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Androlog Summary |
From the Division of Urology, University of Colorado School of Medicine, Boulder, Colorado.
Dr Jay Sandlow describes his patient:
I saw an unusual patient and would like some input. He is a 42-year-old man with a 1-year history of perineal pain just after ejaculation. There is no testicular pain, and ejaculation is the only thing that causes this pain. It is severe enough that it limits his sexual activity. His physical exam, including a rectal exam, is benign. He had a work-up by a local urologist with a computed tomography scan and transrectal ultrasound (TRUS), neither of which was very remarkable. The local urologist thought that he saw a cyst on TRUS evaluation and tried to aspirate it; however, he did not get any fluid and there was no change in the patient's pain. He has failed multiple courses of nonsteroidal anti-inflammatory drugs and antibiotics. He has 1 child who was easily conceived and has not had any scrotal, inguinal, or abdominal surgery. I repeated his TRUS and did not see any cysts, calculi, or dilated seminal vesicles. Any ideas about the etiology of his pain or suggestions for treatment would be appreciated.
Dr Richard Berger offers advice based upon his own clinical experience with patients such as this:
This is a difficult problem. My approach would be to try a broad alpha blocker, phenoxybenzamine, until the patient develops anejaculation. If pain persists, it is probably not due to accessory gland contractions. I would then try selective seratonin reuptake inhibitors as sometimes these affect the ejaculatory process (I am not sure how) enough to decrease pain. Perineal pain is most likely related to pelvic floor spasm. If the above does not work, try 100 units of botulinum toxin type A into the perineal muscles and specifically the bulbospongiosus. You might combine this with pelvic floor physical therapy. If that does not work, refer him to a colleague.
Dr Woet Gianotten offers his own perspective as a psychotherapist in the management of patients with complaints such as this:
I am interested in the way this man has sex. Is there anything abnormal in his sexual stimulation (or did anything change 1 year ago when the symptoms started)? What does he do with his pelvic floor muscles? Is he very tense? Does he expect now to get perineal pain and accordingly contract his perineum? Does he have any other signs of hypertonic pelvic floor?From the sexologic perspective, I could imagine 2 causes. The most likely one is indeed a hypertonic reaction of his pelvic floor muscles. If that is the case, pelvic floor physiotherapy could help him (and maybe also a muscle relaxant before having sex). The other (less likely) cause is a late reaction on not yet sufficiently addressed sexual abuse (or physical violence) from the past. Unexplained penile, scrotal, or perineal pain during sexual excitement, orgasm, or postejaculation can be a late sign of sexual abuse.
Dr Toeman Kadiogly suggests ejaculatory duct reflux as a possible etiology:
This may be a muscular spasm type of pain or pain from reflux from the ejaculatory ducts into the prostate. Maybe you could do a cystourethroscopy to see if the duct openings are of refluxive nature that may transmit the pressure during ejaculation.
Dr Michael Perelman joins the discussion, suggesting a specific evaluative approach aimed at determining the presence of a muscular component to this patient's pain:
Dr Woet Gianotten, in an earlier e-mail, suggested that the most likely etiology is a hypertonic reaction of his pelvic floor muscles. I would support this supposition and suggest the following: To determine whether or not there is a muscular component to your patient's pain, encourage him to try masturbating while sitting in a hot bath. He may have difficulty reaching orgasm in this situation, if he feels uncomfortable with the concept. Equally, he may only become aware of a "just noticeable difference" in his level of postejaculatory pain. However, any such change experienced in this manner is highly suggestive of a muscular component to the etiology, which then suggests different potential treatment paths, from many of those our colleagues have recommended. If there is a difference in his response using this approach, I would then have a series of follow-up questions and subsequent recommendations for treatment. Presumably, you have already explored the circumstances surrounding his first experience of postejaculatory pain that you reference as occurring approximately 1 year ago and are satisfied that there was neither any psychosocial or physical trauma.
Finally Dr Jorge Hallak suggests that acupuncture might be considered in the management of this patient:
I had a younger patient with the same complaint. In that case, his symptoms improved with pelvic floor rehabilitation and acupunture. I really do not know the value of acupunture, but it did work better than rehabilitation alone.
Footnotes
Note: Postings to Androlog have been lightly edited before publication.
References
Nickel JC, Elhilali M, Emberton M, Vallancien G; The Alf-One Study Group. The beneficial effect of alfuzosin 10 mg once daily in "real-life" practice on lower urinary tract symptoms (LUTS), quality of life and sexual dysfunction in men with LUTS and painful ejaculation. BJU Int. 2006; 97: 1242 –1246.[CrossRef][Medline]
Nickel JC, Elhilali M, Vallancien G; ALF-ONE Study Group. Benign prostatic hyperplasia (BPH) and prostatitis: prevalence of painful ejaculation in men with clinical BPH. BJU Int. 2005; 95: 571 –574.[CrossRef][Medline]
Shoskes DA, Landis JR, Wang Y, Nickel JC, Zeitlin SI, Nadler R; Chronic Prostatitis Collaborative Research Network Study Group. Impact of post-ejaculatory pain in men with category III chronic prostates/chronic pelvic pain syndrome. J Urol. 2004; 172: 542 –547.[CrossRef][Medline]
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