Spontaneous ejaculation followed by obsessive-compulsive symptoms successfully treated with fluoxetine

Dear Editor, Spontaneous ejaculation is a rare clinical phenomenon characterized by ejaculation occurring in the absence of sexual stimulation or subjective arousal. Reported causes include spinal cord lesions, epilepsy, rabies, medication effects, and psychological conditions.[1] Most psychiatric reports have described associations with anxiety-related states such as panic disorder and acute stress reactions.[2,3] To the best of our knowledge, the subsequent development of obsessive-compulsive symptoms following spontaneous ejaculation has not previously been reported. We describe a young man who developed contamination obsessions, compulsive rituals, and avoidance behaviors after recurrent spontaneous ejaculation, with marked improvement following fluoxetine treatment. A 26-year-old single male presented with persistent guilt, feelings of contamination, repetitive religious rituals, cleaning compulsions, and avoidance of situations requiring prolonged sitting. Two years earlier, he experienced sudden ejaculation while seated at a barber shop. The episode occurred without sexual desire, erotic stimulation, penile erection, or pleasurable sensation. Following this incident, he developed intense embarrassment and began avoiding barber visits, attending only once every three months. Soon afterward, he developed recurrent intrusive thoughts that he was “dirty” or morally contaminated, accompanied by repetitive washing behaviors and frequent religious rituals aimed at reducing distress. Approximately one year before presentation, he experienced a second similar episode while driving in traffic. Since then, he had completely avoided driving due to fear of recurrence. Yale-Brown Obsessive Compulsive Scale (Y-BOCS) score was 28, indicating severe symptoms. Routine blood tests, thyroid function tests, vitamin B12, folate levels, and urological examination were unremarkable. There was no history of substance use, neurological disease, or medication exposure. A diagnosis of obsessive-compulsive disorder was made. Fluoxetine was initiated at 20 mg/day and increased to 40 mg/day. After 12 weeks, Y-BOCS score decreased to eight, with marked improvement in obsessions, compulsions, and avoidance behaviors. He resumed regular barber visits and driving. The psychopathological sequence in this case may be conceptualized within a cognitive-behavioral framework of obsessive-compulsive disorder. The unexpected ejaculation episodes appear to have been interpreted as shameful or contaminating experiences, triggering intrusive thoughts and compulsive neutralizing behaviors.[4] In culturally sensitive contexts, involuntary sexual symptoms may evoke intense guilt, concerns regarding purity, and fear of loss of control, thereby contributing to obsessive-compulsive symptom formation in vulnerable individuals. Neurobiologically, the unexpected and uncontrollable nature of the episodes may have engaged amygdala-mediated threat appraisal and fear-conditioning mechanisms, whereby neutral contexts such as sitting at a barber’s chair or driving acquired aversive significance. Stress-related modulation of cortico-striato-thalamo-cortical circuits, together with serotonergic dysregulation implicated in both obsessive-compulsive disorder and ejaculatory control,[5] may provide a plausible link between the somatic event and subsequent obsessive-compulsive symptoms. However, this interpretation remains hypothetical, as no neurobiological measures were obtained. Patients presenting with unusual sexual symptoms should not be evaluated solely from neurological or urological perspectives, particularly when guilt, ritualistic behaviors, intrusive thoughts, or avoidance are present. Early psychiatric assessment may prevent prolonged functional impairment and facilitate effective treatment. Patient consent Written informed consent was obtained from the patient for publication. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.