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Viagra falls: Is there a relationship between sex and nosebleeds?

In previous blogs I have covered a number of different topics relating to various human behaviours involving blood including haematophagia (the eating and/or drinking of blood products), haemolacria (the crying of blood), clinical vampirism as a sexual paraphilia, and menophilia (sexual arousal from women menstruating). Today’s blog adds to the list by taking a brief look at sex and nosebleeds (medically known as epistaxis).

There are many causes of nosebleeds. The two most common are nose picking and being exposed to dry air for long periods. Other reasons include having high blood pressure, having a cold or flu, allergic rhinitis (nose allergies), acute sinusitis, heavy alcohol use, being exposed to chemical irritants, being on certain medications (such as blood thinners and non-steroidal anti-inflammatory drugs), nose trauma, cocaine use, and haemophilia. Added to this, there is plenty of anecdotal evidence of people claiming to get nosebleeds during vigorous sex.

However, an article in Culture Smash by Brian Ashcroft quoted an otolaryngologist, Dr. Kouichirou Kanaya (an ear, nose, and throat specialist) who was quoted as saying:

“The notion that sexual arousal causes the heart rate and blood pressure to rise is something that’s a well documented fact; however, in actuality, sexual arousal and bloody noses have no direct connection”

However, while researching this article I came across a number of medical papers showing that there is one area where nosebleeds have been related to sexual activity. More specifically, there have been a number of cases in the literature where men taking sildenafil (Viagra) and/or tadalafil (Cialis) have had nosebleeds during sex. For instance, Dr. L.A. Hicklin and colleagues reported two cases in a 2002 issue of the Journal of the Royal Society of Medicine. These are reported verbatim below followed by a 2006 case by Dr. G. Pomara and colleagues in the International Journal of Impotence Research, and a 2005 case by Dr. H. Ismail and Dr. P.G. Harries in the journal Acta oto-laryngologica:

  • Case 1: “A man in his late 50s was admitted from the emergency department with heavy prolonged epistaxis…During the admission the patient volunteered that, in the hours before his first nose-bleed, he had been engaging in energetic sexual activity. To enhance his sexual performance he had taken 50 mg sildenafil. Over the subsequent few days he had had several short but heavy epistaxes, and on the day of admission bleeding had continued for 6 hours without stopping. With packing and bed rest the bleeding gradually settled and he was discharged after six days”.
  • Case 2: “A man in his early 70s was admitted from the emergency department after 5 hours of epistaxis. He had taken sildenafil to enhance his sexual performance in the morning before his epistaxis…This was his first nose-bleed requiring medical attention…[After] two days and he was discharged home with no further epistaxis”.
  • Case 3: “A 32-year-old male presented to our department for recurrent epistaxis during sexual intercourses…During the consultation, he volunteered that the trigger for the epistaxis appeared to have been misuse of phosphodiesterase (PDE)-5 inhibitors, Viagra and Cialis. This first report of epistaxis after PDE-5 inhibitors in a young patient underline the possibility that in the next years the number of similar cases might increase due to the diffusion of PDE-5 inhibitor misuse in recreational settings”.
  • Case 4: A 66-year-old male presented to our department with recurrent epistaxis. On examination it was not possible to identify the source of the bleeding, despite various measures…During a consultation the patient volunteered that the trigger for the epistaxis appeared to have been energetic sexual activity. To enhance his sexual performance he had taken Viagra; however, on stopping the Viagra and changing to the newer drug Cialis, the episodes of epistaxis continued. We document what we believe to be the first case of epistaxis caused by Cialis”.

So why would Viagra and Cialis cause nosebleeds? Given that these medications help engorge erectile tissue, the nose also contains erectile tissue and the authors of these case reports believe that nasal engorgement also took place and lead to the nosebleeds. The phenomenon may be under-reported because individuals that use Viagra to enhance their sex lives may be too embarrassed to discuss this with doctors if it relates to sexual dysfunction. (I also came across a case report in a 2009 issue of the Indian Journal of Chest Diseases and Allied Sciences by Dr. R. Dixit and colleagues of a 38-year old man persistently coughing up of blood [haemoptysis] whenever he used Viagra during sex).

Another interesting angle on sexual nosebleeds comes from Japanese cartoon animation (and more specifically Manga comics). In an online article entitled ‘Nosebleeds: Manga just wouldn’t be the same without them’, the author argues that Manga cartoons contain a number of specific tropes (i.e., a significant or recurrent theme). These tropes (amongst others) included nosebleeds, sweat drops, snot bubbles, and popping veins. Sexual nosebleeds were the number one trope in the article. The article noted that:

“A nosebleed, in the wonderful world of manga, equates to sexual arousal. I saw this trope for the first time in Dragonball, when Bulma lifts her dress and the lecherous Master Roshi spurts blood from his nose. Although Bulma was commando at the time, nosebleeds can be triggered by seeing something as mild as a pair of panties. In the case of the boy in the following image, it seems his bloody nose was triggered more by a fetish for swimsuits rather than the girl wearing them: Clearly, horn dogs don’t spontaneously get nosebleeds in real life. So why is it so in manga? I think it’s generally accepted that a rush of blood to the head and the resulting nosebleed is a visual metaphor for blood rushing to, er, somewhere else – which probably explains why I’ve only ever seen guys get nosebleeds, although I could be wrong about that”.

I’ve never watched a full Manga cartoon in my life but from everything I’ve read, male nosebleeds are common cliché in anime cartoons and are known as ‘hanaji’. According to the online Urban Dictionary, hanaji is “when you see a boy get a nosebleed in anime, [and] usually means his blood pressure has suddenly severely increased from seeing a really cute girl”. In an article by Brian Ashcroft for Culture Smash, he also noted the nosebleed trope in Manga cartoons:

A character, male or female, gets excited—often sexually excited. Blood dribbles, or squirts, out of the character’s nose. The notion that arousal or excitement induces bloody noses…isn’t just part of anime or manga iconography. It’s also become an old wives’ tale of sorts…The trope is very much a Japanese one, appearing throughout the country’s popular culture and with various nuances in anime and manga. It is not a new trope and has existed for years…Manga artist Yasuji Tanioka is believed to be the first one to introduce the motif with his early 1970s manga Yasuji no Mettameta Gaki Dou Kouza. Other manga artists liked the expression and began replicating it in their own work”.

In relation to the nosebleed trope in anime cartoons, Dr. Kouichirou Kanaya (the ear, nose, and throat specialist quoted above) speculated that:

“Bloody noses are probably used to show in a powerful way just how excessively large the change induced by sexual arousal is. It’s a climax, and in manga, it often seems to be code for ejaculation”.

There are also anecdotal cases of nosebleed fetishes (called epistaxiophilia). However, the love of nosebleeds appears to have been created by using the name of nosebleed phobia (epistaxiophobia) and changing the suffix ‘phobia’ for ‘philia’. To my knowledge, there has never been an academic paper or clinical case study published on epistaxiophilia. However, I did come across a number of online confessions of individuals that admitted (if they are true) that they were sexually aroused by nosebleeds. Here are some extracts that I found in various online forums:

  • Extract 1: “Was just reading a thread on r/Askmen about men who get nosebleeds during sex. My brain processed SEX and NOSEBLEEDS and I immediately imagined myself riding a guy home when he suddenly got a nose bleed. I was strangely turned on by that idea. I don’t think I’d be comfortable sharing this newly discovered turn on with any of my friends because I feel like it’s so damn weird” (Female, Reddit, AskWomen forum)
  • Extract 2: “Nosebleed fetish? Does anyone have it? I normally don’t like blood but I find nosebleeds really hot. I wouldn’t ever hurt my loved one, but I have to admit that I’m quite aggressive towards normal people because of it” (Inwealorwoe [Male], Yahoo! Answers)
  • Extract 3: “I’ll completely understand and I won’t take offense if you run from this post flailing and gagging…For the longest time, I’ve had a nosebleed Maybe that links to the fact that I’ve also got haematophilia and a vampire fetish. But you know what I really like? When someone sneezes while they have a nosebleed” (Proclaimer, Female, 21 years old)
  • Extract 4: “I think it’s incredibly sexy when a guy has a nosebleed. Sneezing while having a nosebleed. I would agree that nosebleeds are probably a turn-on for me because of the whole vulnerability/loss of control factor. Same as with sneezing and colds and things like that” (Helter Skelter, female, 19 years old)
  • Extract 5: “I actually do have a blood/vampire fetish. I often find myself getting very thirsty as well as aroused when watching vampires feed in movies. However I don’t really find nosebleeds all that appealing. I’m not disgusted by it or anything, but it just wouldn’t really do anything for me. I guess it’s just not the type of bleeding that I’m attracted to. I can see how it might be appealing to others though” (Shayla, female 31 years)

Obviously I cannot vouch for the veracity of these claims but I have no reason to doubt them (and the final extract liked other blood fetishes but not a nosebleed fetish). There is no detail in any of these extracts to speculate as to why anyone develops a fetish to nosebleeds. However I’ll leave you with a reply to the person in Extract 2 above:

“[Nose bleed fetishes] makes sense. A sexual therapist said that our sexual fantasies are derived from non-sexual things in our life. So your fetish for nosebleeds could actually stem from something non-sexual in your life. For example, it probably turns you on because it makes you feel empowered and aggressive, since if the person you are with has a nosebleed it means you must have been rough with them. So I would say that your fetish is probably normal, because many people are turned on by feeling empowered and aggressive. Sounds normal to me” (The Way It Is, Yahoo! Answers)”.

Dr. Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Ashcroft, B. (2012). Sexual arousal doesn’t cause bloody noses, says medical science! Culture Smash, October 19. Located at: http://kotaku.com/5953124/sexual-arousal-doesnt-cause-bloody-noses-says-medical-science

Dixit, R., Jakhmola, P., Sharma, S., Arya, M., & Parmej, A. R. (2009). Recurrent haemoptysis following sildenafil administration. Indian Journal of Chest Diseases and Allied Sciences, 15, 119-120.

Hicklin, L.A., Ryan, C., Wong, D.K.K., & Hinton, A.E. (2002). Nose-bleeds after sildenafil (Viagra). Journal of the Royal Society of Medicine, 95(8), 402-403.

Ismail, H., & Harries, P. G. (2005). Recurrent epistaxis after treatment with tadalafil (Cialis). Acta oto-laryngologica, 125(3), 334-335.

Pomara, G., Morelli, G., Menchini-Fabris, F., Dinelli, N., Campo, G., LiGuori, G., & Selli, C. (2006). Epistaxis after PDE-5 inhibitors misuse. International Journal of Impotence Research, 18(2), 213-214.

Throbbin’ blood: A beginner’s guide to haemolacria

“A girl has become a holy shrine in India where worshippers watch her cry blood instead of tears. Doctors in Patna, north-east India, have been stumped by Rashida Khatoon’s condition, which causes her to shed tears of blood several times a day. But local Hindu holy men have declared her a miracle. And followers now flock to her home, showering her and her family with gifts as holy offerings” (The Sun, April 7, 2009)

The case of Rashida Khatoon caused headlines around the world a few years ago and was for many people the first time they had come across haemolacria (that literally means “bloody tears”). The condition of haemolacria has been documented a number of times on the medical literature and is a physical condition that causes individuals to cry tears that (in part) consist of blood. Haemolacria can be a symptom of various medical conditions including the relatively minor (such as eye inflammation and bacterial conjunctivitis) to the very serious (such as tuberculosis or a tumour in the tear ducts). However, in Khatoon’s case, there didn’t seem to be any underlying pathology to explain her bloody tears. Arguably the most well known person suffering from haemolacria is another Indian, Twinkle Dwivedi who has appeared on both the Body Shock television series (The Girl Who Cries Blood) and a television documentary on the National Geographic channel. However, the Wikipedia entry on haemolacria casts some doubts on her condition and notes:

“In lack of a medical explanation for her condition, possible religious explanations have been posed. She could have an unknown disease that only she appears to be suffering from, but more skeptical views hypothesize that the case might be explained by the so called Munchausen syndrome by proxy, meaning her mother, seemingly the only one to witness her bleeding actually starting, is fabricating the story and somehow inducing the effect on the girl”.

Given most of the published papers on haemolacria are case studies, one of the largest studies was published in 1991 by Dr. E. Ottovay and Dr. M. Norn in the journal Acta Ophthalmologica. In their study, 125 healthy individuals were specifically examined for blood in their tears. The authors reported that haemolacria was found in 18% of fertile women (most often while menstruating), 7% of pregnant women, none of the menopausal women (n=7), and 8% of men. The authors claimed that haemolacria among fertile women appears to be induced by hormones, whereas haemolacria among men is due to local factors (bacterial conjunctivitis, environmental damage, injuries, etc.).

In 2003, Dr. M. Wiese published a case study of a 56-year old women with short lasting haemolacria in the British Journal of Ophthalmology. She turned up to the hospital’s emergency department following two hours of continuous bleeding from her right nostril. She tried to stop her nose bleeding by pinching her nose but then experienced bleeding from her right eye and ear. Dr. Wise reported that”

“Its anatomical basis lies in the intimate connection of nose and eye via the lacrimal apparatus. An increase in pressure within the nasal cavity during epistaxis [nosebleeds] – for example, by pinching or blowing the nose, can cause retrograde flow of blood through the system and thus lead to bloody tears emerging from the ipsilateral eye. As our patient had longstanding perforation of both tympanic membranes, the blood in her nose was also able to travel retrograde via the auditory tube and middle ear into the external auditory canal. This led to the additional bleeding from the right ear”.

A similar case was reported by Dr. Stephan Weiser in a 2012 issue of the Emergency Medicine Journal. Weiser reported the case of a 73-year old man with arterial hypertension (i.e., high blood pressure) who while trying to stem the flow of blood from a nosebleed, pinched his nose, stopped the nosebleed but then started bleeding from his eyes. A different cause of haemolacria was published in 2010 by Dr. K. Mukkamala and his colleagues in the journal Retina. They reported haemolacria being a possible consequence of scleral buckle (SB) infection. SBs are used to help repair detached retinas and Mukkamala’s paper reported three patients (two males and one female) all of who had been crying bloody tears following the placement of an SB.

Many of the published case studies appear to be young girls. In 1987, Dr. B. Ahluwalia and his colleagues reported the case of a 15-year old girl with haemolacria in the Indian Journal of Ophthalmology. That may have been due to psychological (rather than physiological) causes. The first time the girl’s bloody tears were observed was by her parents when she was revising for her exams and in deep concentration reading her books. Her haemolacria was accompanied by giddiness and a headache but her eyesight was unaffected. It was on the third occasion of crying blood that her parents sought medical attention for their daughter. At the time of publishing their case study, the authors noted that she had had a total of 11 attacks (and that there was no relationship with her menstrual cycle). Physical tests revealed no abnormalities although the girl’s consulting psychiatrist reported that she had ‘hysterical traits’. The authors concluded that:

“In the present case of bloody tears we could not detect any organic cause for haemolacria after complete local and systemic examination and through investigations. The presence of hysterical traits as confirmed by the consulting psychiatrist led us to label hysteria as a possible case’ of bloody tears in this case. [Other authors have] also reported cases of haemolacria in patients of hysteria but the mechanism of production of bloody tears in these patients remain obscure, so far”.

Similarly, in 1999, a Brazilian team (led by Dr. T. Freitas) reported the case study of a young female with haemolacria in the journal Arquivos Brasileiros de Oftalmologia. They also found no organic cause despite extensive diagnostic investigations. A recent 2012 study in the Indian Journal of Pediatrics by Dr. B. Praveen and Dr. Johny Vincent reported the very rare case of a 10-year old girl who not only cried tears of blood but also sweated blood too (known medically as haematidrosis). She was successfully treated with propranolol (a beta-blocker often used to treat anxiety, panic and hypertension). More recently, Dr. K.M. Özcan and colleagues published the case of an 11-year old girl with haemolacria in the International Journal of Pediatric Otorhinolaryngology. The girl in question had been crying blood along with nosebleeds from both nostrils for two years before treatment was sought. Medical examination revealed that she had hyperaemia (i.e., the increase of blood flow to different tissues in the body, in this case the nose) and increased vascularity (i.e., bulging veins) in the nasal cavity.

The youngest case of haemolacria that I have come across in the medical literature was a 2010 paper by Dr. K. Kumar and colleagues in the journal Pediatric Allergy, Immunology, and Pulmonology. They reported an infant with immune thrombocytopenic purpura (a bleeding disorder where the blood doesn’t clot the way that it should) who arrived at a paediatric emergency department with bloody tears. The infant was treated with intravenous gamma globulin therapy (immunoglobulin injections that are given in an attempt to temporarily boost a patient’s immunity against disease).

It would appear that most cases of haemolacria have a distinct physiological cause but the cases where no organic cause was found suggest that psychological factors may play a role. This is certainly an area that I (no pun intended) will be keeping an eye on.

Dr Mark Griffiths, Professor of Gambling Studies, International Gaming Research Unit, Nottingham Trent University, Nottingham, UK

Further reading

Ahluwalia, B.K., Khurana, A.K. & Sood, S. (1987). Bloody tears (haemolacria). Indian Journal of Ophthalmology, 35(1), 41.

Freitas, T. G., Justa, V., & Soares, E. J. (1999). Bloody tears: Case report. Arquivos Brasileiros de Oftalmologia, 62, 628-630.

Kumar, K., Waseem, M., Panayiotopoulos, A., & Frieri, M. (2010). An infant with bloody tears in the Pediatric Emergency department: Evaluation and treatment – A case report and review of the literature. Pediatric Allergy, Immunology, and Pulmonology, 23, 207-210.

Mukkamala, K., Gentile, R. C., Rao, L., & Sidoti, P. A. (2010). Recurrent hemolacria: A sign of scleral buckle infection. Retina, 30, 1250-1253.

Özcan, K. M., Özdaş, T., Baran, H., Ozdogan, F., & Dere, H. (2012). Hemolacria: Case report. International Journal of Pediatric Otorhinolaryngology. 77, 137-138.

Ottovay, E., & Norn, M. (1991). Occult haemolacria in females. Acta Ophthalmologica, 69, 544-546.

Praveen, B. K., & Vincent, J. (2012). Hematidrosis and hemolacria: A case report. Indian Journal of Pediatrics, 79(1), 109-111.

Wiese, M.F. (2003). Bloody tears, and more! An unusual case of epistaxis. British Journal of Ophthalmology, 87, 1051.

Wieser, S. (2012). Bloody tears. Emergency Medicine Journal, 29, 286.

Wikipedia (2013). Haemolacria. Located at: http://en.wikipedia.org/wiki/Haemolacria