By Marcello Cherchi, MD PhD
For patients
Some people experience disequilibrium while having sex, usually during or shortly after orgasm. In some cases this can occur due to problems with the ear, brain or heart. Your doctor may check several tests of inner ear balance function, or refer you to a heart doctor.
For clinicians
Overview
Coital vertigo refers to disequilibrium typically beginning during or shortly after orgasm, lasting minutes to an hour. There is a paucity of literature on this subject, perhaps because patients are often embarrassed to report the circumstances of symptom onset. The differential diagnosis is thought to include otologic, neurologic and cardiovascular etiologies.
Introduction
Disequilibrium occurring during or shortly after orgasm is referred to in the literature as coital vertigo. Symptoms usually last minutes (less commonly closer to an hour). This sometimes occurs due to appearance of a perilymphatic fistula (in a patient with a prior history of otologic surgery) or due to other otologic disease (such as superior semicircular canal dehiscence, Ménière’s disease, benign paroxysmal positional vertigo). Other proposed mechanisms include cardiovascular (cardiac arrhythmia, hyperventilation, post-orgasmic hypotension) and perhaps coital migraine (with migraine-associated vertigo). Workup for these possibilities is reasonable. The prognosis depends on the underlying cause.
Epidemiology
Coital vertigo is infrequently reported (perhaps because patients are embarrassed to report the circumstances of symptom onset), making it difficult to estimate incidence or prevalence.
Pathophysiological mechanism of disease
The literature suggests several possible mechanisms for coital vertigo.
- Otologic etiologies:
- Dawlatly (Dawlatly 1998) reported on four patients who had undergone various ear surgeries, and developed episodes of disequilibrium during or immediately after sexual intercourse, attributed to appearance of a perilymph fistula.
- Lee and colleagues (Lee et al. 2018) reported on several patients in whom primary otologic disease appeared to be the mechanism of coital vertigo, including superior semicircular canal dehiscence (SSCD) and Ménière’s disease.
- Given the positions and changes of position that may occur during sexual activity, benign paroxysmal positional vertigo (BPPV) is a consideration.
- Neurologic etiologies. Coital headache is fairly well-described (Martin 1974; Martinez et al. 1988; Maynard and Pace 2024; Ostergaard and Kraft 1992), and some such headaches are likely to be migraine (Porter and Jankovic 1981), which in turn could manifest with migraine associated vertigo (MAV).
- Cardiovascular etiologies. Mann and colleagues (Mann et al. 1982) described a case of coital syncope and reviewed other reported cases, whose proposed mechanisms included cardiac arrhythmia, hyperventilation, and post-orgasmic hypotension. Frank syncope is not usually experienced as disequilibrium, but can sometimes be confused therewith both by patients and clinicians.
Lee and colleagues (Lee et al. 2018) note that in the series of 7 patients they described, two (29%) had no identifiable cause of coital vertigo.
Clinical presentation
Lee and Kim (Lee et al. 2018) provided a case series of 7 patients with coital vertigo. They reported the duration of disequilibrium to range from “a few minutes to one hour.” The patients we have encountered with this condition generally describe the symptom duration towards the shorter end of this range (a few minutes).
Lee and Kim (Lee et al. 2018) state that in their series of 7 patients, 6 (86%) reported auditory symptoms, including tinnitus in 4 (57%), aural fullness in 2 (29%), autophony in 1 (14%), hearing impairment in 1 (14%) and hyperacusis in 1 (14%).
Physical examination
Physical examination in patients complaining of coital vertigo is generally normal, though there are a few exceptions.
If coital vertigo is due to benign paroxysmal positional vertigo (BPPV), then the corresponding nystagmus may be observable on video oculography (VOG).
If coital vertigo is due to superior semicircular canal dehiscence (SSCD), then Valsalva-induced nystagmus may be observable on video oculography (VOG).
Differential diagnosis
Given the mechanisms of disease described earlier, the differential diagnosis of coital vertigo includes:
- Development of a perilymphatic fistula in a previously operated ear.
- Superior semicircular canal dehiscence (SSCD).
- Ménière’s disease.
- Benign paroxysmal positional vertigo (BPPV).
- Migraine associated vertigo (MAV).
- Cardiovascular causes (arrhythmia, hyperventilation, post-orgasmic hypotension).
Treatment
If a patient with coital vertigo reports a prior history of ear disease (particularly any kind of otologic surgery), then referral to otolaryngology is appropriate.
If there is no known prior history of otologic disease, then a medically reasonable workup includes:
- Audiometry to evaluate for Ménière’s disease.
- Cervical and ocular vestibular evoked myogenic potentials (VEMP) with thresholds to screen for superior semicircular canal dehiscence (SSCD). If compatible with SSCD, then consider checking a temporal bone CT without contrast for confirmation.
- Electrocardiogram.
If the above are unrevealing, then referral to cardiology (e.g., to evaluate for cardiac arrhythmia) is medically reasonable.
Prognosis
The prognosis depends on the underlying cause, if determinable.
References
Dawlatly EE (1998) Coital vertigo after ear surgery: when is sex safe? Am J Otolaryngol 19: 278-82. doi: 10.1016/s0196-0709(98)90132-6
Lee SU, Kim HJ, Koo JW, Choi JY, Kim JS (2018) Vertigo Induced During Coitus. Front Neurol 9: 1187. doi: 10.3389/fneur.2018.01187
Mann S, Craig MW, Gould BA, Melville DI, Raftery EB (1982) Coital blood pressure in hypertensives. Cephalgia, syncope, and the effects of beta-blockade. Br Heart J 47: 84-9. doi: 10.1136/hrt.47.1.84
Martin EA (1974) Headache during sexual intercourse (coital cephalalgia). A report on six cases. Ir J Med Sci 143: 342-5. doi: 10.1007/BF03004787
Martinez JM, Roig C, Arboix A (1988) Complicated coital cephalalgia. Three cases with benign evolution. Cephalalgia 8: 265-8. doi: 10.1046/j.1468-2982.1988.0804265.x
Maynard P, Pace A (2024) Primary Headache Associated with Sexual Activity: A Review of the Literature. Curr Pain Headache Rep. doi: 10.1007/s11916-023-01206-2
Ostergaard JR, Kraft M (1992) Natural course of benign coital headache. BMJ 305: 1129. doi: 10.1136/bmj.305.6862.1129
Porter M, Jankovic J (1981) Benign coital cephalalgia. Differential diagnosis and treatment. Arch Neurol 38: 710-2. doi: 10.1001/archneur.1981.00510110070011
