Case Study: Severe Anorgasmia and Testicular Pain in a Young Adult on Paroxetine

Case at a Glance

A 19-year-old male being treated with paroxetine for anxiety and depression presented with a one-year history of inability to ejaculate and associated severe, debilitating testicular pain. This case highlights the significant impact of SSRI-induced sexual dysfunction and the importance of differentiating severe epididymal hypertension from other testicular pathologies.

Patient's Story

A 19-year-old male, with a lean build weighing 90kg, presented with a concern that had persisted for over a year. He reported a complete inability to ejaculate (anejaculation) despite normal libido and ability to achieve erection. This symptom began shortly after he started treatment for anxiety and depression with 50mg of paroxetine daily. Concurrently, he experienced episodes of severe testicular pain following sexual arousal, which he described as 'blue balls.' The pain was intense enough to cause him significant discomfort and inability to cross his legs. He was concerned whether this was a normal side effect or indicative of a more serious medical condition.

Initial Assessment

The patient's presentation was highly suggestive of medication-induced sexual dysfunction. Paroxetine, a Selective Serotonin Reuptake Inhibitor (SSRI), is well-known for causing anorgasmia and delayed ejaculation. The testicular pain described is consistent with epididymal hypertension, a benign condition resulting from prolonged vasocongestion in the testes and epididymis during sexual arousal without orgasm. However, the reported severity of the pain warranted careful consideration to rule out other causes of testicular pain, such as epididymitis, orchitis, or intermittent torsion.

The Diagnostic Journey

The diagnostic process focused on the patient's history. The clear temporal relationship between the initiation of paroxetine and the onset of anejaculation strongly pointed to the medication as the primary cause. It was explained to the patient that sexual side effects are common with this class of antidepressants. While 'blue balls' (epididymal hypertension) is a known phenomenon, the severity he described is unusual and distressing. The primary recommendation was a formal clinical evaluation to confirm the diagnosis and rule out any underlying urological issues. A physical examination of the scrotum and testes would be the crucial next step.

Final Diagnosis

SSRI-Induced Anorgasmia (Anejaculation) with associated severe Epididymal Hypertension. While this is the most probable diagnosis based on the history, other organic causes of testicular pain must be formally excluded through a physical examination.

Treatment Plan

The immediate recommendation was for the patient to schedule an appointment with his prescribing physician to discuss these debilitating side effects. The following management strategies were considered for discussion with his healthcare provider:

1. Medication Adjustment: Exploring a dose reduction of paroxetine.
2. Switching Antidepressants: Transitioning to a different class of antidepressant with a lower incidence of sexual side effects, such as bupropion or mirtazapine.
3. Adjunctive Therapy: Adding a medication to counteract the sexual side effects.
4. Urological Consultation: A referral to a urologist for a physical examination and possible scrotal ultrasound to definitively rule out other pathologies given the severity of the pain.

Outcome and Follow-up

The patient acknowledged the information and understood the need for a medical consultation. Follow-up with his prescribing physician is essential to manage his treatment for anxiety and depression while addressing the medication's side effects. The goal is to find a therapeutic regimen that effectively manages his mental health without causing unacceptable adverse effects, thereby improving his overall quality of life.