Approach to dyspareunia in men

INTRODUCTION AND DEFINITION — 

The term "dyspareunia" refers to pain associated with sexual intercourse, which causes significant psychologic distress. Symptoms vary widely, from isolated scrotal or penile pain to more generalized lower pelvic pain. Sexual dysfunction may also be present. While male dyspareunia is often used to describe a heterogenous group of symptoms, a consistent, unifying factor is the presence of recurrent or persistent genital or pelvic pain with sexual activity, lasting for three months or more [1]. The condition often leads to embarrassment and may be difficult for the patient and clinician to discuss openly.

This topic will focus on the evaluation of dyspareunia in men, particularly when genital discomfort with sexual activity is the primary concern. Discomfort with sexual activity as a component of other conditions is discussed with each primary condition. As examples:

●(See "Lower urinary tract symptoms in males".)

●(See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia".)

●(See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

Genitourinary infections in men are a common cause of dyspareunia, typically accompanied by additional symptoms outside of sexual activity. These are included in this topic as part of the diagnostic workup for dyspareunia and are discussed in further detail separately:

●(See "Urethritis in adults and adolescents".)

●(See "Acute simple cystitis in male adults".)

●(See "Acute bacterial prostatitis".)

●(See "Acute epididymitis in adolescents and adults".)

●(See "Chronic bacterial prostatitis".)

A general overview of sexual dysfunction in men, anorectal symptoms in men who have sex with men, and dyspareunia in women are also discussed separately:

●(See "Epidemiology and etiologies of male sexual dysfunction".)

●(See "Evaluation of anorectal symptoms in men who have sex with men".)

●(See "Female sexual pain: Evaluation".)

In this topic, when discussing study results, we will use the term "men" as it is used in the studies presented. Symptoms of dyspareunia may be experienced by people assigned male at birth, transgender men, and gender-expansive people. We encourage the reader to consider the specific counseling and treatment needs of transgender and gender-expansive patients as they relate to the information presented in this topic.

EPIDEMIOLOGY — 

Studies report that approximately 1 to 5 percent of men suffer from pain with sexual intercourse [2-4]. However, because of the social stigma associated with sexual disorders, underreporting is common, and the true frequency may be higher. Most studies describing dyspareunia in men are case reports on associated conditions, such as chronic prostatitis or Peyronie's disease. Few long-term studies have been published.

Among patients without identified genitourinary abnormality, uncircumcised patients report dyspareunia more frequently than circumcised patients [5]. This association is not entirely explained by greater physical trauma associated with sexual intercourse in uncircumcised men.

ETIOLOGY — 

Dyspareunia in men describes a heterogeneous group of disorders that may be caused by physical and psychologic issues.

The predominant symptom of dyspareunia is genital or pelvic pain with sexual activity [1,6].

●Location – Common sites of pain include the glans penis, scrotum, pelvis, and pelvic floor musculature. Pain may be isolated to a single site or may be present at multiple sites.

●Associated symptoms – In addition to pain with sexual activity, patients may also report any of the following:

•Sexual dysfunction

•Situational symptoms (occurring only with select situations, eg, pain only with coital sexual activity, orgasm, or ejaculation or pain related to bladder fullness)

•Tenderness or swelling of the scrotum, separate from sexual activity

•Skin changes in the genital area

•Anatomic abnormalities involving the foreskin or glans penis

•Generalized symptoms or symptoms separate from sexual activity

•Feelings of guilt about sexual pleasure, body image issues, or other negative feelings surrounding sexual activity

The predominant presenting symptom assists with classification (table 1) [1,6]:

Ejaculatory pain — Painful ejaculation is a common type of ejaculatory dysfunction [7]. The incidence of painful ejaculation in patients above the age of 50 ranges from 1 to 6.7 percent [8,9]. Painful ejaculation can have a significant impact on quality of life, negatively affecting self-esteem and reducing desire for sexual intercourse [10]. Among men who report painful ejaculation, 90 percent considered this condition to be a serious problem [9,11].

The most common presentation of painful ejaculation is penile pain during or after ejaculation, although some describe pain in the urethra, testicles, rectum, or abdomen [12]. In most cases, the pain lasts for less than five minutes after ejaculation; reported symptom duration may vary from less than one minute to several days [13].

Common causes of painful ejaculation include the following, though in some cases, no underlying cause is identified. Presenting features are reviewed below and in the tables (table 2 and table 1) [10,14]:

●Genitourinary infection – Acute and chronic genitourinary infections (eg, infections of the urethra, prostate, seminal vesicles, epididymis, or bladder) can lead to intense burning or itching sensations following ejaculation. Sexually transmitted infections (eg, gonorrhea, chlamydia) may cause associated urethral discharge and penile pain. Patients with epididymitis may also report diffuse scrotal pain.

•(See "Treatment of Chlamydia trachomatis infection in adults and adolescents".)

•(See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents".)

•(See "Urethritis in adults and adolescents".)

•(See "Acute epididymitis in adolescents and adults".)

•(See "Acute bacterial prostatitis" and "Chronic bacterial prostatitis".)

●Urethral or ejaculatory duct obstruction – There is a higher incidence of ejaculatory pain amongst patients with enlarged prostates. The etiology is unclear [15]. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia".)

Urethral strictures can lead to penile pain during or after ejaculation due to obstruction of the outflow of semen and increased urethral pressure/spasm [16]. (See "Strictures of the adult male urethra".)

Similarly, obstruction of the ejaculatory duct or seminal vesicles, as well as stones or cysts in the ejaculatory duct, are a rare cause of discomfort with ejaculation [14].

●Surgical sequelae – Pain with ejaculation can occur after lower abdominal and urologic surgery. As examples:

•In a nationwide Danish survey, approximately 3 percent of patients aged 18 to 40 reported moderate to severe pain-related sexual dysfunction (largely related to pain with ejaculation) following groin hernia repair [17]. (See "Post-herniorrhaphy groin pain".)

•Ejaculatory pain can also occur following vasectomy as part of postvasectomy pain syndrome [18]. (See "Vasectomy", section on 'Post-vasectomy pain syndrome'.)

•Pain with orgasm (with or without ejaculation) after radical prostatectomy for prostate cancer has been reported in some patients [12].

●Medication effect – Ejaculatory dysfunction is a well-defined side effect of selective serotonin reuptake inhibitors and tricyclic antidepressants. While the most common sexual sequelae of these medications are delayed ejaculation or anejaculation, painful ejaculation has been reported amongst patients on antidepressants, antipsychotics, and cyclobenzaprine [19-21].

●Postorgasmic illness syndrome – The postorgasmic illness syndrome is a rare condition in which patients experience flu-like or allergic symptoms in addition to feelings of confusion, anhedonia, weakness, or extreme fatigue immediately following orgasm [22,23]. Episodes are self-limited and resolve spontaneously within hours to days. While pain is not usually a prominent symptom, patients may report discomfort and avoidance of sexual activity that the clinician may characterize as dyspareunia.

While no definitive etiology has been established, it is hypothesized to be immunogenic in origin or related to underlying mu-opioid receptor dysfunction [24].

Scrotal pain — Chronic scrotal pain is defined as unilateral or bilateral pain in the scrotum or testicles lasting more than three months [25]. Forty percent of patients with chronic scrotal pain reported that sexual activity worsens discomfort [26]. While sometimes no cause is identified, chronic discomfort in the scrotum causing dyspareunia may arise in the setting of the following conditions, reviewed below and in the table (table 1):

●Chronic epididymitis or epididymo-orchitis

●Varicocele

●Recent scrotal surgery

●Referred pain from other sources, such as a hernia or hip injury

Penile anatomic abnormalities

●Peyronie's disease – Peyronie's disease is the formation of an inelastic scar or plaque of the tunica albuginea that may cause a pathologic curvature of the penis and painful erection (figure 1 and figure 2). It is a common cause of chronic dyspareunia in men [27]. (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, resulting in discomfort with erection and intercourse (picture 1) [28]. Phimosis is caused by balanitis or other inflammatory dermatologic conditions. (See "Balanitis in adults", section on 'Phimosis and paraphimosis'.)

●Frenulum breve – The frenulum of the penis is an elastic band of tissue at the base of the glans that connects the foreskin to the head of the penis (figure 3). In cases of frenulum breve, also known as "tethered glans," a congenitally thickened and short frenulum causes tensile restriction of the foreskin at the base, making it difficult to retract. In the erect state, frenulum breve may cause downward curvature of the glans, leading to pain with erection and intercourse [29]. (See "Care and complications of the uncircumcised penis in infants and children", section on 'Frenulum breve'.)

While phimosis typically results in circumferential constriction of the foreskin, in frenulum breve, the primary area of restriction is at the base of the glans. As a congenital condition, pain with erections from frenulum breve often begins in adolescence or with initiation of sexual activity; however, reluctance to seek medical attention may result in presentation later in adulthood.

Dermatologic conditions — The following dermatologic conditions of the penis have been associated with dyspareunia (table 1) [30,31]:

●Lichen planus (picture 2 and picture 3)

●Lichen sclerosis

●Zoon's (plasma cell) balanitis

●Balanitis/balanoposthitis (picture 4) (see "Balanitis in adults")

●Penile carcinoma (picture 5) (see "Carcinoma of the penis: Clinical presentation, diagnosis, and staging")

Other etiologies — Generalized symptoms separate from sexual activity are a more prominent feature of these conditions (table 1).

●Chronic pelvic pain syndrome – Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) is characterized by urologic symptoms and/or pain in the pelvic region without an identifiable cause. CP/CPPS is frequently associated with postejaculatory pain and other symptoms of dyspareunia, in addition to urinary symptoms and discomfort in other areas of the body.

In spite of the nomenclature, chronic bacterial prostatitis is considered a separate condition from CP/CPPS, as chronic bacterial prostatitis is diagnosed with positive culture of urine or expressed prostate secretion, while patients with CP/CPPS do not have these findings (table 3). (See "Chronic prostatitis and chronic pelvic pain syndrome" and "Chronic bacterial prostatitis".)

Chronic bacterial prostatitis may cause dyspareunia, typically secondary to ejaculatory pain. (See 'Ejaculatory pain' above.)

●Pudendal nerve entrapment – Compression of the pudendal nerve within the pudendal canal (also known as Alcock's canal) or surrounding ligaments may cause sexual dysfunction in rare circumstances (picture 6). It can also result in penile pain without sexual activity, usually exacerbated with sitting. The distribution of pain typically lateralizes to one side, along the anatomic distribution of the pudendal nerve [32].

●Interstitial cystitis (painful bladder syndrome) – Interstitial cystitis refers to chronic bladder pain in the absence of an identifiable cause. Patients may experience intense pain with intercourse and at the moment of ejaculation [33]. In addition, patients commonly describe discomfort that increases with bladder filling and improves with voiding. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis".)

●Psychologic trauma – Psychologic trauma resulting from child or sexual abuse, relationship difficulties, and body image issues has been associated with dyspareunia in men [34]. Guilt about sexual pleasure, sometimes related to religious or cultural background, can sometimes lead to pain with sexual intercourse. Patients may describe intense negative feelings at the time of orgasm; they may also report the absence of symptoms with masturbation.

DIAGNOSTIC APPROACH — 

The patient's description of symptoms is critical for determining the etiology of dyspareunia. Patients may avoid discussing symptoms of dyspareunia due to embarrassment or concern for social stigma. The clinician may facilitate this dialogue by incorporating questions about sexual concerns into the comprehensive health visit.

History — Evaluation of dyspareunia requires a detailed sexual history using open-ended and nonjudgmental questions (eg, "Do you have any sexual concerns?"). If the response is affirmative, each concern should be discussed in further detail.

Key historical features are reviewed below and in the table (table 1):

●Does the pelvic discomfort occur only in certain settings?

•Symptoms limited to isolated ejaculatory pain suggest a more limited list of potential etiologies (table 1).

•Discomfort limited to coital sexual activity and absent with masturbation may suggest a psychosexual etiology.

●Is there generalized discomfort outside the pelvis?

•Chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) presents with both pelvic discomfort and discomfort in other areas of the body, along with urinary symptoms.

•Postorgasmic illness syndrome presents with diffuse, flu-like symptoms.

●Are there associated urinary symptoms?

•Dysuria or discharge suggests genitourinary infection.

•Weak urine stream or difficulty passing urine suggests urethral stricture.

•Increasing discomfort with bladder filling suggests interstitial cystitis.

•CP/CPPS presents with a range of urinary symptoms, including dysuria, frequency, and urgency.

●Is pain localized to the glans penis and scrotum or throughout the pelvis?

•Isolated scrotal discomfort suggests epididymitis, varicocele, or other scrotal condition.

•Referred pain from pudendal nerve entrapment results in unilateral pelvic pain.

●Is there associated unilateral hip or lower abdominal discomfort?

•Referred pain from hip pathology is associated with unilateral discomfort in the hip.

•Referred pain from inguinal hernia is associated with discomfort in the lower abdominal region.

●Is the discomfort also present outside of sexual activity? Discomfort separate from sexual activity suggests any of the following:

•Pudendal nerve entrapment

•Referred pain from hernia or hip injury

•Interstitial cystitis

•Epididymitis

•Varicocele

●Has the patient noticed acute or chronic skin changes or anatomic abnormalities?

•Dermatologic conditions (eg, lichen planus, lichen sclerosis, Zoon's [plasma cell] balanitis, and penile carcinoma) have been associated with dyspareunia.

•Peyronie's disease presents with corporal abnormalities, penile curvature or indentation, and fibrotic plaques. Frenulum breve is typically a congenital condition, whereas phimosis and Peyronie's are acquired conditions.

●Does the medication history include any medications known for causing ejaculatory pain (table 2)?

●Are there psychosexual issues, including a history of trauma, relationship difficulty, or body image difficulty, or are symptoms absent with noncoital sexual activity, including masturbation? These historical features suggest a psychiatric etiology of sexual discomfort.

●Does the patient have a recent history of pelvic surgery? Pelvic surgical sequelae have been implicated in both isolated ejaculatory pain and chronic scrotal pain.

Physical examination — The pelvic examination is performed to confirm expected pelvic anatomy and to assess for tenderness, lesions or other anatomic abnormalities, and signs of infection.

●Visual inspection – Preputial anatomic abnormalities causing sexual discomfort, including phimosis (picture 1) or frenulum breve, may be apparent on visual inspection (figure 3). Occasionally, these anatomic abnormalities are subtle during examination and may be more prominent with erection.

Dermatologic conditions, such as lichen planus (picture 2 and picture 3 and picture 7), lichen sclerosis, or penile carcinoma (picture 5), may be evident.

Urethral discharge suggests urethritis and should prompt evaluation for infection. (See 'Laboratory studies' below.)

●Palpation – Palpation of the flaccid penis may reveal Peyronie's plaques, which present as firm areas of induration involving the corpora of the penis; these may be painful or painless. Application of gentle stretch to the penis can facilitate the identification of these lesions. Peyronie's plaques are most commonly on the dorsum of the penis but can present anywhere along the shaft (figure 1).

Generalized testicular and epididymal swelling and tenderness suggest epididymitis. (See "Acute epididymitis in adolescents and adults".)

Varicocele presents with palpable or visible scrotal swelling above the testis (figure 4) that worsens with prolonged standing or Valsalva maneuver.

Hydrocele presents with painless swelling above the testicle that may fluctuate in size; when transilluminated with a light source at the base of the affected scrotum, the hydrocele will glow, differentiating the process from hematocele, hernia, or mass. (See "Nonacute scrotal conditions in adults", section on 'Palpable abnormalities'.)

An inguinal hernia examination should be performed to evaluate for referred scrotal pain. (See "Classification, clinical features, and diagnosis of inguinal and femoral hernias in adults".)

An enlarged prostate suggests benign prostatic hyperplasia. In rare cases, a midline cystic structure is palpable on prostate examination, suggestive of ejaculatory duct obstruction. Prostatic tenderness on digital rectal examination suggests bacterial prostatitis or CP/CPPS.

CP/CPPS is further suggested by tenderness or spasticity of the pelvic floor musculature. (See "Acute bacterial prostatitis", section on 'Diagnostic evaluation' and "Chronic bacterial prostatitis", section on 'Diagnosis' and "Chronic prostatitis and chronic pelvic pain syndrome", section on 'Physical examination and laboratory findings'.)

●Additional testing in selected patients

•Referred hip pain – In patients reporting hip pain, a detailed, bilateral hip examination should be performed to evaluate for referred scrotal pain due to hip pathology. (See "Approach to the adult with unspecified hip pain".)

•Pudendal nerve entrapment – Pudendal nerve entrapment is an uncommon condition that should be evaluated in patients with unilateral symptoms for whom the underlying etiology is not suggested by the preceding evaluation (picture 6). Features of pudendal nerve entrapment are suggested by the Nantes criteria, which include pain along the distribution of the pudendal nerve that lateralizes to one side, increased symptoms with prolonged sitting, intact pelvic sensation, lack of symptoms during sleep, and resolution of pain with administration of a pudendal nerve block [35]. (See "Nerve injury associated with pelvic surgery", section on 'Pudendal nerve'.)

Alternatively, the bulbocavernosus reflex may be performed to test for S2, S3, or S4 nerve impairment due to pudendal nerve entrapment [32]. With the patient supine, the test is performed by squeezing the glans penis between the thumb and index finger. Reflex contraction of the external anal sphincter is detected with the examiner's contralateral index finger in the distal aspect of the anal canal. Reduced or absent external anal sphincter contraction suggests possible pudendal 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 (see "Urethritis in adults and adolescents", section on 'Diagnostic approach' and "Acute bacterial prostatitis", section on 'Diagnostic evaluation'). In the absence of symptoms suggestive of infection, additional laboratory studies are usually unnecessary.

Ancillary studies in selected patients — In patients with suspected benign prostatic hyperplasia, urethral stricture, or ejaculatory duct obstruction causing painful ejaculation, cystoscopy, urodynamic studies, and prostate imaging (eg, transrectal ultrasound or magnetic resonance imaging) may be pursued in consultation with urology. (See "Clinical manifestations and diagnostic evaluation of benign prostatic hyperplasia" and "Strictures of the adult male urethra", section on 'Diagnostic evaluation'.)

The diagnosis of chronic bacterial prostatitis may be elusive, as patients may have a normal prostate examination and normal urinary tests. If chronic bacterial prostatitis is suspected, expressed prostatic specimens for analysis and culture may be obtained, usually in consultation with urology (see "Chronic bacterial prostatitis"). The presence of inflammatory cells in the absence of positive culture may indicate CP/CPPS (table 3). (See "Chronic prostatitis and chronic pelvic pain syndrome", section on 'Diagnostic approach'.)

SUBSEQUENT MANAGEMENT BY ETIOLOGY — 

The initial evaluation is usually sufficient to identify the cause of dyspareunia in most cases (see 'Etiology' above and 'Diagnostic approach' above). Management is directed at the underlying etiology in consultation with dermatology, urology, or other appropriate specialty referral.

●Isolated ejaculatory pain – Dyspareunia due to medication effect is confirmed by improvement with a supervised trial off these medications. Patients with dysuria or urethral discharge should be evaluated and treated for genitourinary infection. In patients with postsurgical etiologies of dyspareunia, surgical correction may offer relief [36]. (See "Post-herniorrhaphy groin pain".)

If ejaculatory pain persists after infectious, medication-related, and postsurgical issues are addressed, the patient should be evaluated for urethral or ejaculatory duct obstruction in consultation with urology (see 'Ancillary studies in selected patients' above). Management of obstruction is discussed separately based on anatomic location:

•(See "Medical treatment of benign prostatic hyperplasia" and "Surgical treatment of benign prostatic hyperplasia (BPH)".)

•(See "Strictures of the adult male urethra", section on 'Management'.)

●Scrotal pain – Genitourinary infection is suggested by dysuria, urethral discharge, and testicular swelling and tenderness. Infection is confirmed by results of urine testing (see 'Laboratory studies' above). Genitourinary infections should be treated with appropriate antimicrobial therapy. (See "Urethritis in adults and adolescents" and "Acute simple cystitis in male adults" and "Acute bacterial prostatitis".)

Varicocele is evident on scrotal examination. Referred pain from hernia or hip pathology is also evident from the physical examination. Management of these conditions is discussed separately. (See "Nonacute scrotal conditions in adults", section on 'Management' and "Overview of treatment for inguinal and femoral hernia in adults".)

●Penile anatomic abnormalities – Anatomic abnormalities, including Peyronie's disease, phimosis, and frenulum breve, are usually evidenced by history and physical examination. (See 'Penile anatomic abnormalities' above.)

•Peyronie's disease – Options for the management of Peyronie's disease include observation, intralesional injection therapy, or surgery, depending upon the severity and psychologic impact of the condition. (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 "Male adult circumcision".)

●Dermatologic conditions – 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. Dermatologic or urologic consultation may be warranted. (See "Balanitis in adults" and "Carcinoma of the penis: Clinical presentation, diagnosis, and staging".)

●Pudendal nerve entrapment – Pudendal nerve entrapment is suggested by unilateral penile and pelvic pain in the distribution of the pudendal nerve (picture 6). Treatment typically involves surgical evaluation for decompression. (See "Nerve injury associated with pelvic surgery", section on 'Pudendal nerve'.)

●Psychosexual issues – If the clinician identifies a psychologic basis for dyspareunia, a referral to a sexual counseling specialist is recommended. Mental health interventions may improve pain in patients with dyspareunia [1,34,37].

●Diagnoses of exclusion – Interstitial cystitis and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) are diagnoses of exclusion when the above etiologies have been ruled out.

CP/CPPS may have some objective features that support the diagnosis (table 3). Patients with CP/CPPS are offered combination therapy with anti-inflammatories, alpha-1 blockers, pelvic floor physical therapy, and cognitive-behavioral therapy. (See "Chronic prostatitis and chronic pelvic pain syndrome".)

Various therapies for interstitial cystitis have been offered, including pentosan polysulfate, amitriptyline, and intravesical instillations [38-40]. (See "Interstitial cystitis/bladder pain syndrome: Management".)

TREATMENT FOR PERSISTENT OR REFRACTORY SYMPTOMS — 

When no underlying etiology for dyspareunia has been identified or symptoms are persistent despite the above treatment, pharmacotherapy and other referrals may assist with symptomatic relief.

●Pelvic floor physical therapy – Pelvic floor dysfunction may have varied presentations, including dyspareunia. In patients with chronic pelvic pain that is not clearly caused by a reversible or identifiable cause (see 'Subsequent management by etiology' above), we suggest referral for pelvic floor physical therapy. Pelvic floor physical therapy may offer benefits through manual therapy, myofascial trigger release, neuromuscular re-education, and instruction on behavioral modification [41,42]. The therapist may also identify nonurologic contributors to sexual discomfort (eg, hip pathology).

●Pharmacotherapy

•Patients with painful ejaculation after surgery or radiation – Alpha-1 receptor blockers, which target the contractility of the vas deferens, have been used with some success in patients with idiopathic painful ejaculation or orgasmic pain after radical prostatectomy, herniorrhaphy, or radiation therapy. Because studies of their efficacy are mixed, they should be prescribed using a shared decision-making approach with anticipatory guidance regarding the likelihood of benefit. In observational studies of patients with postejaculatory pain after radical prostatectomy, radiation therapy, or antidepressant use, symptoms improved or resolved completely with tamsulosin (0.4 mg once daily) [13,43]. In contrast, in a small, randomized trial, pain scores were similar after six weeks of treatment with either tamsulosin or placebo [44]. Further studies are needed to determine the role of alpha-1 blockers in the treatment of persistent ejaculatory pain.

•Patients with features of chronic pain or nociplastic pain syndromes – Based on studies supporting the use of tricyclic antidepressants and gabapentin in the management of chronic pain, these medications have also been used in the treatment of refractory dyspareunia (see "Overview of pharmacologic management of chronic pain in adults"). Although there are no published data to support this approach and no data to support the use of one agent over another, we have noted symptomatic improvement in some patients with gabapentin 300 mg daily, gradually increasing to a maximum of 300 mg three times daily, or imipramine 25 to 50 mg daily.

•Patients with features of interstitial cystitis – Amitriptyline has been used in the treatment of interstitial cystitis and is therefore a reasonable option for patients with symptoms of both dyspareunia and interstitial cystitis (eg, pain with intercourse or ejaculation in addition to discomfort with bladder filling or other bladder-related symptoms). The diagnosis and management of interstitial cystitis are discussed separately. (See "Interstitial cystitis/bladder pain syndrome: Clinical features and diagnosis" and "Interstitial cystitis/bladder pain syndrome: Management", section on 'Amitriptyline as first-line therapy'.)

Patients who derive benefit from treatment with gabapentin or tricyclic antidepressants will likely require long-term therapy. In such cases, we recommend referral to a comprehensive pain program for longitudinal care, including follow-up and medication management by a specialist. (See "Approach to the management of chronic non-cancer pain in adults", section on 'Comprehensive pain rehabilitation program'.)

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 email 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 topics (see "Patient education: Dyspareunia (painful sex) (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Definition – Dyspareunia in men is defined as recurrent or persistent genital or pelvic pain with sexual activity that is present for three months or longer. Associated symptoms may include sexual dysfunction, skin or anatomic abnormalities in the genital area, or psychosexual issues. Symptoms may be generalized or situational (eg, occurring only with coital sexual activity or in other specific circumstances). (See 'Introduction and definition' above.)

●Etiology – Dyspareunia in men describes a heterogeneous group of disorders that may be caused by physical and psychologic issues. The predominant presenting symptom assists with classification as per below and in the table (table 1) (see 'Etiology' above):

•Isolated ejaculatory pain

•Scrotal pain

•Penile anatomic abnormalities

•Dermatologic conditions

•Other etiologies

●Diagnostic approach – The etiology of dyspareunia is frequently identified from the history. Key historical features include the distribution of pain, the presence of urinary symptoms, genital skin or anatomic abnormalities, and psychosexual issues. The medication history should be reviewed for medications associated with painful ejaculation (table 2). (See 'History' above.)

The pelvic examination assists with confirming expected pelvic anatomy and assessing for areas of discomfort, lesions or other anatomic abnormalities, or signs of infection. (See 'Physical examination' above.)

Urinalysis, urine culture, and urinary assays for sexually transmitted infections should be performed in patients who have urethral discharge, dysuria, or other urinary symptoms. In the absence of symptoms suggestive of infection, additional laboratory studies are usually unnecessary. (See 'Laboratory studies' above.)

●Management – Management of dyspareunia in men is directed at the underlying cause, when identified (see 'Subsequent management by etiology' above):

•Genitourinary infections should be treated with antimicrobial therapy.

•If patients are taking medications associated with dyspareunia, a trial off of them may be warranted.

•Skin conditions are treated in consultation with dermatology.

•Peyronie's disease, phimosis, frenulum breve, herniorrhaphy sequelae, and pudendal nerve entrapment are addressed by urologic or surgical intervention.

•If the clinician identifies a psychologic basis for dyspareunia, referral to a sexual counseling specialist is recommended.

●Treatment for persistent symptoms – Pelvic floor dysfunction may have varied presentations, including dyspareunia. In patients with chronic pelvic pain that is not clearly caused by a reversible or identifiable cause, we suggest a referral for pelvic floor physical therapy (Grade 2C). This may offer benefits through manual therapy, neuromuscular re-education, and instruction on behavioral modification.

For patients with refractory painful ejaculation after prostatectomy, radiation therapy, or herniorrhaphy, we suggest treatment with tamsulosin 0.4 mg once daily, an alpha-1 receptor blocker that targets the contractility of the vas deferens and ejaculatory muscles (Grade 2C). While evidence supporting its use is mixed, tamsulosin is generally well tolerated and may offer symptomatic relief for patients with few additional therapeutic options.

For patients with features of chronic pain, nociplastic pain syndromes, or interstitial cystitis, we suggest treatment with a tricyclic antidepressant or gabapentin (Grade 2C). The use of these medications is extrapolated from their use in the management of chronic pain and interstitial cystitis. Although there are no published data to support this approach and no data to support the use of one agent over another, we have noted symptomatic improvement in selected patients receiving pharmacotherapy with these agents. (See 'Treatment for persistent or refractory symptoms' above.)

ACKNOWLEDGMENT — 

The UpToDate editorial staff acknowledges Kenneth DeLay, MD, who contributed to earlier versions of this topic review.