1 Introduction

The autonomic nervous system, consisting of the sympathetic and parasympathetic pathways, plays an important part in the symptomatology of both anxiety and ejaculation. Anxiety leads to an increase in sympathetic activity, leading to an increase in norepinephric and dopaminergic neurotransmitters [1]. Additionally, the sympathetic neuronal pathways in the pelvis plexus are primarily responsible for the physiology of ejaculation, primarily through the release of norepinephrine. Hence, the two processes could occur concurrently [3]. Even though there is a well-known association between anxiety and sexual arousal, the literature only finds two case reports documenting the association between anxiety and spontaneous ejaculations [5, 6]. The following is a case report of a patient experiencing spontaneous ejaculations in the setting of acute psychosis, managed successfully by pharmacological therapy.

2 Case presentation

A 30 year old African-American male with no documented past psychiatric history was brought to the emergency room by his grandmother for bizarre and erratic behavior develo** over the past 1–2 years. According to his grandmother, he had been exhibiting paranoid ideation, had recently lost his job and had been severing close relationships. Patient’s grandmother also stated that she and other members of his family had observed the patient responding to internal stimuli. Upon evaluation in the emergency department, he denied all symptoms reported by his family; however, he exhibited flight of ideas, rapid pressured speech, hyper-religiosity and paranoid delusions with religious undertones. He was deemed a danger to himself and/or to others and hence was placed on involuntary psychiatric hold and was admitted to the inpatient psychiatric department. In the inpatient unit, the patient underwent further evaluation with differential diagnoses including bipolar disorder with psychotic features, schizophrenia and schizoaffective spectrum disorders. He was initially managed with oral risperidone 0.5 mg twice daily, with an alternative of intramuscular olanzapine 2.5 mg twice daily if he refused oral medication. His regimen also included oral lorazepam 2 mg and oral haloperidol as needed for agitation and anxiety. He tolerated these medications well and did not report any adverse effects.

Upon further evaluation in the inpatient unit, the patient was hyperverbal with tangential thought process and demonstrated a preoccupation with losing body fluids due to routine blood draw performed on the previous day. He also reported having frequent spontaneous ejaculations in the setting of anxiety and loud noises for the past 6 years. He stated that the emissions were not preceded by penile erection or stimulation, and they were not associated with sexual arousal. The patient stated that these episodes distressed him; however, he denied any associated pleasure or guilt in relation to them. Physical and neurological examination findings were unremarkable.

In response to these complaints and continued symptoms of mania and psychosis, risperidone was increased to 2 mg orally twice daily with nightly quetiapine 200 mg per oral to augment, as patient continued to struggle with sleep. Once improvement and tolerability were established orally, he was subsequently transitioned to the long-acting injectable formulation of paliperidone palmitate to ensure medication adherence as well as decrease rehospitalization.

The patient reported two events of spontaneous ejaculations occurring during his admission prior to increase in dosage of risperidone and initiation of quetiapine. With this change in his medication regimen, he reported improvement in his manic symptomatology as well as cessation in spontaneous ejaculations until discharge. Total length of stay was 10 days. The frequency of spontaneous ejaculations was reduced to a mean of once every week as reported by the patient during follow-up phone call 2 weeks after discharge.

3 Discussion

Ejaculation is a physiologic process that is regulated by the autonomic nervous system. Sympathetic neuronal pathways of the pelvic plexus that primarily secrete norepinephrine are the neuronal basis for ejaculation [2]. The role of serotonin in this phenomenon of ejaculation has been well-documented. 5HT receptor agonism has been found to have an overall inhibitory effect on ejaculation; 5HT1A receptors have a cumulative facilitatory effect, whereas 5HT1B and 5HT2C receptors have an inhibitory effect on the process [3]. Penile erection, on the other hand, is primarily mediated by the parasympathetic nervous system through the sacral reflex arc [2]. Anxiety decreases parasympathetic activity, thereby inhibiting penile erection while simultaneously increasing sympathetic activity, which could trigger ejaculation. An increase in sympathetic activity is associated with an increase in noradrenergic and dopaminergic activity and a decrease in serotonergic activity. Therefore, the neuronal pathways between anxiety and ejaculations are linked and are not necessarily associated with penile erection and/or sexual arousal.

The patient, whose history is previously described, was diagnosed with bipolar I disorder with psychotic features and anxiety disorder, unspecified, associated with spontaneous ejaculation. Antipsychotics have documented side effects of sexual dysfunction, predominantly due to their strong dopaminergic effect and increase in prolactin levels. Risperidone is a second-generation atypical antipsychotic that exhibits its effect by blocking dopamine and serotonin receptors [4]. Hence, it was an appropriate choice, with its dual neurotransmitter effect, to successfully manage both the symptoms of psychosis/mania and spontaneous ejaculations simultaneously.

Upon review of literature, the authors found two previously documented case reports of individuals with anxiety disorder presenting with spontaneous ejaculations. Freeman SA [5] describes the case of a 42-year-old male with panic attacks associated with spontaneous ejaculation who was successfully treated with citalopram and clonazepam. Senormanci et al. [6] present the case of a 20-year-old male with panic disorder with spontaneous ejaculations which was pharmacologically managed by sertraline and alprazolam. Both case reports hypothesize similar mechanisms for simultaneous presentation of anxiety and spontaneous ejaculations. They further express that it is unclear whether the spontaneous ejaculations resolved upon resolution of anxiety or if it was due to the effect of the SSRI on serotonergic receptors. By the resolution of spontaneous ejaculations by use of risperidone, we hypothesize that spontaneous ejaculations can effectively be controlled by blockade of serotonergic receptors and suppression of dopaminergic activity at the mesolimbic dopaminergic circuit.

Assessment of the presented case in the light of the scarce literature indicates that spontaneous ejaculations without sexual stimulus can gradually subside with introduction of D2 and serotonin antagonists such as risperidone or paliperidone. Our patient had spontaneous ejaculations for about 6 years without sexual desires in the context of anxiety promoting situations during these ejaculations until he was admitted to inpatient psychiatric unit where he received appropriate treatment with antipsychotic drugs for diagnosed bipolar 1 disorder. Therefore, spontaneous ejaculation occurring in situations without apparent or direct sexual precipitation should be questioned in patients with psychiatric problems concurrent with anxiety symptoms. Consciously patients may feel embarrassed or fear humiliation and never disclose this information to anyone including family members as in this case or even a treating provider. Consequently, the role of inpatient psychiatric stabilization with initiation of antipsychotic drugs in decreasing the frequency of spontaneous ejaculation in the presented case is also thought to have occurred via control of psychiatric symptoms and its adverse effects on ejaculation.

Since this patient was seen only on the acute inpatient unit without long term outpatient follow up after discharge, historical data was challenging to validate as extended observation could not be obtained. Nevertheless, the lack of research on the interaction between psychopharmacological agents and spontaneous ejaculation constitutes a limitation for analyzing the presented case where our conclusions were based on treatment response to clinical observations.