What can I do to make sex painless and pleasurable again?

DEAR DOCTOR K:

I’m a man, and sex is often painful. Why? What can I do to make sex painless and pleasurable again?

DEAR READER:

If you go by what you see on TV, the only thing standing between you and a satisfying sex life is erectile dysfunction. The truth is, pain during sex can also be an obstacle.

I spoke to my colleague Dr. Michael O’Leary, a professor of surgery at Harvard-affiliated Brigham and Women’s Hospital. He noted that while the reason for painful sex can be difficult to diagnose and treat, it’s worth talking to your doctor. Together, you may be able to identify the problem — and a solution.

A number of conditions can cause painful sex. For example, infections of the prostate, bladder, urethra or the semen-producing glands can trigger painful burning or itching during or after ejaculation. If an infection is causing your symptoms, antibiotics may help to clear them up.

Another reason for painful sex is chronic pelvic pain syndrome (CPPS). The pain from CPPS can be widespread. It may affect the groin, the genitals and the area behind the scrotum. Men with CPPS can also have discomfort when they ejaculate.

We don’t know what causes CPPS. Theories that it is a bacterial infection of the prostate gland (prostatitis) have not been proven by studies. Some speculate that it is caused by a viral infection of the nerves in the pelvic region, but there is little evidence of that, at least so far.

CPPS can be difficult to treat. The standard options include antibiotics, anti-inflammatory drugs, nerve blocks injected in the pelvic area, and drugs used to treat an enlarged prostate. Find a doctor willing to research the options and work closely with you in your search for relief.

Another potential cause of painful sex is Peyronie’s disease, which causes a change in the shape of the penis. It happens when scar tissue forms inside the penis, causing it to bend or twist.

Some men with Peyronie’s have pain when they have an erection, particularly when the penis first starts to develop scar tissue. This usually goes away within six to 12 months. Even without pain, the curvature can make intercourse difficult, unsatisfying or impossible.

Two types of pills are sometimes prescribed to treat Peyronie’s: pentoxifylline (Trental, Pentoxil) and the supplement coenzyme Q10. But limited evidence suggests they don’t work very well.

Another option is an injectable drug that breaks down scar tissue and may reduce some of the curvature. However, it comes with a risk of permanent damage to the penis and other side effects. Men with Peyronie’s may also consider surgery — but it, too, is not very effective.

It’s probably obvious from what I’ve said that the medical field remains mostly ignorant about the causes of pelvic pain and what to do about them. The only solution to that is more research.