Abstract

Post-Orgasmic Illness Syndrome (POIS) is a rare and poorly understood condition characterized by a cluster of physical and psychological symptoms following ejaculation. This case report presents the first documented instance of POIS in Libya, about  a 50-year-old Libyan male who experienced recurrent fatigue, epigastric discomfort which is gastritis like, and cognitive dysfunction, within an hour of ejaculation.

These symptoms used to persist for up to a week, significantly impairing his quality of life. The patient’s medical history included treated Hepatitis C virus infection and a history of duodenal ulcer, but physical examination and laboratory tests, including hormonal, inflammatory, and infectious markers, were unremarkable. Semen analysis and culture also yielded normal results. A diagnosis of POIS was made based on the patient’s history and symptom profile. Treatment with antihistamines and alpha-blockers provided partial relief, while NSAIDs and other pharmacological agents showed limited efficacy.

The patient’s psychological perspective suggested a potential link between his symptoms and feelings of guilt related to masturbation during adolescence, prompting consideration of cognitive-behavioral therapy (CBT). However, access to specialized psychological care proved challenging. This case emphasizes the complexity of diagnosing and treating POIS in Libya, the lack of epidemiological data in Libya, and the need for further research into its pathophysiology and management. It also highlights the importance of addressing both physiological and psychological factors in treating this debilitating condition similar spectrum.

Case Report

In Tuesday morning's gastroenterology-Clinic a 50-year-old Libyan gentleman came on account of dyspepsia and gastritis-like symptoms, and further history revealed correlation to a history of recurrent flu-like symptoms, including fatigue, muscle pain, headache, and lack of concentration.

In the first few visits many etiologies were considered including infectious, autoimmune, endocrinopathies and vitamin deficiencies!  

In one visit and after a long conversation with the patient to explore his opinion, fears and expectations about the health condition he was experiencing, the patient accurately described the diagnosis, however the treating gastroenterologist was not yet familiar with this diagnosis! what led to some diagnostic delays. What made the presentation strange and motivated the treating physician to pick the diagnosis was the correlation of symptoms with the patient's sexual activity!

The patient also noted that the symptoms used to get relived after a week of abstaining sexual activity. The patient has been suffering from this constellation of symptoms 10 years ago since the time he got married.

In average the symptoms start in minutes to an hour of ejaculation and last for up to a week maximally, significantly impacting the patient's ability to engage in sexual activity.

The patient’s medical history includes: cured Hepatitis C virus infection with consequent subtle cirrhotic changes in the liver otherwise normal liver function, 7 years before presentation to our center. Also he has a history of operated bleeding duodenal ulcer a decade ago and he used omeprazole for more than five years and received Helicobacter pylori eradication antibiotics twice before with negative H-pylori stool test by the time of last presentation and normal gastro duodenoscopy as well.

The patient's social history showed that he had never smoked or consumed alcohol. He was also financially well off and lived a relatively happy life with his wife and three daughters.

Physical examination and laboratory tests were unremarkable including (Testosterone, FSH, LH, Prolactin, and basal cortisol levels), CBC, ESR, CRP, LFTs and RFTs were also normal, with negative viral serology ruling out infectious or inflammatory processes.

Semen analysis and culture were normal including cytology.

Based on the patient's history and symptoms, a diagnosis of POIS was made.

The patient was referred to the urologist who in turn tried some symptomatic treatments.

Although many other therapies, supplements and herbal remedies have been attempted by the patient himself, none of these have shown consistent efficacy.

The treatment protocol in our patient included the use of antihistamine, NSAIDS, alpha blockers.

A trial of antihistamine had good effect on his gastrointestinal symptoms, alpha-blocker administration i.e. Silodosin 8 mg once, was chosen as the first-line therapy.

Our patient experienced partial improvement of symptoms on combination of an antihistamine (cetirizine 10mg) and alpha-blockers (silodosin 8 mg), with no complete resolution of symptoms.

The patient also reported no improvement of symptoms after taking a Diclofenac sodium 75 mg twice daily.

Other pharmacological agents with a relieving effect on autonomic hyperactivity, such as Nifedipine, could possibly be a treatment option in patients with POIS but it was not used in our patient due to his lowish blood pressure. Other potential treatments, such as glucocorticoids, and Phosphodiesterase inhibitors were discussed with the patient but the patient didn’t prefer using them due to the fear of their side effects.

Our article highlights the lack of definitive treatments for POIS and the need for further research to figure out the magnitude of this disease.

The patient’s view: upon asking the patient about his own perspective of his illness, he said that: (it could be the feeling of guilt I used to experience since my adolescence whenever I masturbated!), since the patient believes that it is a forbidden act to do, and he tried many times – in his premarital life- to abstain from it but in vain.

The patient also wanted to undergo vasectomy since he is not longing to have more children, a procedure that he thought may put an end to his suffering.

This has led us to think of initiating cognitive and behavioral therapy (CBT) in an attempt to erase the debilitating effects of the past guilt feeling episodes, however finding a trained psychologist to run the CBT sessions for such a sensitive issue was quite difficult!

The patient was counseled about the nature of POIS and offered educational materials along with the symptomatic treatment. Additionally, he was advised to abstain from sexual activity or use medications to delay ejaculation, which significantly improved his quality of life so far. Regular urology visits were scheduled to assess the patient's progress and adjust the treatment plan as required.

Literature Review

Post-Orgasmic Illness Syndrome (POIS) is a rare and poorly understood condition characterized by a cluster of physical and psychological symptoms that occur immediately or shortly after ejaculation. First described by Waldinger et al. in 2002(1), POIS has since been reported in a limited number of cases worldwide. Most reported cases involve young males presenting with fatigue, cognitive dysfunction, muscle pain, and flu-like symptoms, which can last for several days post ejaculation (2,3). Despite its significant impact on quality of life, the pathophysiology, prevalence, and optimal treatment of POIS remain unclear.

The exact pathophysiology of POIS remains unclear but is thought to involve an allergic or autoimmune reaction to seminal fluid components (4,5). Mast cells have been implicated in the immune response associated with POIS, as evidenced by elevated levels of histamine in some patients (5.4). Waldinger et al. (2011) (4) conducted a study on 45 Dutch males with POIS and found that the most prevalent symptoms were fatigue, concentration difficulties, and irritability while gastritis-like symptoms were uncommon. Similar findings were reported in a case study of a Chinese male, where symptoms include fatigue, headache, and muscle pain, with no mention of any gastritis or stomach related symptoms (6).

There is currently no specific diagnostic test for post orgasmic illness syndrome (POIS).

 Diagnosis follows the golden rule of combining detailed medical history, careful physical examination, and excluding other possible causes of the symptoms. However, some medical professionals may perform the following tests to confirm POIS (7):

1. Allergy testing: Skin prick tests or blood tests may be done to check for allergies to semen or certain proteins in semen.

2. Hormone testing: Blood tests to measure hormone levels may be done to rule out hormonal imbalances as a cause of symptoms.

3. Semen analysis: Examination of semen to rule out any abnormalities or infections that may be contributing to symptoms.

4. Neuropsychiatric evaluation to assess for any neurological or psychiatric conditions that may be causing mimicking symptoms.

Ultimately, the diagnosis of POIS is primarily based on the presence of symptoms after ejaculation and the vanishing of symptoms after a while of abstaining sexual activity. In addition to the absence of any other underlying medical conditions that could explain the symptoms (8).

Treatment options for POIS are limited and mainly focus on symptom management. Nonsteroidal anti-inflammatory drugs, antihistamines, and corticosteroids have been used with varying degrees of success. (9) Desensitization therapy with repeated exposure to diluted seminal fluid has been proposed as a potential treatment option (10,11) although further research is needed to confirm its efficacy.

Because POIS is poorly understood and may vary significantly among individuals, treatment approaches should include stress Reduction techniques may help reduce overall stress, which can exacerbate symptoms. (12)

CBT by psychologist can help patients cope with the anxiety or depression that can accompany POIS. (12)

Engaging with a sex therapist can assist individuals and couples in exploring intimacy while managing POIS symptoms. (12)

However, it is worth noting that these specialties are not available in Libya at least in the authors' practice sites make the whole responsibility beard by the urologist.

Discussion

What a nuisance when pleasure turns into pain and suffering! 

Perhaps many patients in Libya and similar conservative countries suffer in silence, unable to disclose such symptoms.  Perhaps the groans of pain extend to their spouses, spoiling their quality of life. More importantly, doctors must be aware of this spectrum of illnesses in order to preserve as much of people's quality of life as possible.

The prevalence of post orgasmic illness syndrome (POIS) may not be well known in developed countries. In Libya, it is even rarer because doctors there are not aware of it, and some consider treating sexual diseases a medical luxury because they are not fatal! and the current case report is the first reported case from Libya as far as the authors are aware.

For these probable reasons this spectrum of illnesses generally, and POIS in particular are under reported:

1. Lack of awareness and education: Due to limited resources and priorities in third world countries, there is limited awareness and education about rare conditions like POIS among doctors, let alone the population! This can result in a lack of recognition of the symptoms and a delay in seeking medical help.

2. Limited access to healthcare: In many third world countries, access to healthcare services, especially specialized care for rare conditions, may be limited. This can make it difficult for individuals with POIS to receive a proper diagnosis and treatment.

3. As happened in this case and as often happens, the absence of Libyan specialized CBT teams for sex related diseases makes it more difficult for the treating physician to offer this line of treatment.

4. Discussions about sexual health and related issues may be taboo in some third world countries, which can lead to individuals with POIS feeling ashamed or embarrassed to seek help. This can further contribute to the underreporting of the condition.

5. Lack of research and data: In general, there is a lack of research on rare conditions like POIS, and this lack of data can make it difficult to understand the prevalence of the condition in different populations, including those in developing countries particularly Libya.

Overall, the lack of awareness, availability of healthcare, cultural factors, and research data contribute to the under-recognition of POIS in Libya. Efforts to increase awareness and education about the condition, improve access to healthcare services, and conduct more research on POIS in diverse populations may help to address this issue.

Ensuring that patients have access to reliable information regarding their condition and connecting with support groups and specialized multidisciplinary team can provide emotional support and practical coping strategies.

This is a team-building initiative to combat this silent disease launched by the authors, and it is a call for help that awaits an answer!

References:

1.         Waldinger MD, Schweitzer DH. Post orgasmic illness syndrome: two cases. J Sex Marital Ther. 2002;28:251–5.Waldinger MD, Schweitzer DH. Postorgasmic illness syndrome: two cases. J Sex Marital Ther. 2002;28(3):251-5.

2.         Nguyen HMT, Bala A, Andrew T, Gabrielson AT, Hellstrom WJG. Post-orgasmic illness syndrome: a review. Sex Med Rev.2018;6:11–15. https://doi.org/10.1016/j.sxmr.2017.08.

3.         Waldinger MD. Post orgasmic illness syndrome (POIS). Transl Androl Urol. 2016;5:602–6. https://doi.org/10.21037/tau.2016.07.01

4.         Waldinger MD, Meinardi MM, Zwinderman AH, Schweitzer DH. Post orgasmic illness syndrome (POIS) in 45 Dutch Caucasian males: clinical characteristics and evidence for an immunogenic pathogenesis. J Sex Med. 2011;8(part 1):1164–70. https://doi.org/10.1111/j.1743-6109.2010.02166.

5.         Le TV, Nguyen HMT, Hellstrom WJG. Postorgasmic illness syndrome: what do we know so far? J Rare Dis Res Treat.2018;3:29–33.

6.         Jiang N, Xi G, Li H, Yin J. Postorgasmic illness syndrome (POIS) in a Chinese man: no proof for IgE-mediated allergy to semen. JSex Med. 2015;12:840–5. https://doi.org/10.1111/jsm.12813.

7.         Abdessater M, Elias S, Mikhael E, Alhammadi A, Beley S. Post orgasmic illness syndrome: what do we know till now? Basic Clin Androl. 2019;29:13. https://doi.org/10.1186/s12610-019-0093-7

8.         Strashny A. First assessment of the validity of the only diagnostic criteria for postorgasmic illness syndrome (POIS). Int J Impot Res. 2019;31:369–73. https://doi.org/10.1038/s41443-019-0154-7

9.         Chea M, Teng M, Chesnel C, Lagnau P, Amarenco C, Hentzen C. Postorgasmic illness syndrome: one or several entities? A retrospective cohort study, J Sex Med, Vol. 20, 2023;12:1407–1413. https://doi.org/10.1093/jsxmed/qdad139

10.       Waldinger MD, Meinardi MMHM, Schweitzer DH. Hyposensitization therapy with autologous semen in two Dutch Caucasian males: beneficial effects in post orgasmic illness syndrome (POIS; Part 2). J Sex Med. 2011;8:1171–6. https://doi.org/10.1111/j1743-6109.2010.02167

11.       Kim T, Shim Y, Lee S, Son ES, Shim JW, Lee SP. Intralymphatic immunotherapy with autologous semen in a Korean man with post-orgasmic illness syndrome. Sex Med. 2018;6:174–9. https://doi.org/10.1016/j.esxm.2017.12.004

12.       Duran, M.B., Rubin, R.S., Reisman, Y. et al. Recognition and practice patterns of sexual medicine experts towards postorgasmic illness syndrome. Int J Impot Res (2023). https://doi.org/10.1038/s41443-023-00753-x.