Shedding Light on Male Pelvic Pain and Sexual Dysfunction

Jeannette M. Potts, MD

The continued misuse of the generic diagnosis, “prostatitis,” remains a disservice to the vast majority of patients suffering from pelvic and genital pain frequently associated with lower urinary tract symptoms and sexual dysfunction. Growing evidence over the past two decades shows that fewer than 10% of patients have an infectious cause for their symptoms and that end-organ or prostatocentric approaches are inadequate. Meanwhile, more comprehensive care, emphasizing  biopsychosocial  and neuromuscular  components of pain, have been shown to be more beneficial for men suffering with UCPPS. And indeed, the NIH-NIDDK conference of 1996 recognized the fact that the condition may not be a malady of the prostate to begin with!

Unfortunately, when UCPPS is associated with sexual dysfunction, i.e. painful ejaculation or post coital discomfort, patients are more likely to be diagnosed with prostatitis and, therefore, even more likely to endure weeks of unnecessary antibiotic therapy.

Sexual dysfunction in this setting can be manifest in many ways: Dysorgasmia (painful ejaculation), post ejaculatory or post coital aching or pain, painful arousal, and decreases in erectile function and libido secondary to the pain, fear and anxiety.

(It is important to reassure men about these secondary effects, as many believe they have a separate terrible disease.)

During my career, I’ve developed a theory regarding dysorgasmia and postcoital discomfort, within the context of pelvic neuromuscular floor dysfunction and myofascial trigger points. In patients suffering from these sexual symptoms, the pleasurable sensations and “spasms” of orgasm evolve into painful contractions and abnormal tightening of the pelvic floor. This is worsened and perpetuated by the anticipation of yet another unpleasurable or painful climax. (Imagine trying to enjoy sex while fearing the approach of orgasm as pain rather than rapture.)

As I first hypothesized about the neuromuscular influence on this condition, I made another observation: Many men with the condition also described a marked decrease or absence of semen during ejaculation, or, in some, a delayed dripping of the ejaculate. This certainly exacerbated their anxiety as many men justifiably wondered what was happening to the fluid and was it “backing up” into their already allegedly inflamed sex organs. But of course this was not the case.

Yet another clue emerged. And as any sensitive healthcare provider knows, our continuing medical education comes by way of our own patients as much as by a conference, these clues came from unrelated patients.

Several men in my practice practice martial arts and Taoism. To preserve their Chi (energy), they do not ejaculate during sex or climax. They’ve trained themselves to contract the pelvic floor muscles, thereby causing an intentional form of retrograde ejaculation. By squeezing the muscles that tighten the external sphincter muscle, just distal (just beyond the end of the prostate), the ejaculation entering the prostatic urethra no longer travels frontwards and out the tip of the penis. The path of least resistance is no longer outward, as the tightened sphincter now provokes the flow of semen backward and into the urinary bladder. This causes no physical harm and is excreted with the urine during urination. Men who try to do this intentionally require practice and many have experienced significant pain.

It now made sense to me that UCPPS patients with dysorgasmia were involuntarily performing similar techniques practiced by those persons intentionally trying to withhold their ejaculation. This, I’ve termed ejaculatory dyssynergia.

Although this remains just a theory, I am encouraged by yet another piece of the puzzle. As the symptoms of UCPPS in men improve and resolve through specialized pelvic floor PT and manual trigger point release, many patients describe as secondary improvements, increasing pleasure with sex and orgasm, as well as increase in the volume and force of ejaculation.

I believe that ejaculatory dyssynergia helps to better conceptualize this phenomenon as one of the most stressful and debilitating facets of UCPPS. This is especially true among those patients in whom we also observe dysfunctional defecation (tenesmus, puborectalis syndrome, etc) and those whose LUTS may be derived from similar acquired habits such as pseudo-DSD (Detrusor-sphincter-dyssynergia).

Originally published on www.pelvicpainrehab.com on Feb 21, 2014.