Digest of recent discussions on ISSM mail (January

It is interesting that 3 of the last 6 clinical discussions on ISSM List involved post orgasmic headaches or cognitive symptoms. The proposed post-orgasmic illness syndrome (POIS) was brought up during the discussion.

Question Posted

Post-Orgasmic Cognitive Symptoms

Dr. John Dean presented a case of a man in his mid fifties complaining of lifelong transient loss of memory and irritability that occurs after every orgasm. Otherwise the patient has no other sexual complaints, and no neurological disorders diagnosed by a neurologist. Dr. Dean considered asking the patient to masturbate and to have an orgasm whilst he was having his EEG. Dr. Charles Moser reported seeing two similar cases and forwarded an abstract by Dr. Waldinger �published in J Sex Marital Therapy- describing a post-ejaculatory syndrome in two men with spontaneous ejaculations. The syndrome consists of severe fatigue, intense warmth, and a flu like state, with generalized myalgia.

Dr. Gorm Wagner advised in-depth technical and psychological evaluation and considering simple measures such as post-coital blood pressure evaluation. Dr. Giuseppe La Pera advised a 24-hour Holter test, and reported a similar case with post coital elevated blood pressure, where symptoms resolved with beta blockers.

Dr. David Rabinowitz advised a full battery of investigations, and raised the possibility of a dissociative state, or a variant of Transient Global Amnesia. Dr. Ganesh Adaikan forwarded an article from the lancet where a woman with similar symptoms was cured with the antiepileptic, carbamazepine. Dr. Broderick also advised ruling out arrhythmias and blood pressure disorders by an ambulatory halter monitor and Blood Pressure cuff, then proceeding with considering dissociative states.

Detailed discussion

I would value any suggestions that you might have about the following clinical problem.

This man is in his mid-50s, is in good general health and takes no medications. He complains of transient loss of memory and irritability after orgasm. This problem is lifelong and occurs on every occasion of orgasm. He has no other sexual problems. He has apparently been investigated by a neurologist and nothing abnormal was found. I am trying to obtain copies of his records to clarify precisely what was done.

I have come across epileptic attacks precipitated by orgasm before and wonder whether this is post-ictal confusion. However, 2-3 days seems a very long time and I suspect that the neurologist will have looked at this. Whether or not the neurologist asked him to masturbate and to have an orgasm whilst he was having his EEG is a different matter. Neurologists can be very particular about what goes on in their offices! As it is a recurrent and long-standing problem, I doubt it is a cerebro-vascular problem.

On another list a similar syndrome has also been discussed. No one seems to know what to do about it, but I think we should be on the lookout for similar cases. I have seen two cases.

Department of Psychiatry and Neurosexology, Leyenburg Hospital, Leyweg 275, 2545 CH The Hague, The Netherlands. post@m-waldinger.demon.nl

We describe the symptoms of a postejaculatory syndrome in two men with spontaneous ejaculations. The syndrome consists of severe fatigue, intense warmth, and a flulike state, with generalized myalgia. These symptoms occur rapidly after ejaculation and only disappear after 4 to 7 days. The symptoms are so severe that sexual activity is avoided. The cluste r of symptoms is named postorgasmic illness syndrome (POIS). To date, no explanation has been offered for the etiology and pathogenesis of the symptoms, and the prevalence is unknown. Both cases are presented to draw attention to this syndrome for further research regarding etiology, pathogenesis, and treatment.

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technical and psychological investigative talk maybe over several sessions.
First vey simple things that you have suggested 1. Masturbatory invest. and has it occurred with other women ? Simple is also a post-coital comparative blood-pressure measurement etc, But do remember the scene from the film 1900 in which de Niro,s coital activity brings about an epileptic seizure in the women. This is one of the situations where the clinical curiosity really should stands its trial. Let us hear when you have had more precise knowledge about his life etc.

regarding this case I would like to suggest an Holter test for the 24 h pressure monitoring. I had one case similar to this in which I discovered an elevated high blood pressure of which the patient was not aware. The case was treated with beta blockers . I had the oppurtunity to observe this patient for one year. During this period the blood pressure was normalized and the patient did not have no episode of the so called post orgasmic sindrome. At the moment I have no other information on this patient.

I would like to recommend that the patient be examined and evaluated post-orgasm, which, I am sure, can be arranged with appropriate discretion, in which sexual activity can take place in private. While a full battery of investigations should be done, careful attention should be given to his mental state. I would like to raise the question of a dissociative state, or a variant of Transient Global Amnesia. I would like thus to recommend that a psychiatric mental state assessment be included in the workup.

I had come across the following article from Lancet long ago. It is somewhat inversely related to your case. Interestingly, the patient was cured with antiepileptic, carbamazepine 300mg.

Lancet 1997; 350(9093): 1746 Case Report: " UNWELCOME ORGASMS" by Reading PJ and Will RG

A 44-year-old woman was referred to a neurology clinic in March, 1995, after a brief episode of loss of consciousness. For the previous 3 years, she had had recurrent episodes, approximately once every 2 weeks, in which she would suddenly become aware of an internal, ascending feeling indistinguishable from an orgasm, lasting up to a minute. She had not sought medical advice for these episodes. They had no definite triggers and were neither particularly pleasurable nor satisfying because they were out of her control. On several occasions she experienced an episode while driving and had to stop the car. There were no other symptoms, no associated loss of consciousness, and no reduced awareness until on one occasion, in the company of her sister, she had an episode while listening to a radio play. This was followed by jerking of her left hand and collapse to the ground with transitory loss of consciousness. She recovered completely within 2 minutes. Her medical history was unremarkable apart from an episode 2 years previously of a sudden, severe right-sided headache with subsequent nausea and confusion lasting several days. At the time, the episode was thought to be migrainous. General and neurological examination was normal. In particular, she was normotensive, and there were no visual-field defects or audible cranial bruits.

An electroencephalogram showed a right anterior frontotemporal epileptic focus. Computed tomography scan of her head revealed a large vascular abnormality at the right temporal pole with an area of surrounding gliosis. This was confirmed by an angiogram, which showed an arteriovenous malformation at the distal end of the right middle cerebral artery, located in the Sylvian fissure adjacent to the operculum. The lesion was well defined but had numerous small feeding vessels and a large drainage vein, which filled quickly during the venous phase of the angiogram. She was started on carbamazepine and has remained free of her previous episodes on 300 mg twice daily. The risk of a cerebral haemorrhage from the arteriovenous malformation was deemed sufficient to discuss definitive treatment with the patient. She opted for stereotactic radiosurgery and is currently undergoing a course of such treatment. The previous occurrence of sudden severe unilateral headache with nausea in this patient may well have been an undiagnosed intracerebral haemorrhage rather than migraine, and the area of gliosis seen on the computed tomography scan may have represented residual encephalomalacia. Sexual seizures are a heterogeneous group of disorders and have been influential in delineating the neural organisation of psychosexual behaviour.Although sexual disinhibition after seizures triggered by sexual activity itself is well recognised, sexual sensations or behaviour as a direct manifestation of seizures are rare and have been described only recently.Whereas unpleasant or emotionally neutral genital sensations are associated with an epileptic focus in the superior portion of the post-central gyrus region,emotionally charged or erotic feelings, such as those described by our patient, are usually features of temporal lobe epilepsy.In many such patients, routine brain imaging reveals a structural lesion in the right temporal lobe.Various lesions have been described but arteriovenous malformations are rare. There appears to be a preponderance of women with this type of seizure, perhaps providing evidence for dimorphism in cerebral function relating to sexual activity. Furthermore, the fact that such seizures have never been described before puberty implies the importance of hormonal priming. Sexual seizures are rare and, owing to their nature, may present to physicians late. Cerebral imaging, ideally with contrast enhancement, is mandatory because structural lesions are commonly demonstrated.

It seems the essential element to rule out is arrythmia, hypotension - then procede to consider dissociative states.

GAB
Broderick, Gregory A., M.D.
Professor of Urology
Mayo Clinic College of Medicine
Jacksonville, Florida
Residency Program Director
President Sexual Medicine Society NA

Headache at Climax

Dr. Yasusuke Kimoto presented a case of a 56 year old man complaining of severe headaches occurring after every ejaculation, and resulting in ED. Associated conditions included LUTS and cervical disc prolapse. Dr. Stan Honig suggested considering an autonomic dysreflexic response at time of seminal emission and antegrade ejaculation, and proposed a therapeutic trial with an anti hypertensive agent (alpha blocker or calcium channel blocker).

Dr. Gorm Wagner pointed out a paper published in Pain Journal about �pain related sexual dysfunction after inguinal herniorrhaphy�. Dr. Paulo Brito Cunha also referred to a case report published in �Cephalalgia� regarding a patient with orgasmic headaches converting to concurrent orgasmic and benign exertional headaches. Drs. Cunha and Ghanem reminded members of a similar previous discussion where several members reported good results with non-steroidal anti-inflammatory medications. It may be read on the ISSM website http://www.issm.info/ by clicking the 'ISSM list� button and choosing interesting cases / discussions from the dropdown menu, then clicking 'sexual headache under the 'Pain disorders� subtitle.

A 56-years-old man with cervical disc hernia was referred to me from orthopedics.

He said "Every time I ejaculate, I always have severe headache during last few years. That's why I can't complete sexual intercourse."

Has anyone ever experienced such a case? If so, could you kindly tell me the etiology, prognosis and treatment?

KIMOTO Yasusuke, MD
Department of Urology
Spinal Injuries Center
550-4 Igisu, Iizuka, 820-8508
Japan

I see you work at a spinal cord center. He has some degree of cervical spinal cord lesion. I wonder if this has any relationship to some type of autonomic dysreflexic response at time of seminal emission and antegrade ejaculation. Does he have other vasomotor responses of autonomic dysreflexia. Might you pre treat with some anti hypertensive agent- alpha blocker or calcium channel blocker?

May I refer you to a brand new paper : Aasvang et al PAIN ,2006,Epub on March 20 (you may find it through Google Scholar or Pubmed): This is an original and new observation from a local group of colleagues in relation to ejac.pain a condition which according to my own (unpublished) survey occurs in only 0.4 % in the normal population.

Section of Surgical Pathophysiology, The Juliane Marie Centre, Rigshospitalet, Copenhagen, Denmark.

To determine the incidence of pain related sexual dysfunction 1 year after inguinal herniorrhaphy and to assess the impact pain has on sexual function. In contrast to the well-described about 10% risk of chronic wound related pain after inguinal herniorrhaphy, chronic genital pain, dysejaculation, and sexual dysfunction have only been described sporadically. The aim was therefore to describe these symptoms in a questionnaire study. A nationwide detailed questionnaire study in September 2004 of pain related sexual dysfunction in all men aged 18-40 years undergoing inguinal herniorrhaphy between October 2002 and June 2003 (n=1015) based upon the nationwide Danish Hernia Database collaboration. The response rate was 68.4%. Combined frequent and moderate or severe pain from the previous hernia site during activity was reported by 187 patients (18.4%). Pain during sexual activity was reported by 224 patients (22.1%), of which 68 (6.7%) had moderate or severe pain occurring every third time or more. Genital or ejaculatory pain was found in 125 patients (12.3%), and 28 (2.8%) patients reported that the pain impaired their sexual activity to a moderate or severe degree. Pain during sexual activity and subsequent sexual dysfunction represent a clinically significant problem in about 3% of younger male patients with a previous inguinal herniorrhaphy. Intraoperative nerve damage and disposition to other chronic pain conditions are among the most likely pathogenic factors.

A patient with orgasmic headaches converting to concurrent orgasmic and benign exertional headaches.

I wish to remind you of a discussion we had 2 years ago about a similar case, yet much younger man. You may read it on the ISSM website http://www.issm.info/ by clicking the 'ISSM list button and choosing interesting cases / discussions from the dropdown menu, then clicking 'sexual headache under the 'Pain disorders subtitle. For your convenience I pasted the case digest and detailed discussion below.

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Headache and tinnitus after coitus

Dr. Juan Fernando Uribe presented a case of a 55 years old patient complaining of headache, tinnitus and arthralgias after coitus. The patient has multiple allergies manifesting by a skin rash and generalized itching. Previous treatment included domperidone (a dopaminergic antagonist). An auto-allergic syndrome to own-neurotransmitter was suggested by Dr. Uribe. Dr. Pierre Assalian suggested the use of anti-inflammatory medications before coitus, while Dr. David Rabinowitz proposed a full workup of the immune status, allergy status, cardiovascular status, and a full biochemical status, at resting and again within an hour of ejaculation, hoping to reveal important differences that might be therapeutically useful.

A 55 years-old man, medical doctor. Allergic to many substances including almost all medications (between them steroids, opioids and vitamins), allergy to textiles, plants and some meals, always manifested by cutaneous rash and generalized itching. He has had it for 9 years and is increasing.

He complains of 8 years of headache and tinnitus after coitus (only with ejaculation) that improves some hours after, associated with arthralgias and arthritis lasting for about one month or more. Symptoms are getting worse, now he says they are developing too with nocturnal erections and erections without ejaculation (only with sexual stimuli).

He also has a renal disease of unknown origin with creatinine values of 1,8 ng/dl and a variety of �leg unstopped syndrome� of diurnal predominance. He has high blood pressure in treatment.

He received treatment with domperidone (a dopaminergic antagonist) that improved the postcoital headache and tinnitus in a important percentage, but postcoital arthralgias are worsening. The rheumatologists said that he has a gout (They founded uric acid crystals in articular fluid that was obtained after coitus or erections). He has a skin biopsy without signs of mastocytosis.

OPINION: This patient seem to have an auto-alergic syndrome to own-neurotransmitter substances. He has a goutous syndrome with any sexual activity. What we could to do with this patient??

I would like to propose that the patient undergo a full workup for immune status, allergy status, cardiovascular status, and full biochemical status, at a resting baseline and again within an hour of ejaculation. I think that this may reveal important differences that may be therapeutically useful.

Dr. David Rabinowitz
Director, Psychiatric Outpatients' Department
Rambam Medical center
Haifa Israel

Chlorpromazine instead of Phentolamine (Literature and Safety)

Dr. Roberto C. Campos requested literature about the use of Chlorpromazine instead of Phentolamine in intra-cavernous injection therapy. Drs Adolfo Casab� and Hussein Ghanem forwarded references from the Br J Urol and the Journal of Sexual Medicine.

Dr. Pierre Assalian raised the questions of need, safety and possible motor disorders reported with chlorpromazine. H Ghanem suggested that chlorpromazine is needed in intracavernous pharmacotherapy combinations if first-line oral therapy has failed, and as a substitute for phentolamine when unavailable. Drs Sidney Glina, Ramiro Fragas, H Ghanem have all used Chlorpromazine for years with no complications. However, Dr. Mireille Bonierbale confirmed the concerns of Dr Assalian that chlorpromazine may lead to movement disorders that might be acute or chronic.

If you have available, I would like some literature about the use of Chlorpromazine instead of Phentolamine in intra-cavernous injection.

                                    Roberto C. Campos
                                  Department of Urology
                            Hospital dos Servidores do Estado

Dear Dr. Campos
We have researched the topic in Cairo University and published this paper in the Journal of Sexual Medicine 2004. It was part of a master's degree study in Andrology, Sexology & STDs. I hope the information below helpful. Please let me know if you need any further information about this drug combination.
Hussein Ghanem

Intracavernous Chlorpromazine Versus Phentolamine: A Double-blind Clinical
Comparative Study. Rany Shamloul, MD,*Mohamed El-Dakhly, MD,* Hussein
Ghanem, MD,* Amr Gadallah, MD,* and Hany Mokhtar, MD?
J Sex Med 2004; 1: 310-313
Abstract
Introduction: Intracavernous pharmacotherapy is one of the most common treatment modalities of erectile dysfunction. There are different drugs that are used for intracavernous injection including papaverine, phentolamine, prostaglandins E1, phenoxybenzamine and moxisylate. Aim: The aim of this study is to evaluate the efficacy of chlorpromazine as an intracavernous vasoactive agent alone or with other drugs.
Methods: This study was performed on fifty patients presenting to our department complaining of ED. Patients were divided according to the type of
intracavernous drug injected into three groups. Group A included 20 patients who received an intracavernous injection of 1ml bimix (30mg papaverine+1mg
phentolamine) followed a week later by intracavernous test dose using a 1ml mixture of papaverine and chlorpromazine(30mg papaverine+2.5mg
chlorpromazine). Group B included 20 patients who received an intracavernous injection of 1ml trimix (30mg papaverine+1mg phentolamine +10�g PGE1). A
week later they received another intracavernous test dose using a 1ml mixture of papaverine, PGE1 and chlorpromazine(30mg papaverine + 2.5mg
chlorpromazine + 10�g PGE1). Group C included 10 patients who received various intracavernous injections of chlorpromazine in doses 1mg, 2mg, 5mg
and 10mg.
Results: There was no significant difference in erection response and erection duration between phentolamine and chlorpromazine. Prolonged erection occurred in 2 patients of group B and postural hypotension occurred in 3 patients of group C.
Conclusion: chlorpromazine can be used as an intracavernous vasoactive agent, similar to phentolamine in efficacy and short-term side-effect profile

Dear All
As a psychiatrist /Sexual medecine specialist I fail to understand why you
would want to use CPZ which is basically an antipsychotic medication that
even though the dose that is used IC is small ,may lead to movement disorder
that can be acute or permanent.
Pierre Assalian.MD

Thank you for raising the topic of potential side effects of chlorpromazine. Intracavernous therapy is a second line treatment option resorted to only after failure of first line options, mainly oral therapy and psychosexual therapy.

The most potent IC combinations include Phentolamine (an alpha blocker), Papaverine & PGE 1. Unfortunately, as expressed on previous discussions on the list -a few years ago- phentolamine (Regitine) has always been subject to shortages and inconsistent supply worldwide, I don�t know the reason, hospitals still need and order it. Chlorpomazine was suggested on this list as an alternative due to its potent alpha blocking action.

Before the introduction of Chlorpomazine our patients on the self injection program were quite unhappy whenever there was a phentolamine shortage. We have not noticed any serious side-effects apart from the occasional dizziness or prolonged erections as with all intracavernous vasoactive medications. However, the safety issues (permanent movement disorders) that you have raised are very serious and I would appreciate further information regarding such side-effects, they were not raised during our previous discussion of the topic.

The details of the previous discussion may be read on http://www.issm.info/ by clicking ISSM List / interesting cases and discussions / and scrolling down to Intracavernous Therapy. Two interesting subtitles would appear:

The history of CPZ in treatment of ED is similar to the history of using Thioridazine (Mellaril)in the treatment of PE.In psychiatry we were using CPZ and Mellaril for the treatment of Psychotic disorders.These 2 antipsychotics were known to have side effects i.e hypotension,sensitivity to the sun and Mellaril had cardiac side effects like arrythmias .they caused less side effects in terms of Parkinsonian symptoms.We were always told that Idiosyncratic reactions to small doses can always cccur.That is why we abondened the use of Mellaril in PE,in fact the co stopped producing it.

I think one should use CPZ only when other IC medications are not available and for a short time.

Hello Sidney, I remember that when I visited you, in the H. Ellis, in the 2001, you used the blended Clhopromazine with the PGE1, with the same results that if Phentolamine used, after that I have used it and my experience has been good.

A hug all..

Ramiro Fragas.
Urologist
Havana, Cuba.

Mother�s difficulty in handling teenage son�s sexual behavior Penile

Dr. Poosha forwarded a case of a disturbed young teenager with unusual sexual behavior including possible Zoophilia, and keeping soiled toilet-paper at his dowers. The mother also complains of her son�s inappropriate social behavior including lying, stealing, poor performance at school and being very disrespectful.

Dr. Pierre Assalian raised the concern that the patient might eventually become schizophrenic or that we are dealing with severe Borderline Personality. The patient probably has Paraphilia, which is frequently multiple. Dr. Assalian suggested that the best advice to the mother is to see an Adolescent Psychiatrist.

Dr. Charles Moser also suggested that a thorough evaluation by a psychiatrist with training in Clinical Sexology is imperative. However Dr. Moser also noted that there are other diagnoses that can present with unusual sex behavior, including the ones already mentioned by Dr. Assalian. He also advises that there is still insufficient evidence that one Paraphilia presupposes the individual to having others, as the evidence is still anecdotal or based on expert opinion.

Detailed case and discussion

Dear professional colleague,

Here is a mail sent to me by one of my website visitors for assistance:

For the present I have suggested her to consult a child/adolescent psychiatrist near her place, and before doing that, to collect information on her son's peer group, the type of pornographic movies (if) he watches, his collection of books, his medical and developmental history, etc. as these are likely to have bearing on his present behavior. Could some one provide insight about how this should be handled?

Would you consent to your reply being posted on my site (www.sexualcounselling.com) and be acknowledged for the content?

Thank you and regards
Poosha

______________________________________________________________________

A 50-year old mother from Oklahoma, USA, writes:

This concerns our 16 yr old son. I have for some time felt that he has had sexual issues. Masturbation, I do not feel comfortable with him around the grand children. Nothing concrete just an uneasy feeling. (name removed) has some really strange bathroom habits. Instead of setting down and going to the bathroom he just wipes his behind and keeps the toilet paper in his dresser drawers. We have spoken with him several times about these things. He has been in counseling off and on and nothing seems to have really come from that. He stays in his bedroom a lot, he lies, steals, his grades are terrible and he is very disrespectful.

Well yesterday I was looking for him and went to his bedroom he was not there, I looked out his window and he was setting on the ground in some trees, he had his penis in our dogs mouth, forcing himself in her. I could hear her gagging inside the bedroom. Needless to say this made me feel ill. I called him into the house. Although there are some trees it would be possible for him to be seen by the neighbors. He knew that I knew. I did not say anything to him at the time. He kept asking me if I was mad at him. We did talk to him about it later. At first he denied it. I told him that I had seen him. He didn't seem as if it were a big deal.

We are really concerned about this. We are not sure who to call or what to do. What kind of counselor would be the best to deal with this sort of issue. Please advise.

I am worried about this adolescent,either that he eventually become schizophrenic or we are dealing with severe Borderline Personality.He has Paraphilia,usually it is always multiple at lease Zoophilia.

Just for the record, there is not enough information given to make a diagnosis of a Paraphilia by DSM standards. There are other diagnoses that can have unusual sex behavior as symptoms, including the ones already mentioned by Dr. Assalian. Second, even if he has a Paraphilia, there is no empirical evidence that having one Paraphilia presupposes the individual to having others. That is a common belief built upon anecdotes and expert opinion; the plural of anecdotes is not data and the experts are often wrong, see URL below for a paper Dr. Kleinplatz and I wrote on this subject.

I believe a thorough evaluation by a psychiatrist with training in Clinical Sexology is imperative, but diagnoses on this limited amount of data are premature.

Charles Moser, Ph.D., M.D.
Professor and Chair
Department of Sexual Medicine
Institute for Advanced Study of Human Sexuality
San Francisco, CA

You may also be interested in a paper I co-authored on unusual sexual behavior in children and adolescents. One of my co-authors is Dr. Reiner who is in Oklahoma.

Digest of recent discussions on ISSM mail (January - April 2006)

Discussion Digest