Painful intercourse in men

Specialty: Nephrology and urology.

• male dyspareunia
• pain during penetration or male sexual act

Why it occurs

• Phimosis or frenulum brevis (preputial narrowness or short fibrous cord that is painfully pulled and torn during penetration with a complete erection)
• Peyronie's disease (inflammation and extreme curvature of the penis generates painful mechanical tension on the tunica albuginea during penetration)
• Balanitis or active balanoposthitis (direct mechanical friction on the inflamed glans and foreskin exacerbates burning and irritating pain)
• Acute or chronic prostatitis (congestion and pelvic contraction during penetration and sustained erection generates deep pain radiating to the perineum and scrotum)
• Active genital herpes simplex virus infection (painful ulcers or vesicles on the shaft of the penis or glans that rub during intercourse)

Initial workup

Detailed physical genital examination for flaccidity to assess the preputial ring, frenulum, presence of Peyronie's patches or sexually transmitted ulcers; Doppler ultrasound of the penis to rule out abnormalities of the tunica albuginea; urethral smear and culture of balanic secretions; sperm culture if associated chronic prostatitis is suspected.

Standard management

• Acyclovir — 400 mg three times a day orally for 7-10 days, or Valacyclovir 1 g a day, indicated if an active outbreak of genital herpes is demonstrated as the cause of pain
• Clotrimazole 1% cream — applied locally to the glans and foreskin if the pain is secondary to candidal balanitis
• Ibuprofen — 400-600 mg orally as an analgesic before or after intercourse in stable inflammatory phases of Peyronie's disease
• Scheduling for surgical circumcision or frenuloplasty if the cause is phimosis or limiting brief frenulum.