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Med. Surg. J. – Rev. Med. Chir. Soc. Med. Nat., Iaşi – 2019 – vol. 123, no. 2
INTERNAL MEDICINE - PEDIATRICS CASE REPORTS
258
POST COITAL ALLERGY – A CASE REPORT OF POST ORGASMIC
ILLNESS SYNDROME
Celina Silvia Stafie*, Ingrid Ioana Stafie
“Grigore T. Popa” University of Medicine and Pharmacy Iasi
Faculty of Medicine
Department of Preventive Medicine and Interdisciplinary
*Corresponding author. E-mail: cstafie@hotmail.com
POST COITAL ALLERGY-A CASE REPORT OF POST ORGASMIC ILLNESS SYN-
DROME (Abstract) The post-orgasmic illness syndrome (POIS) is a rare, but debilitating
cluster of symptoms, occurring after ejaculation. The clinical case presented is a male p a-
tient, his complains started after ejaculation, four years ago, with flu-like symptoms, fever-
ishness and sweating, brain fog, muscle pain and heavy legs, followed by concentration and
attention difficulties and irritation. This status last for about 5 to 7 days, disappear spontan e-
ously after 3 days and reappear after the next ejaculation. This postcoital illness was worse n-
ing during the years. The clinical assessment and differentiation of the diagnosis was diffi-
cult and consisted in several clinical criteria, a functional test and allergy valuation. The
combination of symptoms and pathophysiological mechanisms pointed to other sex related
allergies, such as seminal plasma protein allergy. Keywords: SEMINAL PLASMA PRO-
TEIN ALLERGY, POST ORGASMIC ILLNESS, SEXUAL DISTRESS.
The only universal in human sexuality is
variability itself (1). During the last 5 years
we have diagnosed and treated three differ-
ent cases of sex allergy: latex allergy, semi-
nal plasma allergy and, the most recent, post
orgasmic illness syndrome (POIS). Sex and
intimate contacts can represent a risk factor
for allergic reactions, because they may
favor direct contact with sensitizing sub-
stances(1).
Pathogenesis of POIS might include type
2 immune allergic reactions, but it does not
necessary involve atopy (2). The mean se-
rum total IgE in the non-atopic males was
27 kU/L (range 6-78 kU/L), indicating that
in these men this immunological marker was
normal (2).
Pathophysiology of POIS shows an im-
munological process which explains the
systemic reaction of the body and not only a
local genital reaction, since only the immune
system is capable of inducing very rapid and
serious physical and mental symptoms (3).
The support for an immunological cause of
these flu-like complaints was found in re-
ports on cytokines inducing a flu-like state
(4, 5). There are two types of POIS, a prima-
ry type in which POIS is manifest from the
first ejaculations in puberty or adolescence
and a secondary type, in which POIS starts
later in life (2, 6).
CASE REPORT
We present the case of a 34-year-old
male patient, with a very demanding job,
married young, heterosexual, with two
healthy children. He had no intimate rela-
tionships with other women after getting
Post coital allergy – a case report of post orgasmic illness syndrome
259
married.
The patient had two appointments at our
clinic during the last 4 years, the first in
2014 and the second in 2017. He initially
presented for a “strong dysphoric status after
intercourse”, during the last months before
his visit, “aggravating each time, from ab-
dominal pain and nausea to generalized
sickness”, to which obnubilation, confusion
and severe migraine were added.
The particularity of the case is that the
patient had no obvious local or generalized
allergic reaction, which can delay and even
obscure the diagnosis. Previously he had
consulted other doctors, urologists and in-
ternists, but the allergist was his last chance
to have this mysterious disease diagnosed
and treated.
Chief complaint: generalized post coi-
tal/post orgasmic illness over the last 4
years.
Past medical history: no history of aller-
gy, high blood pressure (145/90 mm Hg),
endoscopically diagnosed gastric ulcer,
history of recurrent low urinary tract infec-
tions. The patient was asymptomatic at both
consultations.
Family history: one of his children was
diagnosed with atopic dermatitis. No family
history of allergies or diabetes.
Current medication: occasionally, seda-
tives; he was using latex free condoms, with
no influence on symptoms.
Self-observation and self-intervention:
He was hiding the truth from his wife, refus-
ing to deal with the problem as a couple. He
noticed that when he interrupted intercourse
before reaching orgasm, symptoms did not
appear.
Physical exam: absence of physical
signs or symptoms, no local or generalized
eruption or swelling, normal blood pressure
and pulse.
Lab tests showed a total IgE = 12 UI/L;
seminal-fluid specific IgE = 45kUI/L (nor-
mal range < 0.35 kUI/L); CIC (Circulating
Immune Complexes) = 45; serum comple-
ment = 570 UI; (++)presence of cryoglobu-
lins
Skin prick test with his own semen re-
sulted in a 14 mm wheal and erythema (+1),
while patch test with his own semen was
refused, as well as diamine oxidase (DAO)
determination and the skin biopsy for mas-
tocytosis.
Functional Diagnosis 1. A non-specific
clinical test of POIS - advise the patient to
stop masturbating or intercourse just before
the first genital sensations of an impending
ejaculation occur while having a full erec-
tion (2-17). 2. Difficult but clarifying: this is
not easy to perform as one asks the patient
to stop his sexual activity while having an
increasing pleasure in this activity. POIS
symptoms will not become manifest after
this non-specific clinical diagnostic test.
Clinical diagnosis The five criteria of
POIS are as follows: 1: One or more of the
following symptoms: sensation of a flu-like
state, extreme fatigue or exhaustion, muscle
weakness, feverishness or sweating, mood
disturbances and/or irritability, memory
difficulties, concentration problems, inco-
herent speech, congested or runny watery
nose, itchy eyes; 2: All symptoms occur
immediately (e.g., seconds), soon (e.g.,
minutes), or within a few hours after ejacu-
lation that is initiated by coitus, and/or mas-
turbation, and/or spontaneously (e.g., during
sleep); 3: Symptoms occur always or nearly
always in more than 90% of ejaculation
events; 4: Most of these symptoms last for
about 2 to 7 days; 5: The symptoms disap-
pear spontaneously.
Allergy diagnosis Skin prick test with
autologous semen: the purpose was to ob-
jectify the skin reaction after inoculation of
the semen using a protocolized intracuta-
neous (IC) skin-prick test. It was performed
with the male’s own semen (autologous
Celina Silvia Stafie, Ingrid Ioana Stafie
260
semen) and compared with a placebo skin
reaction with IC saline 0.9% (6). The pa-
tient masturbated at home to produce se-
men. In hospital the harvested semen sam-
ple was defrosted and diluted with saline
0.9% to a concentration of 1:40,000. In
addition, 0.05 mL of each dilution was IC
injected at the volar side of the left fore-
arm. The skin reaction to autologous semen
and placebo were interpreted at 15 minutes
after IC injections and found to be positive
when the diameter of the wheal was > 5
mm with local erythema (6). The grading
system of the skin reactions was as follows:
I. wheal and erythema < 5 mm = negative;
II. wheal 5-10 mm and erythema of 11-20
mm = 1+; III. wheal erythema of 21-30 mm
= 2+; IV. erythema of 31-40 mm = 3+; and
V. wheal > 15 mm or erythema of > 40 mm
= 4+ (2, 6).
Positive Diagnosis Based on the func-
tional (positive non ejaculatory test), allergy
(+1 level) and clinical diagnosis (all 5 crite-
ria were met), we made the following posi-
tive diagnosis, as being the most likely: 1.
Post orgasmic illness syndrome type II (late
onset) 2. Seminal Plasma Protein Allergy
(SPPA) (autoimmune)
Differential diagnosis that can explain
at least partially the clusters of symptoms
included: 1.Seminal Plasma Protein Allergy
(SPPA); 2. Systemic Mastocytosis; 3.
Drug/Substance abuse; 4. Autoimmune
disease with involvement of sexual activi-
ty; Unknown syndrome linked to sexual
activity (other Rare forms of Post-coital
Sickness).
Treatment consisted in desensitization
with autologous semen. Since the patient
score was +1 (wheal and erythema +14
mm), the treatment was postponed until the
patient should accept a patch test and di-
amono oxidase (DAO) determination. All
treatments should be performed in hospital
and attentively surveyed by the allergist and
emergency care intervention, if needed.
Desensitization is made with extremely
diluted autologous semen (1/40,000), by
gradually higher concentrations of autolo-
gous semen. Titration are to be performed
according to local skin reactions post inocu-
lation, aiming at a wheal and flare response
of 3+. This score has to be maintained for a
period of at least 2 years.
DISCUSSION
Clinical data from urology and androlo-
gy reported the post-orgasmic disease status
at the beginning of 2000, especially in males
and after ejaculation. There are only 50
cases around the world. From the three dif-
ferent cases of sexual allergy, latex allergy,
seminal plasma allergy and post -orgasmic
disease, the latter most challenged, because
there is no objective local allergic reaction
and all the symptoms are subjectively pre-
sented by the patient, not obvious to the
physician. The only support is the patient's
observation of the inventory and timing of
clinical symptoms.
In this case, we benefited from a very pa-
tient and self-aware patient who self-
intervening if he had given consistent help
because he performed the functional test,
stopped sexual intercourse before the first
genital sensations of an imminent ejacula-
tion, complete erection. The test was posi-
tive and gave us the certainty that the aller-
gic reaction is due to autoimmune allergies
to its own seminal fluid.
The first differential diagnosis was a co-
existing one, because of the high specific
IgE to his own seminal plasma protein, a
range of 0-0.35kUI/L being the normal val-
ues accepted for absence of SSPA. Thus, the
patient has a high degree of autoimmunity to
his own seminal plasma protein. We can
affirm that POIS include SSPA.
The second differential diagnosis was
invalidated, because of the absence of ma-
Post coital allergy – a case report of post orgasmic illness syndrome
261
jor and/or minor criteria for mastocytosis.
There were no obvious rashes or hemato-
logical changes in the number or morphol-
ogy of mast cells. Also, there are no con-
sistent data supporting the third differential
diagnosis, as there was no history or clini-
cal evidence of drug or other substance use,
although clinical status was suggestive of
intoxication. It is also important to estab-
lish any influence on males with POIS, of
the 25-OH D vitamin deficiency, if we
consider the epidemic character and the
implications of this vitamin (7). Is it the
semen or the seminal fluid? The question is
which part of the ejaculate contains the
antigen (Ag) that triggers the immunologi-
cal reaction? Waldinger (3, 4, 5) reported
the occurrence of POIS before and after
sterilization in three men. This phenome-
non means that the Ag is most likely not
bound to the spermatozoa but associated
with the seminal fluid. After sterilization,
spermatozoa are no longer released into the
genital system, but seminal fluid continues
to be produced, for example by the prostate
and/or the seminal vesicles.
CONCLUSIONS
We have presented an allergy case with a
certain immunotherapy status, that is not
associated with elevated serum total IgE or
urticaria but may be associated with an auto-
immune reaction in the plasma protein in the
fluid seed.
Indirect clinical evidence suggests that
the Ag triggering the POIS systemic reac-
tion is not bound to spermatozoa, but to
seminal the fluid produced by prostate tis-
sue.
The crucial benefit of the case is to point
out the importance of self-observation and
self-intervention of the patient with POIS,
for there is no possible diagnosis of this rare
disease, without the contribution of the pa-
tient, since all symptoms are invalidating
and restricting the visit to a doctor and the
possibility of an onsite immediate allergolo-
gy evaluation.
REFERENCES
1. Kinsey A. Sexual Report in Human Male, Indiana University Press, 1948
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1995; 13: 371-406.
3. Waldinger MD, Schweitzer DH. Post orgasmic illness syndrome: two cases. J Sex Marital Ther 2002;
28: 251-256.
4. Waldinger MD, Meinardi MM, Zwinderman AH, et al. Post orgasmic Illness Syndrome (POIS) in 45
Dutch Caucasian males: clinical characteristics and evidence for an immunologic pathogenesis (Part
1). J Sex Med 2011; 8: 1164-1170.
5. Waldinger MD, Meinardi MM, Schweitzer DH. Desensitization therapy with autologous semen in
two Dutch Caucasian males: beneficial effects in Post orgasmic Illness Syndrome (POIS; Part 2). J
Sex Med 2011; 8: 1171-1176.
6. Vial T, Descotes J. Immune-mediated side-effects of cytokines in humans. Toxicology 1995; 105: 31-
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