4 Sex Transm Infect: first published as 10.1136/sti.2003.005132 on 30 January 2004. Downloaded from REVIEW Genital allergy C Sonnex ............................................................................................................................... Sex Transm Infect 2004;80:4–7. doi: 10.1136/sti.2003.005132 Genital allergy should be considered as a possible Local responses consist of genital swelling, burning, irritation, or soreness which may occur diagnosis in all patients with genital soreness or irritation during or soon after intercourse, usually becom- for which no infection or dermatosis can be identified and ing maximal at 24 hours and lasting 2–3 days.45 in whom symptoms remain unchanged or worsen with Semen contact with non-genital skin may also give rise to localised itching and urticaria.67 treatment. Type I and IV hypersensitivity reactions are most Generalised reactions associated with semen commonly encountered and can be assessed by allergy include angioedema of the lips and performing skin prick testing/radioallergosorbent test eyelids,68 laryngeal oedema,9 bronchospasm,10 and anaphylaxis347 but, to date, death has not (RAST) or patch testing, respectively. Type IV reactions been reported. Semen allergy mainly affects (contact dermatitis) may sometimes prove difficult to younger women although postmenopausal cases distinguish clinically from an irritant dermatitis. This clinical are documented.11 12 An increasing intensity of reaction with subsequent episodes of coitus is a review attempts to summarise key features of genital common feature. Levine et al described a married allergy for the practising clinician. woman with a 15 year history of hay fever who ........................................................................... initially presented with swollen eyes, nasal congestion, and sneezing an hour after coitus. Ten days later she developed similar symptoms enital soreness and irritation are common together with diffuse urticaria and a sensation of symptoms and in the majority of cases an throat swelling 5 minutes post-ejaculation. Ginfective or common dermatological cause During the next year her symptoms were can be identified. Occasionally the diagnosis prevented by using a condom or by coitus proves a little more elusive and trials of interruptus. On four occasions these precautions antifungals and topical steroids are unsuccessful. failed and symptoms developed. It is in such patients that the possibility of genital Most affected women have a personal or ‘‘allergy’’ should be considered. There are four family history of atopy,3811 although this is not recognised types of immunological hypersensi- always the case28 and familial ‘‘allergic seminal tivity reaction and types I, III, and IV have been vulvovaginitis’’ has been described affecting a reported to affect the genitalia or genital tract mother and three daughters.4 (table 1). When considering genital skin reac- The specific allergen(s) within semen respon- http://sti.bmj.com/ tions it is important to distinguish between sible for triggering type I hypersensitivity is still irritant problems that result from a direct effect unknown. Mumford et al described a woman of the substance concerned with the genital with post-coital wheezing and dyspnoea who, for epithelium in the absence of an allergic mechan- 3 months before these symptoms, had com- ism and true contact dermatitis (that is, type IV plained of perineal irritation.12 Seminal plasma hypersensitivity). Irritants may cause more separated from sperm produced a positive intense reactions on the vulval epithelium than intradermal skin test but a negative patch test. on September 28, 2021 by guest. Protected copyright. on non-genital skin, probably as a result of a Both tests were negative with sperm only. higher transepidermal water loss, capacitance, Further analysis of the seminal plasma suggested 1 and blood flow in the vulva. Genital hypersen- that the sensitising agent had a molecular weight sitivity reactions may be subdivided into those of between 14 000 and 30 000 daltons. Other that are related to sexual ‘‘activity’’ (for example, studies have confirmed that the potential aller- kissing, foreplay, coitus) and those that may gens are glycoproteins of molecular weight occur in the absence of sexual contact. between 12 000 and 75 000,9 13–15 and are prob- ably derived from the prostate or seminal vesicles since vasectomy fails to prevent symptoms.39 SEXUALLY RELATED HYPERSENSITIVITY A number of studies have found an association ....................... Seminal fluid between the onset of seminal fluid allergy and Correspondence to: In 1958, Specken reported the case of a 65 year genital tract ‘‘procedures’’ such as tubal ligation, C Sonnex, Department of old woman who suffered post-coital generalised hysterectomy, intrauterine contraceptive device GU Medicine, urticaria at times accompanied by brochospasm. insertion, and pregnancy.1 3 6–8 It has been Addenbrooke’s Hospital, Hills Road, Cambridge This was the first description of hypersensitivity suggested that these events may in some way CB2 2QQ, UK; to semen and over subsequent years a number of disrupt normal immunomodulation in the christopher.sonnex@ cases and series of cases have appeared in the female genital tract,16 17 although the precise addenbrokes.nhs.uk medical literature. Symptoms may occur with mechanism by which this may occur has not Accepted for publication first exposure to seminal fluid or after years of been elucidated. 13 September 2003 ‘‘uneventful’’ sexual intercourse and range from Hypersensitivity reactions to seminal fluid ....................... purely local to generalised systemic reactions.23 other than type I are less common. Type III www.stijournal.com Genital allergy 5 Sex Transm Infect: first published as 10.1136/sti.2003.005132 on 30 January 2004. Downloaded from Table 1 Summary of the four types of hypersensitivity KY jelly Contact dermatitis has been reported following the use of KY reaction jelly and is the result of propylene glycol sensitivity.30 Type I Immediate hypersensitivity Propylene glycol is widely used as a vehicle for cosmetics, Dependent on the specific triggering of IgE sensitised mast cells by body lotions, antiperspirants, and topical medicines and antigen—for example, asthma, hay fever, urticaria, anaphylaxis should be considered as a possible sensitising agent in Type II Antibody is directed against antigens on specific host cells and tissues— patients with genital dermatitis without an obvious cause. for example, graft rejection, autoimmuine haemolytic anaemia, myasthenia gravis Oral medications Type III Ingested antigens may pass into seminal fluid and rarely Antigen-antibody complexes are deposited in tissues—for example, produce a hypersensitivity reaction in the sexual partner. rheumatoid arthritis, systemic lupus erythematosus, serum sickness, infective endocarditis, malaria Haddad reported the case of a woman allergic to walnuts who Type IV Delayed hypersensitivity developed an anaphylactic reaction after intercourse with her Antigen sensitisred T cells release cytokines following secondary contact husband.31 He had eaten walnuts before coitus and walnut with the same antigen—for example, contact dermatitis, tuberculosis, protein was subsequently detected in his seminal fluid. Post- leprosy coital hypersensivity reactions have also been described in association with penicillin,32 vinblastine,33 and thioridazine ingestion.34 Topical preparations (immune complex) hypersensitivity to seminal fluid has been Fisher reported the case of a young woman who repeatedly reported in a young woman who developed nasal congestion developed an eczematous eruption on her face, neck, and and urticaria 8 hours after intercourse on her honeymoon.18 occasionally arms after sexual intercourse with her boy- She subsequently developed migratory arthralgia, periorbital friend.35 Patch tests to commonly encountered allergens, oedema, dyspnoea secondary to a restrictive ventilatory including cosmetics, were negative. Further investigation defect, and a haemorrhagic proctitis. Investigations showed revealed that her boyfriend used 5% benzoyl peroxide for the presence of circulating immune complexes in the serum facial acne. Subsequent patch testing showed her to be and evidence of complement activation. sensitive to this preparation and her eczema subsided after There are no reports of pure delayed type hypersensitivity her partner changed to a topical antibiotic cream. A similar (DTH) reactions (type IV hypersensitivity) to seminal fluid case of consort dermatitis affecting the neck and chest caused although DTH reactions involving other factors may accom- by oak moss present in a partner’s aftershave has also been pany type I hypersensitivity to seminal fluid.11 An experi- described.36 mental model of contact sensitivity for the murine oral Massage liniment has been reported to cause a contact mucosa does at least provide some theoretical basis for DTH dermatitis and could therefore potentially cause problems in reactions affecting the genital tract mucosa.19 men, although to date, this has not been described.37 Exercise Spermicides Exercise induced urticaria and anaphylaxis are well docu- Contact dermatitis to spermicidal preparations is an uncom- mented.38 Symptoms may be intermittent and often require mon but well recognised condition, possibly more commonly an additional factor, such as food sensitivity. Although affecting men.20 The sensitising agent may be one of the exercise