Postorgasmic illness syndrome

In men, postorgasmic illness syndrome (POIS) is a rare disease which, immediately following ejaculation, can cause severe muscle pain throughout the body, as well as other symptoms which can be cognitive, psychological, or physiological. The symptoms last for up to a week. Some doctors speculate that the frequency of POIS "in the population may be greater than has been reported in the academic literature", and that many POIS sufferers are undiagnosed. POIS is characterized by rapid onset after ejaculation, absence of local genital reaction, and presence of an overwhelming systemic reaction.

Postorgasmic illness syndrome
Classification and external resources
Specialty	Andrology, Allergy, Endocrinology
Patient UK	Postorgasmic illness syndrome
MeSH	D004542, D012735
Orphanet	279947

Signs and symptoms

The distinguishing characteristics of POIS are:

1. the rapid onset of symptoms after ejaculation;
2. the absence of any local genital reaction; and
3. the presence of an overwhelming systemic reaction.

POIS symptoms, which are called a "POIS attack", can include some combination of the following: severe muscle pain throughout the body, severe fatigue, mild to severe headache, weakness, and flu-like or allergy-like symptoms, such as sneezing, itchy eyes, and nasal irritation. Additional symptoms include cognitive dysfunction, intense discomfort, irritability, anxiety, craving for relief, susceptibility to nervous system stresses (e.g. common cold), depressed mood, and difficulty communicating, remembering words, reading and retaining information, concentrating, and socializing. Affected individuals may also experience intense warmth or cold.

The symptoms begin shortly after or within a half hour of ejaculation.

The symptoms can last for several days, sometimes up to a week.

In some men, the onset of POIS is in puberty, while in others, the onset is in their twenties. POIS that is manifest from the first ejaculations in adolescence is called primary type; POIS that starts later in life is called secondary type.

Many POIS sufferers report lifelong premature ejaculation, with intravaginal ejaculation latency time (IELT) of less than one minute.

Synonyms and related conditions

POIS has been called by a number of other names, including "postejaculatory syndrome", "benign coital headache", "postorgasm illness syndrome", "post ejaculation sickness", and "post orgasmic sick syndrome".

Sexual headache is a type of headache that occurs in the skull and neck during sexual activity, including masturbation or orgasm. One paper speculates that sexual headache and POIS could be the same thing, or could be part of the same spectrum with similar pathogenesis.

Dhat syndrome is a condition, first described in 1960 in India, with symptoms similar to POIS. Dhat syndrome is thought to be a culture-bound psychiatric condition and is treated with cognitive behavioral therapy along with anti-anxiety and antidepressant drugs.

Post-coital tristesse (PCT) is a feeling of melancholy and anxiety after sexual intercourse that lasts anywhere from five minutes to two hours. PCT, which affects both men and women, occurs only after sexual intercourse and does not require an orgasm to occur, and in that its effects are primarily emotional rather than physiological. By contrast, POIS affects only men, consists primarily of physiological symptoms that are triggered by ejaculation and that can last, in some people, for up to a week. While PCT and POIS are distinct conditions, some doctors speculate that they could be related.

An array of more subtle and lingering symptoms after orgasm, which do not constitute POIS, may contribute to habituation between mates. They may show up as restlessness, irritability, increased sexual frustration, apathy, sluggishness, neediness, dissatisfaction with a mate, or weepiness over the days or weeks after intense sexual stimulation. Such phenomena may be part of human mating physiology itself.

Mechanism

The cause of POIS is unknown. Some doctors hypothesize that POIS is caused by an auto-immune reaction. Other doctors suspect a hormone imbalance as the cause. While other causes have been proposed as well, none of the proposed causes seem to fully explain the disease.

Allergy hypothesis

According to one hypothesis, "POIS is caused by Type-I and Type-IV allergy to the males' own semen". Specifically,

Autologous seminal peptides or peptides released from the disrupted urethral lining cells, contact the inner mucosal epithelium of the urethra. During this contact, antigen(s) of semen and / or seminal fluid is recognized and taken up by dendritic cells in the epithelium. These cells then wander to the T-cell zones of lymph nodes, where they present the seminal fluid antigen(s) to naïve T-cells and initiate the cascade of events of a hypersensitivity reaction.

Though the word "allergy" is often used when describing this hypothesis, strictly speaking, according to this hypothesis, "POIS is not the manifestation of an allergy for autologous semen, but POIS is the systemic manifestation of an auto-immune reaction to the man’s own semen".

POIS could also be caused by an auto-immune reaction not to semen itself, but to another substance that is released during ejaculation, such as to cytokines.

The allergy hypothesis has been disputed. According to one study, "IgE-mediated semen allergy in men may not be the potential mechanism of POIS".

Hormone hypothesis

According to another hypothesis, POIS is caused by a hormone imbalance, such as low progesterone, low cortisol, low testosterone, elevated prolactin, hypothyroidism, or low DHEA.

POIS could be caused by a defect in neurosteroid precursor synthesis. In this case, the same treatment may not be effective for different sufferers. Different sufferers may have different missing precursors, ultimately leading to a deficiency of the same particular neurosteroid, causing similar symptoms.

Other possibilities

POIS could also be caused by hyperglycemia or by chemical imbalances in the brain.

Sexual activity for the first time may set the stage for an associated asthma attack or may aggravate pre-existing asthma. Intense emotional stimuli during sexual intercourse can lead to autonomic imbalance with parasympathetic over reactivity, thereby causing release of mast cell mediators that can provoke postcoital asthma and / or rhinitis in these patients.

It is also possible that, in different individuals, the etiologies of POIS are different. POIS could represent "a spectrum of syndromes of differing etiologies".

None of the currently proposed causes for POIS explain the connection between POIS and lifelong premature ejaculation.

Diagnosis

There is no generally agreed upon diagnostic criteria for POIS. One group has developed five preliminary criteria for diagnosing POIS. These are:

1. one or more of the following symptoms: sensation of a flu-like state, extreme fatigue or exhaustion, weakness of musculature, experiences of feverishness or perspiration, mood disturbances and / or irritability, memory difficulties, concentration problems, incoherent speech, congestion of nose or watery nose, itching eyes;
   
2. all symptoms occur immediately (e.g., seconds), soon (e.g., minutes), or within a few hours after ejaculation that is initiated by coitus, and / or masturbation, and / or spontaneously (e.g., during sleep);
   
3. symptoms occur always or nearly always, e.g., in more than 90% of ejaculation events;
   
4. most of these symptoms last for about 2–7 days; and
   
5. disappear spontaneously.

POIS is prone to being erroneously ascribed to psychological factors such as hypochondriasis or somatic symptom disorder.

Management

There is no standard method of treating or managing POIS. Patients need to be thoroughly examined in an attempt to find the causes of their POIS symptoms, which are often difficult to determine, and which vary across patients. Once a cause is hypothesized, an appropriate treatment can be attempted. At times, more than one treatment is attempted, until one that works is found.

Affected individuals typically avoid sexual activity, especially ejaculation, or schedule it for times when they can rest and recover for several days afterwards. In case post-coital tristesse (PCT) is suspected, patients could be treated with selective serotonin reuptake inhibitors.

One patient with low progesterone, who had been symptomatic for 27 years, was successfully treated with oral norethisterone. He took 5 mg of norethisterone half an hour before sexual activity, as well as occasionally 5 mg or 10 mg of norethisterone immediately after sexual activity.

Another patient, in whom POIS was suspected to be caused by cytokine release, was successfully treated with nonsteroidal anti-inflammatory drugs (NSAIDs) just prior to and for a day or two after ejaculation. The patient took diclofenac 75 mg 1 to 2 hours prior to sexual activity with orgasm, and continued twice daily for 24 to 48 hours.

One POIS patient with erectile dysfunction and premature ejaculation had much lower severity of symptoms on those occasions when he was able to maintain penile erection long enough to achieve vaginal penetration and ejaculate inside his partner. The patient took tadalafil to treat his erectile dysfunction and premature ejaculation. This increased the number of occasions on which he was able to ejaculate inside his partner, and decreased the number of occasions on which he experienced POIS symptoms. This patient is thought to have Dhat syndrome rather than true POIS.

In one patient, the POIS symptoms were so severe, that he decided to undergo castration in order to relieve them. The POIS symptoms were cured by the castration.

Two patients, in whom POIS was suspected to be caused by auto-immune reaction to their own semen, were successfully treated by allergen immunotherapy with their own autologous semen. They were given multiple subcutaneous injections of their own semen for three years. Treatment with autologous semen "might take 3 to 5 years before any clinically relevant symptom reduction would become manifest".

Treatments are not always successful, especially when the cause of POIS in a particular patient has not been determined. In one patient, all of whose routine laboratory tests were normal, the following were attempted, all without success: ibuprofen, 400 mg on demand; tramadol 50 mg one hour pre-coitally; and escitalopram 10 mg daily at bedtime for 3 months.

Epidemiology

The prevalence of POIS is unknown. POIS is listed as a rare disease by the American National Institutes of Health and the European Orphanet.

POIS could be part of the same spectrum as sexual headaches, which are estimated to affect between 0.25% and 1% of the population.

Women

It is possible that a similar disease exists in women, though, as of 2016, there is only one documented female patient.