Andrologist, Urologist

Painful ejaculation or painful orgasm- causes, diagnosis and treatment

What is painful ejaculation or painful orgasm ?

Pain before onset of ejaculation or during ejaculation is termed as painful ejaculation. It can be dull or sharp pain and can involve the scrotum, penis root or shaft or perineal region. Pain can persist for few minutes to hours and person can have pain with urination also.

What are the causes of painful ejaculation ?

Various reason for painful ejaculation include – Prostatitis (infection/inflammation of the prostate), urinary tract infection, history of prostate surgery, sexually transmitted infections (STDs), use of medications such as antidepressants, prostate cancer, ejaculatory duct calculi etc. are the most common causes of painful ejaculation.

How to diagnose this condition and its causes ?

Painful ejaculation diagnosis is based on history provided by the patient. Causes leading to painful ejaculation can be assessed with the physical examination including digital rectal examination to palpate the prostate for any infection, urine examination with microscopy and culture, urethral discharge (if any), Trans rectal ultrasound (TRUS), serum PSA test. Additional tests are usually advised based on these initial tests.

What is the treatment for painful ejaculation ?

Treatment depends on the underlying cause. When it is caused by infection with either prostatitis or sexually transmitted infection, treatment is prescribing antibiotics to the patient along with analgesics. When its secondary to prostate surgery, it usually subside with time. Treatment for prostatic duct or ejaculatory duct calculi need endoscopic surgery for ejaculatory duct resection. Change of medicines for antidepressant induced painful ejaculation may be necessary. When painful ejaculation occurs due to prostate cancer, its treatment is done after more elaborate investigations and depending upon stage, type, patients age etc.

Whom to consult if you are having symptoms of painful ejaculation ?

Meet your local Urologist or Andrologist for best treatment.

Uro-oncology, Urologist

Prostate cancer – Part I

What is prostate ?

Prostate is a lemon sized reproductive gland, found only in men, below the bladder. Its function is to produce fluid which helps providing nourishment to sperms in semen. Urinary passage goes through prostate, before reaching the penis.

What all diseases can occur in prostate ?

BPH (BPH (Enlarged prostate) Symptoms), Prostatitis (Infection in prostate), Prostate cancer (Prostate cancer)are the most common diseases that originate from prostate.

What is prostate cancer ?

Like rest of the body cancers, prostate can harbour cancer in it. Malignant growth inside the prostate is called prostate cancer. Most of the prostate cancers are slow growing.

What are the risk factors for prostate cancer ?

Older age, African – American race, family history of ovarian/breast and prostate cancer increases the likelihood of a man being diagnosed with prostate cancer. As men increase in age, the risk of prostate cancer increases. About 60% of prostate cancers are diagnosed in men over the age of 65 years. Besides these, diet high in animal fat has been associated with risk of developing prostate cancer.

What are the symptoms of prostate cancer ?

Prostate cancer can be asymptomatic; meaning there can be no symptoms of cancer. If it does causes symptoms, these can be urinary symptoms or more generalised symptoms, depending upon the stage of prostate cancer. Most common symptoms include- urinary symptoms such as frequency or weak urinary stream, blood in urine (hematuria), erectile dysfunction (ED), Hematospermia (Blood in semen), urinary and bowel incontinence, pain in hips/back/legs etc.

Can we detect prostate cancer in patient who does not have symptoms ?

Prostate cancer can be easily screened with combination of Digital rectal examination (DRE), conducted by doctor and blood test called PSA (Prostate specific antigen). (Prostate cancer and PSA testing). These tests are recommended annually in men over 50 years of age. Combination of these tests can diagnose prostate cancer in men, in whom there are no symptoms of this disease.

What is PSA test ?

The PSA is a blood test which is commonly used to detect possible prostate cancer in a person. Elevated PSA levels may indicate the presence of prostate cancer, but it can be also elevated in certain conditions of prostate such as BPH, prostate infections (prostatitis), UTI (Urinary tract infection), retention urine etc.

If initial tests shows risk of prostate cancer, what happens next ?

The final diagnosis of prostate cancer is made after prostate biopsy done most commonly by ultrasound guidance called TRUS (Trans rectal Ultrasound). Sometimes doctor orders MRI called mpMRI (multiparametric MRI) prostate before undertaking biopsy. Once biopsy shows evidence of prostate cancer, the cancer is staged to look for the extent of cancer spread into the body. This is done by combination of various modalities such as CT scan, MRI , Bone scan and more recently PSMA PET scan.


Prostate enlargement diagnosis

Prostate enlargement diagnosis starts with the history and examination of the patient. Symptoms are scored to assess the severity of disease. (Read symptoms of prostate enlargement at BPH (Enlarged prostate) Symptoms). Per rectal examination in office room gives the initial clue to the enlargement of prostate. Since the urinary symptoms are not exclusive for prostate enlargement in men, few basic investigations are often required to reach final diagnosis before initiating treatment.

  1. Urine examination – patient provides a sample of freshly passed urine in a sterile container. This test tells about presence of any infection in urine.
  2. Uroflowmetry – In this test, patient need to hold urine till he gets urge to pass urine. Patient is asked to pass urine in a machine, which then generates a report about the flow of urine. After patient finished passing urine, the presence of any residual urine in bladder is checked by ultrasound.
  3. Ultrasound abdomen – ultrasound is done to see the kidneys, bladder and size of prostate. Kidneys are part of urinary system and prostate enlargement can affect kidney function.
  4. Serum creatinine – creatinine is marker of kidney function. Long term disease can lead to kidney damage and hence need for checking creatinine.
  5.  Blood PSA – PSA is test done to screen patients aged 55-70 years to rule out presence of prostate cancer. Patient with prostate cancer have raised blood PSA levels. However PSA can be raised in other conditions also such as urine infection, prostate infection, urine retention, large prostate etc. Read more about serum PSA at Prostate cancer and PSA testing
  6. TRUS – Trans rectal ultrasound (ultrasound probe passed through rectum) is conducted in office setting under local anaesthesia as it provides the more accurate size of prostate enlargement compared to abdominal ultrasound.
  7. Endoscopy – Flexible endoscopy through urethra may be ordered by physician as per the symptoms of patients and ultrasound findings.  Patients having severe symptoms with normal prostate size on ultrasound may need this test. Flexible endoscopy is done under local anesthesia in office setting which gives visualised information about intraurethral prostate protrusion, and whether it is causing any mechanical obstruction. Sometimes physician advices about prostate operation based on endoscopy report even if size of prostate is normal on ultrasound.
  8. Urodynamics – This test is selectively performed for patients who are suspected of having poor bladder contractility as the cause of his symptoms. These patients include those having symptoms of bed wetting, spontaneous urine leakage, neurological disorders, having previous prostate surgery etc.

After these tests the decision is taken by the doctor for treating the patient with either medicines or with surgery. Read treatment of enlarged prostate at Treatment of Benign Prostatic Enlargement

Uro-oncology, Urologist

Prostate cancer and PSA testing

  • Prostate is a small walnut sized organ present in men and is the part of male reproductive organ. It helps in the male fertility. Normal prostate size varies from 15-20 gm.
  • Prostate cancer is the most common cancer in men after skin cancer.
  • PSA (Prostate specific antigen) is the blood test which is specific for the prostate.
  • Though PSA is organ specific, it is not disease specific.
  • PSA is raised in many conditions such as prostatitis (prostate infection), prostate cancer, prostate abscess, BPH (benign prostate hypertrophy), acute retention of urine, urine infection, hematuria, prostate surgery etc.
  • Normal PSA value range from 0-4 ng/ml for an average sized prostate and its upper range value corresponds to the advanced patient age.
  • PSA is used for screening of prostate cancer as it is raised in these patients.
  • Raised PSA need thorough evaluation to rule out any other cause of elevation of PSA other than prostate cancer. These tests include DRE (digital rectal examination), urine routine/culture.
  • Absence of urinary infection or in an asymptomatic men with no prior urologic surgery, raised PSA suggests the possibility of harbouring prostate cancer and need further workup for same. These tests include mpMRI (Multiparametric MRI) prostate if PSA is more than 4 ng/ml and less than 10 ng/ml.
  • Any patients with raised PSA and having prostate which is hard on DRE or harbouring nodule, need prostate biopsy directly. Also, patient with PSA more than 10 ng/ml or more than 4 ng/ml and MRI showing high suspicion for prostate cancer need biopsy of prostate.
  • Free PSA (fPSA) is often useful for patients having PSA in range between 4-10 ng/ml. This blood test tells about the risk of prostate cancer in such patients.
  • Final diagnosis is with prostate biopsy in men having raised PSA and is done by the TRUS (Transrectal Ultrasound) under local anaesthesia.

Prostate cancer


  • Prostate is a small walnut-shaped gland in males situated below the bladder in front of the rectum.
  • Prostate cancer is the most common cancer among men (after skin cancer).
  • Prostate cancer is the cancer in prostate gland.
  • Many prostate cancer grow slowly and remain confined to prostate gland, however, few prostate cancer grows rapidly and present in advanced state. Treatment depends upon the stage of prostate cancer.


  • Weak urinary stream

• Difficulty in passing urine

  • Frequent urination
  • Blood in urine
  • Blood in semen
  • Bony pains
  • Loss of weight and appetite
  • Erectile dysfunction

Risk factors

•Older age- Prostate cancer is more common after 50 years of age.

•Familial factors – more common in a person whose relative such as father or brother has prostate cancer.

•Race – black race has more incidence of prostate cancer compared to white race.

•Genetic factors – rarely, few genetic FACTORS lead to development of prostate cancer.

•Obesity- obese people are more prone to development of prostate cancer.


•Most urologist encourage men after 50 years to undergo screening for prostate cancer which include DRE (digital rectal examination) and serum PSA (prostate specific antigen) measurement.


•DRE – prostate gland is felt through rectum and checked for any nodule or hardness of gland which is suspicious for cancer.

•Serum PSA – normal value in average sized prostate vary from 0-3 ng/ml. Increased PSA level suggests possibility of prostate cancer.

•MRI prostate – in suspicious cases with PSA 4-10 ng/ml, multiparametric MRI prostate is advisable. it tell the doctor about the estimated risk of prostate cancer in that patient.

•TRUS biopsy – final diagnosis of prostate cancer is made on prostate biopsy. systematic 12 core prostate biopsy is taken by ultrasound guidance. Severity of disease is also assessed by Gleason scoring on biopsy.


•Staging of prostate cancer is done after checking the level of serum PSA, findings on DRE and biopsy report.

•Staging of prostate cancer is done by PSMA PET scan or CT scan/MRI scan abdomen with bone scan. •After staging tests, patients are segregated into localised, locally advanced or metastatic prostate cancer.


Treatment of prostate cancer depends upon various factors such as stage of disease, level of serum PSA, overall health of patient, life expectancy of patient.

Deferred treatment – very low risk cancers with minimal risk of spread may be kept on surveillance. Similarly, treatment may be avoided in patients with low life expectancy.

Surgery – surgical removal of prostate (robotic surgery- RARP/lap surgery) is done in patients with localised disease. Sometimes it is done in locally advanced prostate cancer in combination with other treatments. •Radiation therapy – radiation therapy involves use of high energy to kill the prostate cancer cells. It is achieved by radiations from external source (ebrt) or from internal source after placing radioactive source in the prostate gland (brachytherapy). 

Hormone deprivation therapy – this therapy is useful in advanced and metastatic stage to decrease the testosterone level in blood. Testosterone hormone helps in growth of prostate cancer. Many injections such as lhrh antagonist and agonist are available which helps in reduction of testosterone hormone level. This can also be achieved by bilateral orchiectomy (testes removal).

Chemotherapy – chemotherapy such as docetaxel/cabazitaxel is used in patients with metastatic prostate cancer.

Bone health – bisphosphonate injections are used to prevent osteoporosis associated with the metastatic prostate cancer.