercourse causes pain sufficient enough to inhibit intercourse [17]. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

●Dermatologic conditions – Dermatologic conditions of the penis, including lichen planus, lichen sclerosis, Zoon's (plasma cell) balanitis, balanoposthitis, and penile carcinoma, have been associated with dyspareunia [13,18]. (See "Balanitis in adults" and "Carcinoma of the penis: Epidemiology, risk factors, and pathology".)

●Surgery or radiation – Prior surgery or radiation in the pelvic region can be associated with dyspareunia.

Other causes of sexual pain

●Psychologic trauma – Psychologic trauma resulting from child or sexual abuse, relationship difficulties, and body image issues has been associated with dyspareunia in men [19]. Guilt about sexual pleasure can sometimes lead to pain with sexual intercourse. This is most commonly expressed in patients from strict religious or cultural backgrounds who manifest intense negative feelings at the time of orgasm.

●Medications – Medications, including antidepressants and antipsychotics, have been associated with dyspareunia in men [20-23].

DIAGNOSIS — Most conditions associated with male dyspareunia can be diagnosed by history and physical examination, along with basic laboratory testing. Imaging and invasive diagnostic procedures are usually unnecessary.

Initial evaluation

History — Evaluation of male dyspareunia requires a detailed sexual history. Particular attention should focus on other urinary symptoms, ejaculation history, congenital or acquired disorders (eg, Peyronie's disease, phimosis), psychosexual issues (eg, fear of relationships, prior child or sexual abuse), and other contributing factors (eg, trauma to region, past surgery, medications). Patients should be asked if pain occurs with noncoital sexual activity including masturbation.

Physical examination — Physical examination focuses on the genital and rectal areas with particular attention to the prostate, and anal sphincter tone.

The penis should be examined for abnormal curvature, which may be more noticeable when erect (figure 1), Peyronie's plaques, phimosis, short frenulum, and superficial lesions. The scrotum should be examined for testicular abnormalities. Prostatic tenderness supports the diagnosis of acute prostatitis or chronic prostatitis/chronic pelvic pain syndrome. Palpation of the pelvic floor musculature during digital rectal examination may reveal tenderness or spasticity. (See "Acute bacterial prostatitis" and "Chronic prostatitis and chronic pelvic pain syndrome".)

Performing the bulbocavernosus reflex is important for initial diagnosis of pudendal nerve entrapment [16]. The bulbocavernosus reflex is a polysynaptic reflex that is useful in testing S2-S4 nerve impairment. The test involves monitoring anal sphincter contraction in response to squeezing the glans penis. The absence of the reflex without a history of sacral spinal cord trauma may indicate nerve entrapment.

Laboratory studies — Urinalysis, urine culture, and urinary assays for sexually transmitted infections should be performed in patients who have urethral discharge, dysuria, or other urinary symptoms to rule out infectious causes. (See "Urethritis in adult males", section on 'Determining the microbial etiology' and "Urethritis in adult males", section on 'Diagnostic approach'.)

Microscopic evaluation of expressed prostatic secretions may show inflammatory cells, although the clinical significance of this finding is unclear. (See "Chronic bacterial prostatitis", section on 'Diagnosis'.)

Determining the etiology — The initial evaluation is generally sufficient to identify the cause of male dyspareunia.

Men who describe isolated ejaculatory pain generally require no further workup. Anatomical problems, including Peyronie’s disease, phimosis, and frenulum breve, are usually evidenced by history and physical examination. Pudendal nerve entrapment is suggested by an absent bulbocavernosus reflex. Concern for ejaculatory duct obstruction, including findings of hypospermia, may prompt prostate imaging with transrectal ultrasound or magnetic resonance imaging (MRI).

Genitourinary infection is suggested by dysuria, urethral discharge, and testicular swelling/tenderness and is confirmed by results of urine testing.

Other etiologies are generally diagnoses of exclusion but can be suggested by certain features. As an example, if pain is not restricted to sexual activity, chronic prostatitis/chronic pelvic pain syndrome should also be explored (see "Chronic prostatitis and chronic pelvic pain syndrome"). An underlying psychologic basis should be considered in patients with dyspareunia who do not report pain with masturbation.

When initial evaluation by the primary care practitioner does not lead to an evident cause, referral for urologic consultation is recommended. Radiological and urodynamic studies may be indicated for the evaluation of other urologic conditions, such as benign prostatic hyperplasia or hematuria. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Etiology and evaluation of hematuria in adults".)

MANAGEMENT — Management of male dyspareunia is directed at the underlying etiology. If patients are taking medications, including antidepressants and antipsychotics, which have been associated with male dyspareunia, a trial off of them may be warranted. In cases of unclear etiology, treatment modalities include pharmacotherapy to psychologic counseling and behavioral therapy to pelvic floor physical therapy.

Addressing the underlying cause

●Peyronie’s disease – Options for the management of Peyronie's disease include observation, medical therapy, or surgery, depending upon the severity and psychological impact of the disease. The management of Peyronie’s disease is discussed in detail separately. (See "Peyronie's disease: Diagnosis and medical management" and "Surgical management of Peyronie's disease".)

●Phimosis and frenulum breve – Circumcision or frenulectomy is the treatment of choice. (See "Balanitis in adults", section on 'Phimosis'.)

●Herniorrhaphy sequelae – Surgical correction, including neurectomy, has been performed for post-herniorrhaphy pelvic pain with modest improvement in small case series [24]. (See "Overview of treatment for inguinal and femoral hernia in adults".)

●Pudendal nerve entrapment – Pudendal nerve entrapment can be treated with release of Alcock's canal, sacrospinal, and sacrotuberous ligaments. In a non-blinded trial of 32 patients, more patients randomly assigned to surgical decompression of the pudendal nerve had greater improvement compared with those who did not undergo surgery (50 versus 1.6 percent) [25]. Both groups were offered steroid pudendal nerve blocks and physiotherapy. Alternatives to surgery include oral topiramate and perineural injection of anesthetics, such as bupivacaine, into the pudendal nerve with computed tomography (CT) guidance, which has been successful in anecdotal cases [26].

●Patients with genitourinary infections should be treated with appropriate antimicrobial therapy. (See "Urethritis in adult males" and "Acute simple cystitis in adult and adolescent males" and "Acute bacterial prostatitis".)

●Patients suffering from interstitial cystitis (painful bladder syndrome) have been prescribed various therapies including pentosan polysulfate, amitriptyline, intravesical alkalinized lidocaine with heparin, and intravesical botulinum toxin [27]. Pentosan polysulfate and amitriptyline appear to be the most effective treatments. Combination therapy with two or more agents has also been advocated as optimal therapy for the management of interstitial cystitis in men, depending on the symptoms of the individual patient [28,29].

●Treatment for dyspareunia associated with dermatologic conditions, including lichen planus, lichen sclerosis, Zoon's (plasma cell) balanitis, balanoposthitis, and penile carcinoma, is directed at the underlying condition. (See "Balanitis in adults" and "Carcinoma of the penis: Clinical presentation, diagnosis, and staging".)

Symptomatic therapy — When no underlying etiology for male dyspareunia has been identified, we have occasionally prescribed gabapentin (starting dose 300 mg daily, gradually increasing to 300 mg three times daily, maximum dose 1800 mg daily) or imipramine (25 to 50 mg daily) based on their effectiveness in the management of chronic pain. Although there are no published data to support this approach, we have noted symptomatic improvement in some patients.

Alpha-1 receptor blockers, which target the contractility of the vas deferens, have also been used with some success in patients with idiopathic painful ejaculation and post-herniorrhaphy dyspareunia, but the evidence is mixed. In observational studies, pain with ejaculation improved or resolved completely with tamsulosin (0.4 mg once daily) [23,30]. In a blinded trial of 118 men randomly assigned to tamsulosin or placebo, there was no significant difference in pain scores after six weeks of treatment, but the study may have been underpowered [31].

Referral to a pelvic floor physical therapist is also a reasonable strategy, as pelvic floor dysfunction will likely be present in many affected individuals [32].

Psychologic counseling/behavioral therapy — Individuals suffering from pain associated with sexual intercourse/ejaculation are sometimes victims of child or sexual abuse or come from cultural backgrounds where sexual enjoyment is considered inappropriate. If the clinician identifies a psychologic basis for male dyspareunia, referral to a sexual counseling specialist is recommended. Mental health interventions may improve pain in male patients with dyspareunia [1,19,33].

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Dyspareunia (painful sex) (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Male dyspareunia is defined as recurrent or persistent genital or pelvic pain with sexual activity that is present for three months or longer. (See 'Etiology and classification' above.)

●Approximately 1 to 5 percent of men complain of dyspareunia. However, the condition may be underreported in the population because of social stigma. (See 'Epidemiology' above.)

●Male dyspareunia can be classified into four broad categories: isolated painful ejaculation, chronic prostatitis/chronic pelvic pain, medical causes, and other causes of sexual pain (table 1). (See 'Etiology and classification' above.)

●Most conditions associated with male dyspareunia can be diagnosed by history and physical examination. Laboratory and imaging studies are usually unnecessary. When initial evaluation by the primary care practitioner does not lead to an evident cause, referral for urologic consultation is recommended. (See 'Diagnosis' above.)

●Management of male dyspareunia is directed at the underlying cause whenever possible. Peyronie’s disease, phimosis, frenulum breve, herniorrhaphy sequelae, and pudendal nerve entrapment are generally addressed by surgical intervention. For patients with idiopathic dyspareunia, we suggest medications, such as gabapentin and imipramine, which are effective in the treatment of chronic pain, or an alpha-1 receptor blocker (eg, tamsulosin) (Grade 2C). If the clinician identifies a psychologic basis, referral to a sexual counseling specialist is recommended. (See 'Management' above.)