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Pain in the Male Genitalia After Coitus (Post-Coital Genital Pain / Male Dyspareunia)

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1. Peyronie's Disease

• Characterized by fibrotic plaques within the tunica albuginea of the corpora cavernosa
• Plaques cause penile curvature (most commonly dorsal) on erection, leading to pain during penetration or thrusting
• Minor repeated penile trauma → microhaemorrhage → fibrosis → inelastic plaque
• The active phase (18–24 months) is painful; the stable phase may leave deformity that mechanically obstructs intercourse
• Associated with Dupuytren's contracture
• Investigations: clinical examination; MRI to confirm plaque location
• Management: conservative during active phase; intralesional collagenase (Xiaflex) or surgical correction (Nesbit plication, plaque incision + bovine pericardial graft) in stable phase

Bailey & Love's Surgery, p. 1572; Textbook of Family Medicine 9e

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2. Chronic Prostatitis / Prostatodynia (Chronic Pelvic Pain Syndrome)

• Patients present with perigenital pain, testicular pain, prostatic pain — all exacerbated by or occurring after sexual intercourse
• Prostatodynia: pain in the absence of objective prostatic inflammation; part of the chronic pelvic pain syndrome (CPPS) spectrum; psychological and stress components often significant
• Chronic bacterial prostatitis may involve Chlamydia, Trichomonas, or common gram-negatives
• Diagnosis: three-glass urine test; prostatic massage fluid showing pus cells ± bacteria
• Treatment: fluoroquinolones (ciprofloxacin) or trimethoprim; doxycycline for Chlamydia; metronidazole for Trichomonas (treat both partners); α-blockers and anti-inflammatories for symptom relief

Bailey & Love's Surgery, p. 9074

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3. Painful Ejaculation (Odynorgasmia)

Campbell-Walsh Wein Urology, p. 2099

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4. Phimosis and Paraphimosis

• Phimosis (tight prepuce that cannot retract over the glans): causes pain during erection and intercourse due to mechanical restriction; tears and fissures in the foreskin may occur
• Paraphimosis (retracted prepuce that cannot be reduced): a urological emergency causing constriction pain and ischemia — can be precipitated by vigorous intercourse
• Management: topical steroids, dorsal slit, or circumcision for phimosis; manual reduction or emergency dorsal slit for paraphimosis

Pfenninger & Fowler's Procedures for Primary Care

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5. Postorgasmic Illness Syndrome (POIS)

• Severe myalgia and fatigue
• Flu-like systemic symptoms
• May include genital discomfort

Campbell-Walsh Wein Urology, p. 1999

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6. Infectious / Sexually Transmitted Causes

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7. Vacuum Constriction Device–Related Pain

Smith & Tanagho's General Urology, 19th ed.

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8. Psychosexual / Functional Pain

• Performance anxiety and psychosexual dysfunction can manifest as perceived genital pain
• CPPS often overlaps with somatization, depression, and stress
• This should be a diagnosis of exclusion after organic causes are ruled out

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Summary: Differential Diagnosis at a Glance

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Clinical Approach

1. History: onset, location, timing (during vs. after coitus, at ejaculation), discharge, fever, prior STIs, medications
2. Examination: inspect penis (plaques, foreskin, ulcers, discharge), palpate testes and epididymides, rectal exam of prostate
3. Investigations: urethral swab/NAAT for STIs, three-glass urine, prostate fluid microscopy, scrotal ultrasound if testicular tenderness, MRI for Peyronie's plaques
4. Refer: urology for Peyronie's, CPPS, ejaculatory duct obstruction; sexual medicine or psychosexual counseling for functional/psychogenic causes

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Management of Post-Coital Male Genital Pain — All Causes

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1. Peyronie's Disease

Phase-Based Approach

Active Phase — Medical Options

• Intralesional collagenase Clostridium histolyticum (Xiaflex) — FDA-approved 2013; dissolves fibrous plaques; first-line non-surgical treatment; incorporated into standard treatment algorithm and allows many patients to avoid surgery
• Oral agents: Vitamin E, potassium para-aminobenzoate (Potaba), colchicine — limited evidence
• Intralesional verapamil or interferon-α2b — used in some centres
• Penile traction therapy — adjunct to intralesional therapy; preserves penile length
• Watchful waiting — natural history shows stabilisation by 18–24 months

Stable Phase — Surgical Options

1. Tunical plication (Nesbit technique / 16-dot technique): Plicates tunica albuginea on the concave side opposite the plaque; good for adequate penile length; risk of further shortening
2. Plaque incision/excision + grafting (bovine pericardial patch, dermis): For severe curvature with hourglass/hinge deformity; higher risk of post-op ED
3. Penile prosthesis implantation: For Peyronie's + significant ED; straightening manoeuvres performed at time of implant

Hinman's Atlas of Urologic Surgery; Bailey & Love's Surgery; Recent systematic review [PMID 36289392]

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2. Chronic Prostatitis / CPPS (NIH Category III)

Conservative

• Education and reassurance — explain the chronic nature; set realistic expectations
• Physical therapy — pelvic floor physiotherapy; myofascial release
• Lifestyle modification — avoid prolonged sitting, cycling; dietary changes (reduce spicy food, alcohol, caffeine)

Pharmacological

Interventional

• Prostatic massage — limited evidence but still used in some centres
• Psychological/psychosexual therapy — CBT for anxiety/somatization component
• CPPS often has significant psychological overlay — combined multidisciplinary approach most effective

Bailey & Love's Surgery, p. 9074; Campbell-Walsh Wein Urology

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3. Painful Ejaculation (Odynorgasmia)

Campbell-Walsh Wein Urology, p. 2099

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4. Phimosis

Conservative (first-line)

• Topical corticosteroid cream (0.05% betamethasone or 0.1% triamcinolone) applied to the tight prepuce twice daily for 4–8 weeks — effective in up to 80% of cases
• Gentle manual stretching exercises after steroid softening

Surgical

• Preputioplasty (dorsal slit/widening) — preserves foreskin
• Circumcision — definitive; indicated when conservative fails, recurrent balanitis, or patient preference

Pfenninger & Fowler's Procedures for Primary Care; Tintinalli's Emergency Medicine

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5. Paraphimosis

Immediate (reduction techniques)

1. Manual reduction — compression of glans oedema followed by foreskin reduction (ice pack/compression bandage first)
2. Osmotic agents — granulated sugar or mannitol applied to reduce oedema before manual reduction
3. Aspiration — needle aspiration of corpora to decompress glans if very oedematous
4. Dorsal slit under local anaesthetic — if manual reduction fails

Definitive

• Elective circumcision once swelling resolved

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6. Sexually Transmitted Urethritis

Gonococcal Urethritis (N. gonorrhoeae)

• Ceftriaxone 500 mg IM single dose (1 g if weight ≥150 kg) — first-line per current guidelines (fluoroquinolones no longer recommended due to resistance)
• + Doxycycline 100 mg BD × 7 days to cover concurrent Chlamydia

Non-Gonococcal Urethritis (C. trachomatis, M. genitalium, Ureaplasma)

• Doxycycline 100 mg BD × 7 days — preferred for Chlamydia
• Azithromycin 1 g stat — alternative (but declining efficacy for M. genitalium)
• Moxifloxacin — for doxycycline/azithromycin-resistant M. genitalium
• Metronidazole — if Trichomonas vaginalis confirmed

Harrison's Principles of Internal Medicine 22e, p. 910; Smith & Tanagho's General Urology

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7. Epididymo-Orchitis

Antibiotic Regimen

• If STI likely (age <35, MSM, unprotected sex):
  • Ceftriaxone 500 mg IM single dose + Doxycycline 100 mg BD × 14 days
• If enteric organisms likely (age >35, urinary tract instrumentation):
  • Ofloxacin 200 mg BD × 14 days, or ciprofloxacin
• Severe/toxic/febrile: Hospitalise; IV antibiotics

Supportive Measures

• NSAIDs (ibuprofen) for pain and inflammation
• Scrotal support (supportive underwear; scrotal elevation)
• Analgesics (paracetamol ± codeine)
• Rest

Schwartz's Principles of Surgery, 11th ed., p. 1789

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8. Balanitis / Balanoposthitis

Schwartz's Principles of Surgery, 11th ed.

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9. Genital Herpes (HSV-2)

First Episode

• Aciclovir 400 mg TDS × 7–10 days, or
• Valaciclovir 1 g BD × 7–10 days (better bioavailability; preferred)
• Reduces severity and duration; does not prevent future recurrences

Recurrent Episodes

• Episodic therapy: Aciclovir 800 mg BD × 5 days, or valaciclovir 500 mg BD × 3–5 days — start at prodrome/first sign
• Suppressive therapy (>6 recurrences/year): Valaciclovir 500 mg OD continuously — reduces recurrence by ~75%, reduces viral shedding and transmission risk

Adjunctive

• Saline bathing of ulcers, analgesics, topical lidocaine gel for pain
• Partner counselling and condom use

Textbook of Family Medicine 9e; The Harriet Lane Handbook

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10. Postorgasmic Illness Syndrome (POIS)

Campbell-Walsh Wein Urology, p. 1999

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11. Psychogenic / Functional Pain

• Psychosexual counselling — exploration of anxiety, relationship factors, performance pressure
• Cognitive Behavioural Therapy (CBT) — mainstay; addresses catastrophizing and avoidance
• Couples therapy — if relationship dynamics are contributing
• Graduated exposure / sensate focus exercises — systematic desensitisation to sexual activity
• Rule out organic cause first — psychogenic is a diagnosis of exclusion

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Summary Algorithm

Post-coital male genital pain
         │
         ├─ Structural penile deformity? → Peyronie's disease → Xiaflex / Surgery
         │
         ├─ Pain with ejaculation? → Prostatitis / Seminal vesiculitis / BPH
         │                          → Antibiotics / α-blockers / TURED
         │
         ├─ Urethral discharge / dysuria? → STI workup → Ceftriaxone + Doxycycline
         │
         ├─ Testicular/scrotal pain? → Epididymo-orchitis → Antibiotics + NSAIDs
         │
         ├─ Foreskin problem? → Phimosis / Balanitis → Steroids / Antifungal / Circumcision
         │
         ├─ Genital ulcers? → Herpes → Valaciclovir
         │
         ├─ Post-orgasmic systemic symptoms? → POIS → NSAIDs / antihistamines
         │
         └─ All negative? → Psychosexual evaluation → CBT / Couples therapy