Sexual Functioning Among Stroke Patients and Their Spouses
Background and Purpose—The aim of this study was to assess effects of stroke on sexual functioning of stroke patients and their spouses and to study the associations of clinical and psychosocial factors with poststroke changes in sexual functions.
Methods—One hundred ninety-two stroke patients and 94 spouses participating in stroke adjustment courses sponsored by the Finnish Stroke and Aphasia Federation completed a self-administered questionnaire concerning their prestroke and poststroke sexual functions and habits. The main outcome measures were (1) libido, (2) coital frequency, (3) sexual arousal, including erectile and orgastic ability and vaginal lubrication, and (4) sexual satisfaction.
Results—A majority of the stroke patients reported a marked decline in all the measured sexual functions, ie, libido, coital frequency, erectile and orgastic ability, and vaginal lubrication, as well as in their sexual satisfaction. The most important explanatory factors for these changes were the general attitude toward sexuality (odds ratio [OR] range, 7.4 to 21.9; logistic regression analysis), fear of impotence (OR, 6.1), inability to discuss sexuality (OR range, 6.8 to 18.5), unwillingness to participate in sexual activity (OR range, 3.1 to 5.4), and the degree of functional disability (OR range, 3.2 to 5.0). The spouses also reported a significant decline in their libido, sexual activity, and sexual satisfaction as a consequence of stroke.
Conclusions—Sexual dysfunction and dissatisfaction with sexual life are common in both male and female stroke patients and in their spouses. Psychological and social factors seem to exert a strong impact on sexual functioning and the quality of sexual life after stroke.
Cerebrovascular diseases are the third leading cause of death and one of the major causes of long-term disability in western countries.1 Despite this high prevalence, little information is available on sexual functioning and sexual satisfaction in stroke patients.2
Most previous studies3 4 5 6 7 have involved either a small sample size or only included subjects younger than 60 years, although 2 studies8 9 have focused on the physiological aspects of sexual behavior rather than on attitudes or psychosocial functioning, which may be important elements in determining the quality of poststroke sexual life.
The most common sexual problems that have been identified after stroke include decline in libido and coital frequency, decline in vaginal lubrication and orgasm in women, and poor or failed erection and ejaculation in men.6 7 The observed decline in sexual functions appears to be multifactorial in nature. In addition to neurological and cognitive deficits, the quality of poststroke sexual life may be impaired because of previous diseases, medication, or various psychosocial factors.2 10 However, the value of these factors influencing sexual behavior after stroke is not carefully outlined, nor do we know the value of sexual counseling and other management approaches.2
Little information is available about the consequences of stroke on the sexual behavior and attitudes of the spouses of stroke patients, although they are very important persons in terms of the well-being of stroke patients. Previous studies7 11 12 suggest that spouses experience negative changes in the quality of their sexual life similar to those of stroke patients, but there is a lack of detailed information regarding the changes in their libido, sexual activity, and satisfaction with sexual life.
A clear understanding of the effects of stroke on sexual behavior would be useful for physicians in planning sexual counseling for stroke patients and their spouses during rehabilitation. We therefore designed the present study to assess the impact of stroke on sexual functioning among stroke patients and their spouses. We particularly aimed to study the associations between the changes in sexuality and the various clinical and psychosocial features of stroke patients and to clarify the complex and multifactorial etiology of poststroke sexual dysfunction.
Subjects and Methods
The series consisted of 192 stroke patients (117 men and 75 women; mean age, 59.1 [SD 10.2] years; range, 32 to 79 years) and 94 spouses (21 men and 73 women; mean age, 57.6 [SD 10.7] years; range, 30 to 79 years) who were recruited from inpatient adjustment courses sponsored by the Stroke and Aphasia Federation in 1997. The total number of patients participating in the courses was 213, of whom 192 (90%) were able and willing to participate in the study. Ninety-four (90%) of the total of 105 spouses agreed to participate in the study. Fifteen patients and 11 spouses who refused to answer the questions, as well as 6 aphasic patients who did not understand the questions, were excluded.
Of the 192 patients, 135 had suffered a brain infarction, 45 had an intracerebral hemorrhage, and 12 had a subarachnoid hemorrhage (93% first-ever strokes). The focal lesion was located in the dominant hemisphere in 100 cases, in the nondominant hemisphere in 58 cases, in the brain stem in 5 cases, and in the cerebellum in 8 cases. Twenty-one patients had multiple brain lesions. The median time from the onset of the first stroke was 23 months. Fifty-one of the 192 patients were previously healthy, while 141 patients had previous diseases, the most common being arterial hypertension (81 patients), diabetes mellitus (42 patients), and coronary artery disease (39 patients). Fifty-four patients suffered from poststroke epilepsy. The majority (159) of the patients were taking medication: 50 β-adrenergic blocking agents, 37 calcium entry blockers, 34 angiotensin-converting enzyme inhibitors, 31 diuretics, 11 digitalis, 23 nitroglycerin, 32 oral diabetes medication, 11 insulin, 7 tricyclic antidepressants, 43 serotonin reuptake inhibitors, and 54 anticonvulsive medication. There were 149 married patients and 43 unmarried, of whom 20 were divorced and 11 widowed.
During the courses, all the patients and their spouses independently completed a questionnaire that included their prestroke and poststroke sexual functions and habits. Dysphasic patients with difficulties in writing (n=21) were assisted by a nurse. Because a validated questionnaire for poststroke sexual functions is not available, we used questions described by Monga et al6 with minor modifications. They were as follows: Libido: (1) increased, (2) no change, (3) diminished, (4) markedly diminished, (5) none; Coital frequency: (1) more than once a week, (2) once a week, (3) one or twice a month, (4) less than once a month, (5) none; Erection, ejaculation, vaginal lubrication, and orgasm: (1) normal, (2) slightly diminished, (3) markedly diminished, (4) none; Satisfaction with sexual life: (1) very satisfied, (2) moderately satisfied, (3) moderately dissatisfied, (4) completely dissatisfied. We also asked about the following: General attitude toward sexuality: (1) extremely important, (2) fairly important, (3) unimportant; Fear of impotence: (1) no, (2) yes; Fear of another stroke: (1) no, (2) yes; Ability to discuss sexuality with the spouse: (1) yes, with ease, (2) yes, with trouble, (3) no; Unwillingness to participate in sexual activity: (1) no, (2) yes. The degree of disability of the patients was scored with the use of the Rankin Scale,13 and the degree of depression was scored with the Geriatric Depression Scale.14 This scale was chosen after a pilot study because it is simple enough for dysphasic patients.
The data were analyzed with SPSS for Windows software. The main response variables, reflecting consequences of stroke on sexual functions, were change in libido, frequency of sexual intercourse, and satisfaction with sexual life. Various clinical factors such as age, gender, diagnosis, location of the lesion, degree of disability, presence and side of hemiparesis, spasticity, hemisensory symptoms, presence and severity of aphasia, previous diseases, and medication, as well as several psychosocial factors such as marital status, presence and degree of depression, ability to discuss sexuality with spouse, fear of having another stroke or fear of impotence, and general attitude toward sexuality, were used to explain the observed alterations in sexual functions (explanatory variables). The statistical significance of factors associated with the measures of sexual functions was evaluated with the χ2 test and multivariate analysis. The response variables were dichotomously divided as follows: (1) decreased libido (answers 3 to 5) versus increased or unchanged libido (answers 1 to 2), (2) coital frequency less than once a month (answers 4 to 5) versus coital frequency more than once a month (answers 1 to 3), and (3) dissatisfaction with sexual life (answers 3 to 4) versus satisfaction with sexual life (answers 1 to 2). Logistic regression analysis, which demonstrates the effect of the explanatory variable on the response variable in such a manner that the other variables can be regarded as adjusted and standardized, was used to test which variables best describe and discriminate patients and their spouses with altered sexual functioning. The stepwise regression procedure of the SPSS statistical package was used. The final models were reported using odds ratios (ORs) and their 95% CIs. The agreement between the answers of the patients and their spouses was analyzed by the marginal homogeneity test, and the Kruskal-Wallis test was used to analyze associations between the degree of depression and changes in sexual functions. The protocol of the study was approved by the ethics committee of the medical faculty, and informed consent of the patient was obtained in each case.
Stroke caused a marked decrease in libido among both the patients and their spouses, with more than half of the patients (57%) and of the spouses (65%) reporting a diminished poststroke libido compared with their prestroke libido. The statistically most essential explanatory variables for the decrease were the general attitude toward sexuality (unimportant: OR, 21.9; fairly important: OR, 7.4), fear of impotence (OR, 6.1), and functional disability (severe: OR, 4.2; mild: OR, 3.2) (Table 1⇓).
The majority of patients (79%) and spouses (84%) reported an active prestroke sexual life, including intercourse regularly at least once a month. After the stroke, however, the number of patients (45%) and spouses (48%) with an active sexual life had markedly decreased. Thirty-three percent of patients and 27% of the spouses reported having ceased sexual intercourse. The decreased coital frequency associated most significantly with the disability to discuss sexuality with the spouse (OR, 18.5), the general attitude toward sexuality (unimportant: OR, 7.7; fairly important: OR, 9.2), and unwillingness to participate in sexual activity (OR, 5.4) (Table 2⇓).
Table 3⇓ shows the effects of stroke on penile erection of the male patients and on vaginal lubrication and orgastic ability of the female patients before and after the stroke. All of these functions decreased markedly as a consequence of stroke, with the majority (75%) of the male patients having a feeling of diminished or absent poststroke erectile capacity and approximately half of the female patients reporting diminished or absent vaginal lubrication (46%) and orgastic ability (55%).
Most of the patients (89%) and their spouses (93%) had been satisfied with their prestroke sexual life. After the stroke, however, dissatisfaction with sexual life increased among both the patients and spouses, with 49% of the patients and 31% of the spouses reporting a feeling of moderate or complete dissatisfaction. The statistically most significant explanatory variables for this reported dissatisfaction were an inability to discuss sexuality (OR, 6.8), unwillingness to participate in sexual activity (OR, 3.1), and functional disability (mild: OR, 5.0; severe: OR, 4.2) (Table 4⇓).
We also found other significant associations between the reported sexual disorders and various clinical factors, which, however, were statistically nonsignificant after the selection of the variables shown in Tables 1⇑, 2⇑, and 4⇑ into the logistic regression model. Erectile dysfunction both before and after the stroke was more frequent among patients with diabetes mellitus than among the other patients (χ2 test, P=0.004), and disorders of erection (P=0.007) and vaginal lubrication (P=0.006) were more common in patients with prior cardiovascular medication than in other patients. A statistically significant association was found between the score of the Geriatric Depression Scale and the poststroke libido (Kruskal-Wallis test, P=0.001), coital frequency (P=0.038), erectile capacity (P<0.001), vaginal lubrication (P=0.003), orgastic ability (P=0.011), and satisfaction with sexual life (P<0.001). Changes in sexual function after the stroke were not related to the gender and marital status of the patients, etiology of stroke, or location of the lesion.
We also analyzed the agreement between the answers of the stroke patients and their spouses, considering the couple as a unit of analysis. There was good agreement in the reported coital frequency and the time to begin sexual activity after the stroke, but the decrease in libido was markedly higher (P=0.007) among the spouses than among the patients, and the spouses reported more dissatisfaction with their prestroke (P=0.041) and poststroke (P<0.001) sexual life than the patients.
The results of the present study, aimed at assessing the effects of stroke on sexual functioning, reveal a significant decline in libido, coital frequency, sexual arousal, and satisfaction with sexual life in both stroke patients and their spouses. The present results also demonstrate that disorders of sexual functions are most significantly associated with various psychosocial factors, such as patients’ general attitude toward sexuality, fear of impotence, and ability to discuss sexuality, as well as with the degree of poststroke functional disability. Moreover, sexual dysfunction was related to the presence and degree of depression, diabetes mellitus, and cardiovascular medication. The etiology or location of the stroke and the gender or marital status of the patients were not associated with changes in poststroke sexuality in patients in the present study.
A few previous studies3 4 5 6 7 8 suggest that cerebrovascular diseases may commonly result in sexual dysfunction, leading to a marked decrease in sexual activity. In their study, performed in 113 stroke patients, Monga et al6 reported diminished or ceased poststroke libido in 79% of male and 66% of female stroke patients. Disorders of erection (62%), ejaculation (78%), vaginal lubrication (61%), and female orgastic ability (77%) were also frequently encountered after the stroke. They also reported that sexual activity, measured as frequency of intercourse, had decreased markedly as a consequence of stroke. Sixty-four percent of their male and 54% of their female patients reported no coital activity after stroke. Significantly decreased poststroke libido,5 8 coital frequency,3 7 8 and erectile and orgastic ability4 5 have also been reported by other authors.
The results of the present study generally agree with the previous studies,3 4 5 6 7 8 but the number of patients who completely stopped having sexual intercourse after the stroke was markedly lower (33% of patients, 27% of spouses) than previously reported.5 6 Moreover, the number of patients satisfied with their poststroke sexual life decreased less in our patients (89% before stroke, 49% after stroke) than reported previously6 (male: 95%, 26%; female: 76%, 37%, respectively). The different findings of these studies are likely to be related to discrepancy in the basic characteristics of the patients, ie, age, previous diseases, and prestroke sexual habits, but they may also reflect different attitudes toward sexuality in different cultures and societies.
Sexual dysfunction in stroke patients is known to be complex and multifactorial. Monga and Ostermann2 suggested in their review that sexual problems in these patients are never a consequence of stroke alone; rather, they may be due to a variety of associated medical conditions and psychosocial factors. Although other authors5 6 7 11 have also suggested that psychological and social factors may significantly affect poststroke sexual functioning, none of these factors has been systematically investigated, and some suggested factors would seem to conflict with each other. In the present study, we have for the first time demonstrated that psychosocial factors play a crucial role in determining sexual drive, activity, and satisfaction after stroke, and their influence is even stronger than that of medical factors. On the other hand, recruiting patients from adjustment courses may overemphasize the role of sexual dysfunction, because stroke patients willing to participate in the courses may have more psychosocial adjustment problems than stroke patients in general. It is also possible that in some patients psychosocial disorders are a cause of poststroke sexual dysfunction instead of being a consequence of sexual problems.
In patients in the present study, poststroke sexual dysfunction was also closely related to the degree of depression measured by the Geriatric Depression Scale, which is also a novel finding. Antidepressant medication, which may sometimes cause sexual disorders, did not explain this finding, because sexual functions were similar in the patients with and without antidepressant medication. Actually, only 7 of our patients used tricyclic antidepressants, which are known to frequently cause sexual disorders, while 43 patients used serotonin reuptake inhibitors and 1 patient used moclobemide, which seldom cause decline in sexual activities.
Our results agree with the previous suggestions that other diseases and medication, such as antihypertensives and antidepressants, may modify the effects of stroke on the sexual behavior of patients and their spouses.2 10 15 16 17 Sjögren and Fugl-Meyer18 reported that stroke patients with previously known arterial hypertension, myocardial infarction, or diabetes mellitus changed their sexual behavior relatively little compared with those without these diseases, reflecting the likelihood of a prestroke decline in their sexual functions. We found a similar association between disorders of erection and the presence of diabetes mellitus in the male patients and between disorders of sexual arousal and previous cardiovascular medication in both genders.
Another interesting finding in the present study was that 19 of our 192 patients, but none of the spouses, reported increased libido after the stroke in comparison with the prestroke libido. These patients were younger (mean age, 50.7 years) than the other patients (60.0 years), but the side and location of the cerebral lesion, clinical deficits, and other diseases or medication of the patients did not differ from those of the other patients. There is also a previous description19 of 3 stroke patients who demonstrated hypersexuality and deviant sexual behavior appearing 3 months after the stroke and remaining stable for years. All 3 patients had temporal lobe lesions and had a history of poststroke seizure activity. Recently, hypersexuality has also been described as a reversible side effect of antidepressant treatment (moclobemide) in 2 patients with ischemic stroke.20
A minor limitation of the present study is that only the Rankin Scale was used to score the degree of disability of the patients. Because different stroke and disability scales are used in various Finnish hospitals and rehabilitation centers, we were not able to compare the severity of stroke using these scales. Moreover, the reported 90% satisfaction with prestroke sexual life among the patients and spouses is surprisingly high and must be regarded with caution. Although these high figures may partly be related to the retrospective behavior of the present study, the decline of satisfaction, particularly among the spouses, is remarkable and is likely caused by the stroke itself.
Approximately half of the stroke patients and spouses in the present study reported an interest in sexual counseling and regarded it as an essential part of stroke rehabilitation, but only a few of them had received it. Although there may be a lack of highly trained sexual counselors, the attitudes toward intimate sexual questions among rehabilitation professionals may also reduce discussion of this topic. The present results, however, suggest that a need clearly exists for sexual counseling after stroke, and we recommend that such counseling be included in the basic information given to stroke patients and their spouses.
This study was supported by grants from the Maire Taponen Foundation, the Medical Reseach Foundation in Oulu, and the Biomedical Engineering Program of the University of Oulu (Finland). We thank the field workers of the Stroke and Aphasia Federation for assisting in the data collection.
- Received November 20, 1998.
- Revision received January 15, 1999.
- Accepted January 15, 1999.
- Copyright © 1999 by American Heart Association
Bonita R, Steward A, Beaglehole R. International trends in stroke mortality. Stroke. 1995;21:989–992.
Monga TN, Ostermann HJ. Sexuality and sexual adjustment in stroke patients. Phys Med Rehabil State Art Rev. 1995;9:345–359.
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