Post-orgasmic illness syndrome : a case report

Post orgasmic illness syndrome (POIS) is a newly described syndrome. Manifestations of this syndrome may be physical, cognitive or both. Many theories have been proposed to explain the causes of this syndrome including allergy to seminal components, allergy to unknown proteins released during ejaculation or a psychosomatic etiology. We present a case of POIS with a manifestation of atopy that may be consistent with the allergy hypothesis. Abdalla M Attia ( ) Corresponding author: abdalla_attia@hotmail.com Attia AM, Yasien HA and Al-Ziny MH. How to cite this article: Post-orgasmic illness syndrome: a case report [version 1; referees: 3 2013, :113 (doi: ) approved with reservations, 1 not approved] F1000Research 2 10.12688/f1000research.2-113.v1 © 2013 Attia AM . This is an open access article distributed under the terms of the , which Copyright: et al Creative Commons Attribution Licence permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. The author(s) declared that no grants were involved in supporting this work. Grant information: No competing interests were disclosed. Competing interests: 19 Apr 2013, :113 (doi: ) First published: 2 10.12688/f1000research.2-113.v1 1 1

.This recently described syndrome may be more prevalent than one might expect, but has not received much attention and, we think, many cases may be misdiagnosed.
To the best of our knowledge, aside from two cases reported by Waldinger and Schweitzer 1 , two by Ashby and Goldmeier 2 , and one each by Dean (personal communication), Mullhal (personal communication) and Ashworth (personal communication), and the self reported cases on the site of the Naked Scientist's discussion forum (www.thenakedscientists.com/forum), no more scientific discussion on POIS exists in textbooks, medical journals, or scientific meetings or congresses.
POIS appears to be principally a male orgasmic disorder, as most of the reported cases are males.Its manifestations start within seconds after orgasm and may continue for 4-7 days.These manifestations differ in their severities but, in most cases they are severe enough to make the patient abstain from the sexual activities; especially ejaculation and orgasm.They are not uniform for each patient and can be grouped based on having a specific cluster of symptoms 1,2 .
The most commonly reported manifestations are cognitive disorders and flu-like symptoms.The former is described by the patient as including brain fog, with inability to focus, communicate or process information.Some patients may suffer from temporary aphasia, irritability, anxiety, inability to relax and social phobias.The flu-like manifestations are; fever, sore throat, headache, chill, over-sweating with severe muscular, and bone and joint pains to the extent of severe exhaustion and fatigue 1 .One patient reported transient memory loss after each orgasm 2 .
Nothing is currently known regarding the underlying etiopathology of POIS, but the presence of manifestations in symptom clusters and absence of uniformity may point to different etiologies of the disease.It has been theorized that an allergic reaction could be responsible 1 .Waldinger and Schweitzer stated that during ejaculation and orgasm, many chemicals are released in the blood and an allergic reaction may occur in response to one (or more) of them, causing POIS manifestations.Alternatively, a psychosomatic disorder theory has been proposed by Krishnamurti and Ashoor (personal communications), who stated that these manifestations occur in individuals who believe that loss of vital fluid from the body (i.e.semen) causes weakness.Hypothyroidism (Dean, personal communication), hyperglycemia, hypertension, cortisol depletion, decreased (Dehydroepiandrosterone) DHEA, decreased testosterone, elevated prolactin and disorders of the CNS including alterations in serotonin, catecholamine and endorphin activity, are other suggested theories for this syndrome 1 (Dean, personal communication; Ashworth, personal communication).
There is currently no effective treatment for POIS.Strong analgesics, such as NSAIDs, tramadol HCl and selective serotonin re-uptake inhibitors, taken one hour pre-coital may help some patients but are of no benefit in others 1,2 .

Case
Here we present a 45 year old Egyptian engineer who had been in a stable marriage for 10 years and had 3 children.Shortly post-orgasm (within 4-5 seconds), he feels severe fatigue, tiredness and exhaustion with severe muscular, bone and joint pains so that opening his hands becomes very painful.The condition is accompanied by headache, a pale face, eye irritation, low concentration, anxiety and dizziness with severe itching.The patient reported that these manifestations started early with puberty and increased in severity with age and occur with all orgasms whatever the type of sexual activity; night emission, masturbation or vaginal ejaculation.These manifestations are so severe that during the first 2 days post-orgasm he can't go to work, though they gradually fade and disappear by the 5 th day.The patient abstains from sexual activity, although he has a strong desire and rigid erections.He has no history of chronic diseases, operations or drug intake except for life-long atopic manifestations of bronchial asthma, allergic rhinitis and neurodermatitis and occasionally uses symptomatic treatment to treat these manifestations.
On examination the patient had fair general health, was well built and had complete secondary sex characters.His weight was 97 kg, height was 177 cm and blood pressure was 125/85 mm/Hg.
The results of routine laboratory tests (complete blood picture, renal function, blood sugar and prostatic smear) were all normal.The results of other laboratory tests are shown in Table 1.
The patient received strong analgesics in the form of Ibubrofen (400 mg on demand) and tramadol (50 mg one hour pre-coitally) but there was no reported benefit.A selective serotonin re-uptake inhibitor (escitalopram 10 mg daily at bedtime for 3 months) was also tried with no benefit.

Discussion
The exact etiopathology of POIS is currently unknown.The presentation of symptoms appear in clusters and the differences from one patient to another suggests that there may be more than one cause for this syndrome.Hyperglycemia 1 , low cortisol, low testosterone, elevated prolactin (Ashworth, personal communication), hypothyroidism (Dean, personal communication) and low DHEA 1 have all been proposed to explain the etiopathology of POIS.All of these parameters were assessed in this patient and proved to be normal.We believe that the psychosomatic theory, where the belief that loss of vital fluid (i.e.semen) causes weakness, is not applicable to this patient as he is highly educated, successful in his job, has an intact personality and a stable marital life.The elevated liver enzymes in this patient are not related to his problem as his POIS manifestations have been present since puberty.
What should be considered in this patient is his life-long atopy, including neurodermatitis.He reported severe itching after each orgasm as one of his POIS manifestations.We believe this factor to be very interesting, as it may point to and support an allergic etiology 1 in this patient.Previously reported cases did not inquire about or evaluate allergic reactions 1,2 .As such, we believe that it is very important to re-evaluate these cases and any forthcoming reported ones for any allergic and hypersensitive reactions.

Conclusion
Much more attention to POIS is necessary to avoid misdiagnosis, to determine its exact etiopathology and to identify an effective treatment.A possible association with different allergic reactions is worthy of further investigation and evaluation.

Consent
Written informed consent for publication of clinical details was obtained from the patient.We would like to note that we encourage the publication of case reports on Post Orgasmic Illness Syndrome (POIS).POIS was previously recognized and reported by Waldinger who proposed 5 et al. preliminary criteria, which were extracted from a large study of 45 Dutch males with POIS .Moreover, in 2011 Waldinger . postulated that POIS is caused by an immunological reaction against a man's own et al semen.This concept was based on a placebo-controlled study amongst 33 men who underwent skin-prick tests with diluted auto-semen .The skin prick reaction appeared to be positive in 88% .In addition, hyposensibilisation with auto-semen showed to ameliorate POIS symptoms in two men who consented with hyposensibilisation .Notably, Waldinger also showed that of all 45 men with POIS et al. 58% had an atopic constitution, suggesting a relationship between an allergic constitution and POIS .
Apart from being incomplete in their references (references 1 and 2 are not mentioned in the article of Attia ), the authors of the current case report quoted the first publication of Waldinger and Schweitzer et al. erratically by mentioning that analgesics, such as NSAIDs, tramadol and SSRIs taken precoital "may help some patients" suggesting that these drugs may be effective in some way to treat POIS.However, in the original description of POIS in 2002, none of these drugs were suggested as being clinically effective to reduce POIS symptomatology.Existence of atopic or allergic conditions remains a cornerstone of POIS and was clearly previously reported in the aforementioned original studies.Therefore, it is ironical and also flawed when Attia stated that "previous reported cases did not inquire about or evaluate allergic et al. reactions".We feel obliged to clarify these wrong statements since scientific prudence must prevail particularly in case of claims of new disease concepts.We have read this submission.We believe that we have an appropriate level of expertise to state that we do not consider it to be of an acceptable scientific standard, for reasons outlined above.
No competing interests were disclosed.

Competing Interests:
Author Response 13 Jun 2013 , Menoufia University, Egypt abdalla attia Dear Prof Waldinger, Thank you for your review of this paper.Although we respect your opinion, we are disappointed and surprised at your comments on the article, particularly as you state that you would encourage further publications on POIS.
We discovered our case of POIS at the end of 2009.At this point, there seemed to be only one similar publication (Waldinger & Schweitzer, 2002) on POIS but this did not refer to atopy.We found that our patient was atopic.In addition to the cognitive and body pains he feels post orgasm, his atopy flares up, producing eye irritation and severe body itching.After preparing our first report in December 2009, and before publication, we did try to contact you for your opinion as the sole other reporter of this syndrome but received no response from repeated attempts.
In 2010, we shared this case report at the ISSM forum.To our knowledge, this was before any other published report of atopy in relation to POIS.Many of our colleagues who are ISSM members commented and discussed the case at this forum, one of them being Prof. David Goldmeier.This case report was also presented as a poster at the 20th World Congress for Sexual Health, held in June 12-16, 2011, in Glasgow, UK, and was published in the conference proceedings.On the basis of this history, we suggest that we may have been the first to suggest that atopy may be a precipitating factor for POIS and that this condition should be checked for in any POIS cases.
We would also like to respond to your other comment regarding the use of NSAIDs, tramadol and SSRIs in this condition.The reference to Waldinger 2002 in this section is related to the et al. sentence 'There is currently no effective treatment for POIS' and we apologise if this is unclear.We agree that this reference should be corrected so that it is attached to the correct statement.Our patient did not get any benefits from trying these drugs in contrast to the results of Ashby &  Goldmeier (2010).
In regards to testing for allergic reactions, we would like to ask whether you think that the skin prick test is reliable as a diagnostic test for allergy.Is it valid to conclude that POIS patients are allergic to their own semen on the basis of this test and suggest that this is the cause of POIS?We would suggest that skin prick tests can lead to many false positive and negative results.As andrologists we know (and there is a body of evidence for this), that semen is regarded as foreign by the body and the immune system.Immune tolerance to semen is not present.Semen is separated from the immune system by a very competent blood-testis barrier that is formed by the highly efficient Sertoli-Sertoli cell junctional complex.We would suggest that this is not a 'hypothetical membrane'.In certain known pathological conditions this barrier may be broken.If this occurs, auto-antibodies can form against semen.Thus, if a subject's own semen is then injected 2-In our case, severe itching and eye irritation, which are some of the atopic manifestations, started just after orgasm each time it occured.3-Although levocetrizine use is a good idea and we did not try it, it alone seems to be insufficient in relieving atopic symptoms and we estimate the results may be not satisfactory.We tried to use systemic steroids but the patient had refused.4-Niacin did not reach our knowledge at that time to use it, but we think it is worthy enough to try.5-No he has not suffered from chronic fatigue syndrome.6-He tried ibuprofen 400 mg before and after sexual activity, tramadol hydrochloride as we mentioned but with no response.7-POIS manifestations started in this patient only after orgasm and not sex without orgasm No competing interests were disclosed.

Michael Fraser
Department of Urology, Royal Infirmary & Southern General Hospitals, Glasgow, UK I find this case report interesting, but no more than that.The clinical entity which has acquired the acronym POIS is intriguing and for that reason alone worthy of appearing in print to increase awareness of its possible existence.I do feel that a cluster of symptoms does not make for greater interest.I would be fascinated to see someone consider neuroradiologic imaging (PET/MRI) in these subjects.
I have read this submission.I believe that I have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however I have significant reservations, as outlined above.
No competing interests were disclosed.

Competing Interests:
Author Response 03 May 2013 , Menoufia University, Egypt abdalla attia Dear Dr Fraser, Thanks for your comment.Here in our case, we propose an allergic theory that may correlate between POIS and Atopy.So, we think that PET/MRI may be just wasting money, especially if the patient has these signs and symptoms just after each orgasm, apart, he is completely normal or has signs and symptoms of atopy.Otherwise, these patients may need to be investigated in regard to the issue of atopy to prove or deny our theory.

Thanks, Abdalla Attia
The author of the case No competing interests were disclosed.Competing Interests: Department of Pharmacology, Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, Netherlands Department of Internal Medicine and Endocrinology, Reinier de Graaf Groep of Hospitals, Delft-Voorburg, Netherlands

Table 1 Laboratory results of a patient with post-orgasmic illness syndrome. Test Patient's result Normal lab range
* These elevations are due to fatty liver with no viral cause (as determined by PCR & liver ultra-sonography) DHEA-S: Dehydroepiandrosterone sulfate