Sexual activity-related emergency department admissions: eleven years of experience at a Swiss university hospital
- Carmen Andrea Pfortmueller1,
- Jana Nimia Koetter2,
- Heinz Zimmermann2,
- Aristomenis Konstantinos Exadaktylos2
- 1University Department of General Internal Medicine, Inselspital Bern, Bern, Switzerland
- 2University Department of Emergency Medicine, Inselspital Bern, Bern, Switzerland
- Correspondence to Dr Carmen Andrea Pfortmueller, University Department of Emergency Medicine, University Hospital Bern, Murtenstrasse 10, Bern CH-3010, Switzerland;
- Accepted 20 September 2012
- Published Online First 25 October 2012
Principals Most people enjoy sexual intercourse without complications, but a significant, if small, number need to seek emergency medical help for related health problems. The true incidence of these problems is not known. We therefore assessed all admissions to our emergency department (ED) in direct relation to sexual intercourse.
Methods All data were collected prospectively and entered into the ED's centralised electronic patient record database (Qualicare, Switzerland) and retrospectively analysed. The database was scanned for the standardised key words: ‘sexual intercourse’ (German ‘Geschlechtsverkehr’) or ‘coitus’ (German ‘Koitus’).
Results A total of 445 patients were available for further evaluation; 308 (69.0%) were male, 137 (31.0%) were female. The median age was 32 years (range 16–71) for male subjects and 30 years (range 16–70) for female subjects. Two men had cardiovascular emergencies. 46 (10.3%) of our patients suffered from trauma. Neurological emergencies occurred in 55 (12.4%) patients: the most frequent were headaches in 27 (49.0%), followed by subarachnoid haemorrhage (12, 22.0%) and transient global amnesia (11, 20.0%). 154 (97.0%) of the patients presenting with presumed infection actually had infections of the urogenital tract. The most common infection was urethritis (64, 41.0%), followed by cystitis (21, 13.0%) and epididymitis (19, 12.0%). A sexually transmitted disease (STD) was diagnosed in 43 (16.0%) of all patients presenting with a presumed infection. 118 (43.0%) of the patients with a possible infection requested testing for an STD because of unsafe sexual activity without underlying symptoms.
Conclusions Sexual activity is mechanically dangerous, potentially infectious and stressful for the cardiovascular system. Because information on ED presentation related to sexual intercourse is scarce, more efforts should be undertaken to document all such complications to improve treatment and preventative strategies.
Sexuality is an essential aspect of normal human function, well-being and quality of life.1 ,2 It plays a major role in gender relationship, contributes to general health,1 and has physical and emotional components.3 The physiology of the sexual response is characterised by a complex interaction between the sympathetic and parasympathetic arms of the autonomic nervous system.3 Sexual activity is strenuous for the whole body, regardless of age.3 The human sexual response cycle has four distinct stages with specific physiological changes in heart rate, blood pressure, respiratory rate and cerebral perfusion rate (figure 1).4
Research has shown that interest in and the frequency of sexual activity is more marked in the younger population.5 Sexual activity among older men and couples has, however, increased over the last 10 years, possibly due to the development of drugs to treat erectile dysfunction. Most people enjoy sexual intercourse without complications, but a significant, if small, number need to seek emergency medical help for related health problems.6 ,7 Studies have even demonstrated an inverse relationship between sexual activity and risk of death.2 In a study by Palmore8 investigating the relationship between general health and sexual activity in 270 men, the author suggests that the frequency of sexual intercourse in men is a significant predictor for longevity. Little has been published, however, about trauma related to consensual sexual intercourse.9 But despite the potential health benefits of sexual intercourse, an active sex life may have a certain morbidity and mortality. The true incidence of emergency department (ED) admissions associated with sexual intercourse is not known because patients may not report the sexual circumstances of their health problems to healthcare professionals.6 ,7 Complications of sexual intercourse leading to ED admission are generally underestimated.7
We therefore reviewed all admissions to our ED with a direct relationship to sexual intercourse over an 11-year period and report on our results here.
All data were collected prospectively and entered into the ED's centralised electronic patient record database (Qualicare, Switzerland) and retrospectively analysed. The database was searched for patients aged ≥16 years, admitted between 1 January 2000 and 31 December 2011.
The database was scanned for the standardised key word ‘sexual intercourse’ (German ‘Geschlechtsverkehr’) or ‘coitus’ (German ‘Koitus’). Patients with duplicated (n=23) and incomplete (n=213) records (lack of medical history) and those with a sexual activity-related health issues not related to the main reason for ED admission (n=170) were excluded from the analysis.
Baseline demographic data (age, gender, nationality, profession) and the following clinical data were recorded: reason for presentation, clinical features and diagnosis.
Syphilis was diagnosed from blood serology and, if available, from ulcer swabs. Urethritis was diagnosed clinically; urethral discharge was swabbed and sent to our central laboratory for evaluation since there are no microscopes available at our ED. Patients then were referred the urological outpatient clinic for follow-up. Standard antibiotic therapy was initiated in our ED.
Evaluable data were collected from 445 patients: 308 (69.0%) were men and 137 (31.0%) women. The median age was 32 years (range 16–71) in men and 29 (range 16–70) in women. Patients younger than 40 years accounted for 348 (78.0%) of our sample. From 2000 to 2011, we observed a steady increase in emergencies related to sexual intercourse, from 20 patients in 2000 to 50 patients in 2011.
In total, 48 different types of emergency occurred, which we split into five categories (figure 2).
Two men had cardiovascular emergencies: one aged 41 years suffered myocardial infarction and the other aged 52 years aortic dissection.
A total of 46 (10.2%) patients presented with trauma; 41 (89.0%) were men. The median age was 26 years (range 17–68) in men and 20 (range 19–47) in women. In all, 38 (79.0%) of the patients were younger than 40. A total of 36 (78.0%) of the patients suffered injuries to the genitals. All were men. The most frequent trauma to the genitals was a torn frenulum (21, 58.0%), followed by penile excoriation (6, 17.0%), penile haematoma in four patients, scrotal haematoma in two, and testicular torsion, penile pain, and scrotal pain in one patient each. Trauma to other body regions occurred in 10 (22.0%) patients; the most frequent was musculoskeletal pain.3
Neurological emergencies occurred in 55 (12.4%). Overall, 75.0% (n=41) of these patients were men and 14 (25.0%) women. The median age was 47 years (range 18–67) in men and 49 (range 22–69) in women. In all, 21 (38) of these patients were younger than 40. The most frequent neurological emergencies were headache 27 (49.0%), followed by subarachnoid haemorrhage 12 (22.0%), transient global amnesia 11 (20.0%), stroke 4 (7.0%) and subdural haematoma in one patient (figure 3). A total of 23 (85.0%) of the patients with headache were men and 4 (15.0%) women. The median age was 34 years (range 18–67) in men and 43 (range 35–51) in women. In all, 9 (75.0%) of the patients with subarachnoid haemorrhage were men and 3 (25.0%) women. The median ages here were 51 years (range 41–67) in men and 63 (range 45–63) in women (figure 4).
Possible infection was the reason for presentations in 276 (62.0%) of our patients. Of these, 197 (71.0%) patients were men and 79 (29.0%) women. The median age was 28 years (range 16–62) in men and 25 (range 16–70) in women. A total of 236 (86.0%) of the patients presenting due to a possible infection were younger than 40. The reasons for presentation were either presumed infection 158 (57.0%) or fear of a sexually transmitted disease (STD) (118, 43.0%) without any symptoms.
A total of 154 (97.0%) of the patients presenting with presumed infection actually had infections of the urogenital tract; 107 were men (70.0%) of these patients were men and 47 (30.0%) were women. The median age was 29 years (range 18–62) in men and 25 (range 16–70) in women. Overall the most common infection was urethritis (64, 41.0%), followed by cystitis (21, 13.0%), epididymitis (19, 12.0%), infectious penile ulcer (11, 7%), prostatitis (11, 7%), pyelonephritis (7, 4.0%), infectious penile swelling (7, 4.0%), balanitis,6 abscess in the genital region, adnexitis in three patients each and two cases of vulvitis. Four patients had non-urogenital infections.
An STD was diagnosed in 43 (16.0%) of all patients presenting with a presumed infection. This corresponded to 9.7% of our whole study population. Of these, 40 (93.0) patients were men and 3 (7.0%) were women. The median age was 30 years (range 18–52) in men and 23 (range 22–31) in women. In all, 33 (77.0%) of these patients were younger than 40. The most frequent STD diagnosed was gonorrhoea (25, 58.0%), followed by syphilis (7, 16.0%), genital herpes (5, 12.0%), Chlamydia in three patients, and condylomata acuminata, hepatitis, and HIV in one patient each (figure 5).
A total of 118 (43.0%) of the patients with a possible infection (26.5% of our whole sample) requested testing for an STD because of unsafe sexual activity without underlying symptoms. Of these, 87 (74.0%) patients were men and 31 (26.0%) women. The median age was 28 years (range 17–5) in men and 26 (range 17–45) in women. A total of 99 (84.0%) of these patients were younger than 40.
In all, 66 (14.8%) of patients presented for other reasons; 27 (41.0%) of these were men and 39 (59.0%) women. The most frequent reason was non-specific abdominal pain 27 (41.0%), followed by psychological crisis (10, 16.0%), non-traumatic, non-infectious scrotal pain 8 (12.0%), gross haematuria 7 (11.0%), pregnancy in five patients, ejaculation problems in four, dyspareunia in three and eczema in two patients.
Complications of sexual intercourse leading to ED admissions are rare and account for only about 0.1% of all patients admitted to our ED annually. In Switzerland, sexual health is mainly managed by general practitioners, gynaecologists and specialised outpatient clinics. In Bern, female sexual assault victims are examined by specially trained teams consisting of three women: a gynaecologist, a nurse and a police officer. It is therefore likely that some patients were referred to these services during office hours rather than being managed in our ED. To the best of our knowledge, this is the first study to report on ED admission related to sexual activity.
Only two patients were admitted as cardiovascular emergencies in the context of sexual activity during the 11-year period of our study. The incidence of myocardial infarction triggered by sexual activity is not known,7 but it has been estimated to be lower than 1%.10 ,11 As confirmed by our analysis, the number of events is very small.11 Evidence suggests that the risk of a cardiovascular event is up to 2.7% higher during sexual activity.11–14 Aortic dissection related to sexual intercourse is rare in comparison with other vascular events (myocardial infarction and ruptured intracranial aneurysm),15 as our study also shows. Our patients with cardiovascular-related ED admissions were also older than other groups of emergency patients in the present study. These findings are similar to those of other studies.2 ,13 A possible explanation is that the prevalence of coronary artery disease is higher in a population older than 40 than in a younger age group.2 According to a study by Drory2, emotional and physical stress during sexual activity leads to reduced myocardial oxygen supply and the onset of a prothrombotic state which may trigger myocardial infarction.
Figures on the incidence of patients treated in EDs with trauma in the context of sexual activity have not been published. It is therefore difficult to consider our findings in a wider context. Our study showed trauma from sexual intercourse to be more common in men, a finding confirmed by a study by Eke6 on urological complications of coitus. In this study, patients presented with penile fracture, swelling, deviations and haematoma.6 Our findings were similar. In contrast to our study, however, the most frequent injury was penile fracture,6 which we did not see. We have no explanation for this, other than that penile fractures appear to occur more frequently in the Middle East.16 In the USA, penile fracture is seen in 0.3–1.4 patients per 100 000 emergency admissions, and the numbers in Europe are estimated to be smaller.16
We did not observe any genital injuries in women. A study by Zink et al,9 however, found that anogenital injuries occur during sexual activity in at least 11% of adult women. The only explanation for this difference is that women may more often consult a gynaecologist than an ED for the treatment of intercourse-related injuries.
Neurological complications were the second most frequent complication of sexual intercourse in our study. The patients in this group were older than other groups of emergency patients in the present study, and were marked older than in studies reported elsewhere.17 ,18 Our study also confirmed that patients with postcoital headache are generally younger than patients with sexually triggered subarachoid haemorrhage.4 ,17 ,18 According to a review by Reynolds et al4 on sexual intercourse-related rupture of cerebral aneurysm, the high rate in the over-50s might be explained by the increased prevalence of hypertension, which is associated with increased aneurysm wall tension and a consequent increased risk of rupture.
We found no publications on admission to EDs with neurological complications of sexual intercourse. A study by Kriz in 51 patients on coitus as a predisposing factor for neurological complications found, however, that about 50% suffered from headaches, 8% from subarachnoid haemorrhage and 20% from ischaemic cerebral symptoms.19 Our figures for sexually triggered headache were similar, but the numbers of patients with subarachnoid haemorrhage and ischaemic cerebral disease differ greatly between the two studies. An explanation for these latter differences may be that the study by Kriz was conducted in 1971 before computer tomography came into use. The detection of ischaemic or haemorrhagic cerebral diseases relied mainly on clinical examination and may therefore have been misdiagnosed.
The most frequent neurological complication in our study was headache. The actual incidence of orgasmic headache is unknown.17 ,20 As in our study, Larner found that men were more frequently affected.7 ,17 The sudden and severe onset of orgasmic headache means that arterial dissection and subarachnoid haemorrhage should always be excluded.7 ,17 ,21 The latter was the second most common sexually triggered neurological emergency in our study. No figures on sexually triggered subarachnoid haemorrhage have been published,4 but there is a strong relationship between coital subarachnoid haemorrhage and ruptured cerebral aneurysm.4 As a review by Reynolds et al4 showed, there is a direct relationship between increased blood pressure during sexual intercourse and the likelihood of rupture of a pre-existing cerebral aneuryms.4 Many case series have demonstrated that up to 14.5% of patients who suffer a ruptured cerebral aneurysm had coitus before onset of the symptoms.4 ,7 Transient global amnesia is estimated to be related to sexual activity in up to 5% of cases as described in a review by Larner.17 Our figures were higher. Stroke associated with sexual activity is rare,7 as this study also shows.
More than 60% of our sample presented with a possible STD. The true prevalence of STDs in the general population is not known.22 In some European countries, the rate of diagnosis of STDs has been increasing since the mid-1990s, in particular of syphilis, gonorrhoea and chlamydia.23 About 10% of our study population was diagnosed with an STD. According to Borhart and Birnbaumer,22 STDs pose a significant public health risk in all demographic groups, especially among young people, and our study found this too. This may be because many of them do not use condoms, as shown by the Youth Risk Behaviour Surveillance Summary in 2009 in the USA, where only about 60% of 15–21-year-olds used condoms.24 Also, a study by Wolfers et al on risk estimates for STDs among Dutch students showed that at least half of their study population with sexual experience underestimated their susceptibility for STDs.23 ,25
More than a quarter of our patients requested STD screening because we offer testing, counselling and a follow-up service. This might explain the increased rates of attendances for STD screening. Again, no exact figures on patients presenting at EDs for the purpose of STD testing have been published. Patients who test positive for HIV at our ED are referred to our infectious diseases outpatient clinic. Patients with gonorrhoea, chlamydia and syphilis are followed up in our outpatient clinic or by specialist departments (eg, urology, infectious diseases), as determined by the attending consultant. An HIV testing rate of about 4%–8% of sexually active heterosexual adolescents has been reported.25 In our study, mainly men wished to exclude STD. As a study by Patinkin et al on people who practice unsafe sex and have themselves tested repeatedly for HIV showed, this is not an uncommon phenomenon in mostly young male adults.26 They also found that some men have many casual sexual encounters with numerous partners despite being aware of the risks involved.26 Patinkin et al26 suggested that patients requesting HIV testing should be informed of the risks accompanying unsafe sexual contacts and the importance of regular testing. This means that emergency physicians must also always be on the lookout for risk factors for STDs and their clinical features.22
Our study has some limitations. The data were collected retrospectively from narrative comments in notes which means that information bias and interpretation bias cannot be excluded. Standard protocols were not used and we therefore do not know how many of our patients were suffering from underlying diseases such as coronary artery disease or aneurysm of the intracranial artery. We also did not document sexual habits nor did we assess whether safer sex practices were used or whether medication to assist with sexual performance was used. Also, because patients younger than 16 years and gynaecological emergencies are treated in different EDs in our hospital, under-reporting of STDs or emergencies characteristic for women or adolescents younger than 16 years cannot be excluded.
Sexual activity is mechanically dangerous, potentially infectious and stressful for the cardiovascular system. Mainly young persons and especially young men are affected. A wide range of neurological ED admissions can be related to sexual intercourse and emergency physicians should be aware of the relatively high prevalence of subarachnoid haemorrhage in this population.
ED personnel should be trained in recognising and treating sexual intercourse-related ED admissions and especially help educating patients on STDs, since numbers are worldwide rising again.
Because information on ED presentation related to sexual intercourse is scarce, more efforts should be undertaken to document all such complications to improve treatment and preventative strategies.
Contributors Acquisition of data: JK. Analysis and interpretation of data: CAP, JK. Drafting of the manuscript: CAP, AKE. Critical revision of the manuscript for important intellectual content: HZ, AKE. Administrative, technical and material support: HZ, AKE. Study supervision: AKE. AKE had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.