John Patrick Mulhall, MBBCh, FACS, FECSM
BASICS
DESCRIPTION
• Dysorgasmia specifically refers to pain that occurs immediately preceding, at or immediately following orgasm.
• The pain is usually located in the penis or testicles but may be present in the lower abdomen, groin, perineum, or elsewhere.
• The severity of pain ranges from mild and of nuisance value to crippling and may last seconds to hours after orgasm.
• The condition is best identified and studied in the postradical prostatectomy setting.
• Ejaculatory pain may be seen in other conditions such as chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS), or NIH category III prostatitis, and is discussed in Section II (“Ejaculation, painful”).
EPIDEMIOLOGY
Incidence
• The most frequent correlate of dysorgasmia is radical prostatectomy and this condition occurs in about 10–15% of patients.
• In this population, the pain is usually self-limiting with most sufferers experiencing complete resolution by 2 yr postoperatively
Prevalence
N/A
RISK FACTORS
• Radical prostatectomy
• Prostate radiation
• Chronic pelvic pain syndrome (CPPS)
Genetics
None known
PATHOPHYSIOLOGY
• While unproven one of the postulated mechanisms is that the pain is related to pelvic floor or bladder neck spasm.
– This is the rationale for the use of α-blockers.
• Dysorgasmia decreases in frequency and degree over time after RP.
ASSOCIATED CONDITIONS
• Chronic pelvic pain syndrome (NIH category III prostatitis)
• Erectile dysfunction (1)
• Prostate cancer
GENERAL PREVENTION
None known
DIAGNOSIS
HISTORY
• Medical history
• Focusing on assessment of orgasmic pain location, severity and duration.
• Prior history of radical prostatectomy, radiation therapy, or CPPS.
PHYSICAL EXAM
• General physical exam
• Genital exam (although often there are no specific findings)
DIAGNOSTIC TESTS & INTERPRETATION
Lab
None are useful
Imaging
None are useful
Diagnostic Procedures/Surgery
None
Pathologic Findings
None
DIFFERENTIAL DIAGNOSIS
• Penile pain:
– Penile compressive neuropathy
– Penile trauma
– Peyronie disease
– Sexually transmitted infection (STI)
– Ureteral stone
• Testicular pain:
– Epididymitis
– Orchitis
– Testicular tumor
– Trauma
TREATMENT
GENERAL MEASURES
Reassurance that the condition is most often self-limiting
MEDICATION
First Line
• α-Blockers (daily initially; if successful attempt on-demand) (2).
• Up to 70% of men using α-blockers will have significant improvement in pain.
• Side effects include syncope, orthostasis, retrograde ejaculation, asthenia, and nasal congestion
– Alfuzosin 10 mg/d
– Doxazosin start 1 mg/d to max 8 mg
– Silodosin 8 mg/d
– Tamsulosin start 0.4 mg to max 0.8 mg
– Terazosin start 1 mg/d to max 20 mg
Second Line
• Centrally acting pain relievers
• Optimum dose and duration not established
• Gabapentin
– 900 to 1,800 mg/d and given in divided doses (3 times a day) using 300 or 400 mg capsules
• Pregabalin
– Begin dosing at 150 mg/d, increase to 300 mg/d within 1 wk. Maximum dose of 600 mg/d
SURGERY/OTHER PROCEDURES
Case reports exist of excision of retained seminal vesicle following radical prostatectomy with relief of symptoms (3)
ADDITIONAL TREATMENT
Radiation Therapy
N/A
Additional Therapies
N/A
Complementary & Alternative Therapies
N/A
ONGOING CARE
PROGNOSIS
• Recovery is expected following radical prostatectomy.
• At 24 mo, a statistically significant decrease in symptoms was seen in one study (4).
– 72%, 26%, and 7% of patients still complained of pain at 12, 18, and 24 mo, respectively.
COMPLICATIONS
N/A
FOLLOW-UP
Patient Monitoring
Routine radical prostatectomy follow-up appears most appropriate.
Patient Resources
N/A
REFERENCES
1. Mehta A, Stember DS, O’Brien K, et al. Defining the aetiology of erectile dysfunction in men with chronic pelvic pain syndrome. Andrology. 2013;1(3):483–486.
2. Barnas J, Parker M, Guhring P, et al. The utility of tamsulosin in the management of orgasm-associated pain: A pilot analysis. Eur Urol. 2005;47:361–365.
3. Yamamoto A, et al. Case Reports: Robot-Assisted Seminal Vesiculectomy for Dysorgasmia Following Seminal Vesicle-Sparing Radical Prostatectomy bjui. org: 29/01/2013. DOI: 10.1002/BJUIw-2012-072-web
4. Matsushita K, Tal R, Mulhall JP. The evolution of orgasmic pain (dysorgasmia) following radical prostatectomy. J Sex Med. 2012;9(5):1454–1458.
ADDITIONAL READING
• Anothaisintawee T, Attia J, Nickel JC, et al. Management of chronic prostatitis/chronic pelvic pain syndrome: A systematic review and network meta-analysis. JAMA. 2011;305:78–86.
• Salonia A, Burnett AL, Graefen M, et al. Prevention and management of postprostatectomy sexual dysfunctions part 2: Recovery and preservation of erectile function, sexual desire, and orgasmic function. Eur Urol. 2012;62:273–286.
See Also (Topic, Algorithm, Media)
• Ejaculatory Disturbances (Delayed, Decreased, or Absent)
• Ejaculation, Painful
• Post-orgasm Illness Syndrome (POIS)
• Prostatitis, Chronic Nonbacterial, Inflammatory and Noninflammatory (NIH CP/CPPS III A and B)
CODES
ICD9
• 607.89 Other specified disorders of penis
• 608.89 Other specified disorders of male genital organs
• 789.09 Abdominal pain, other specified site
ICD10
• N48.89 Other specified disorders of penis
• N50.8 Other specified disorders of male genital organs
• N53.12 Painful ejaculation
CLINICAL/SURGICAL PEARLS
• Dysorgasmia is common after radical prostatectomy.
• It is usually self-limiting.
• It is often responsive to α-blocker therapy.