Orgasm-induced seizures: Male studied with ictal electroencephalography
Article Outline
Abstract
Reflex seizures can occur in response to a variety of stimuli, both sensory and emotional. Common triggers include light and music; however, in a growing number of case reports, the phenomenon of sexual activity triggering epileptic seizures is described. The majority of these case reports have been in women so far, and most have been found to localise to the right cerebral hemisphere on interictal electroencephalography (EEG). We report the case of a 34-year-old male with orgasm-induced seizures, recorded on ictal EEG. This gentleman's electrophysiology localised his seizure focus to the left cerebral hemisphere, making his case atypical in comparison with the majority of previous reports. Orgasm-induced seizures are an increasingly well-described phenomenon and we suggest that this should be taken into account when assessing patients with possible reflex seizures.
Keywords: Reflex, Seizures, Orgasm
1. Introduction
Reflex seizures occur in response to a specific stimulus, and reflex epilepsy is a tendency to recurrent seizures, some of which are provoked by the stimulus in question. In one study, 8.9% of 526 patients with epilepsy had a diagnosis of reflex epilepsy, of which 70.2% experienced complex partial seizures and the remainder had generalised tonic–clonic seizures.1 This Sri Lankan study may, however, reflect a higher incidence than that in the western world, especially given that there is a tendency towards phenomena such as “hot water epilepsy” in this region. Photosensitive epilepsy is the most common cause of reflex seizures, but other external visual stimuli and auditory triggers (as in musicogenic epilepsy) are recognised.2 Internal mental processes are less commonly implicated, including reading and mathematical calculation, and seizures have also been provoked by activities such as eating.2 Seizures triggered by sexual orgasm are more rare in the literature, with few sporadic reports3, 4, 5, 6 until a case series was published in 2006.2 From these cases, several trends are apparent. All but one6 of the reported cases has been female. One patient in the 2006 series was diagnosed with idiopathic generalised epilepsy, but the rest experienced complex partial seizures with or without secondary generalisation. Discharges were localised to the right hemisphere in the majority of those who had focal abnormalities on electroencephalography (EEG), although bilateral temporal foci and a left frontal abnormality have also been reported.2 In some patients, neuroimaging has revealed specific underlying lesions accounting for the seizure tendency, including hippocampal sclerosis,2 focal cortical dysplasia,2 astrocytoma,4 and post-traumatic scarring.6 We report the first case of a patient with orgasm-induced seizures studied with ictal EEG.
2. Case report
A right-handed 34-year-old white male presented with a nine-month history of “attacks” following penetrative sexual intercourse and less commonly after tactile stimulation via his partner. He had not experienced these in previous sexual relationships or with masturbation, and attributed the change to an increased intensity of orgasm with his current partner. He experienced up to five episodes each night, and would only have occasional orgasms that were not followed by an attack. Episodes usually started within a minute of ejaculation, while cuddling; a feeling of intense tiredness would be the first indication of an event. Subsequently, according to his partner, he would become dazed, his eyes would roll back and his eyelids flicker, and he would slump on to the bed. Thirty seconds later, a brief obstructed exhalation was noted, followed by asynchronous jerking of all four limbs, suggestive of myoclonus. Rarely, this evolved into a milder form of generalised shaking, lasting between 30 and 120
s before he regained consciousness. No post-ictal confusion or drowsiness was evident; the patient reported feeling as if he had had a long sleep.
Past medical history included a motorcycle accident three years previously, with minor head trauma and return of consciousness at the scene. He had also had one episode at his workplace, where he slumped and appeared “asleep” to his colleagues for 10min, in the absence of any sexual activity. In his family, a great-aunt had a history of staring episodes and her mother had a tendency to convulsive seizures. He was a non-smoker, who drank minimal alcohol, and took no medications. His neurological examination revealed no focal abnormalities, though his reflexes were symmetrically brisk throughout.
Routine blood tests were unremarkable and interictal EEG and a magnetic resonance (MR) scan of the brain were normal. He and his partner were willing to try and provoke attacks during 24-h ambulatory EEG. Two seizures were captured, both following sexual activity and orgasm. The first lasted 30s, involving eye rolling and generalised twitching, followed by sleep. The next episode lasted 100s and was similar in nature. The history of both events was corroborated by his partner and correlated with EEG changes: 2–2.5Hz good voltage rhythmic delta activity arising from the left temporal lobe and spreading to the right hemisphere, followed by brief post-ictal slowing into the delta range (Fig. 1, Fig. 2, Fig. 3, Fig. 4 depict EEGs showing pre-ictal activity, transition to ictus, ictus and post-ictal activity respectively).
Fig. 1.
Pre-ictal EEG.
Fig. 2.
Transition from normal activity to ictus.
Fig. 3.
Ictal EEG.
Fig. 4.
Post-ictal EEG.
On the basis of the patient's clinical presentation and investigation findings, a diagnosis of orgasm-induced reflex seizures was made. He has been treated with a variety of anti-epileptic drugs, leading to a reduction in the intensity of his seizures, but not complete resolution. Various medications were poorly tolerated, including levetiracetam (causing agitated depression), topiramate (fatigue) and lamotrigine (leg twitching). His current drug regimen comprises modified-release carbamazepine, 800mg twice daily, zonisamide, 150mg twice daily and clobazam, 10mg as required, i.e. prior to sexual intercourse. His seizures continue, and the frequency of non-orgasm-induced events has increased over time.
3. Discussion
Common descriptions of reflex epilepsy (according to the International League Against Epilepsy) do not include orgasm as a recognised stimulus.7 However, growing numbers of reports confirm that this is a potential seizure trigger. This is in contrast to the recognised phenomenon that seizures can manifest as orgasm, as described by Reading and Will.8 In most cases of orgasm-induced epilepsy, electrophysiology has confirmed a focus and underlying lesions have been found on cranial imaging in a proportion. Our case, in some ways, is atypical. For example, the majority of sufferers have been female, with only one other male mentioned in the literature.6 This may be related to higher rates of medical consultation within females, and perhaps a lower threshold for revealing intimate details such as sexual triggers. Furthermore, most patients with EEG changes have had right-sided or bilateral foci, with only one patient showing abnormalities arising from the left frontal lobe.2 Thus, to the best of our knowledge, this is the first report of a patient with orgasm-induced seizures arising from the left temporal lobe.
Ozkara et al. postulated that the tendency for these events to arise from the right cerebral hemisphere may reflect this as a locus for human sexual function.2 Our case suggests that orgasm may also activate left temporal lobe structures. Alternatively, the autonomic effects of orgasm may activate any potentially epileptogenic brain region.
The differential diagnosis of this presentation includes psychogenic seizures and orgasm-induced cataplexy. However, the findings here strongly favoured reflex epilepsy precipitated by orgasm, with a clear and consistent history of prior sexual stimulation and convincing ictal EEG abnormalities temporally linked to sexual activity.
This case adds to the existing literature on orgasm-induced seizures, a phenomenon that is under-represented within current descriptions of reflex epilepsy.7 Therefore, we suggest that it is beneficial to consider sexual experiences as triggers when evaluating patients with seizures. Patients may not spontaneously volunteer this information, and therefore it is important to ask the question specifically. This diagnosis can have important pragmatic implications: for example, trigger avoidance is likely to be unpopular with patients. Equally, however, there may be a case for fewer lifestyle restrictions, such as driving and bathing, if seizures are only ever brought on by orgasm. Such recommendations would clearly be decided on a case-by-case basis.
References
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PII: S1059-1311(10)00082-8
doi:10.1016/j.seizure.2010.04.007
© 2010 British Epilepsy Association. Published by Elsevier Inc. All rights reserved.
