Sex after stroke in the older patient

Psychological consequences of stroke are numerous and often more disabling than motor or cognitive impairments. These can include feelings of fear, frustration and anger, adjustment reactions to new physical and cognitive limitations, depressions and also anxiety^1,2. Sex, often a private concern, is not frequently addressed.

Sex and sexual function encompass an array of meanings that have resulted in a range of measurements of sexual function such as coital frequency, erectile and orgasmic ability, vaginal lubrication, libido and sexual satisfaction^3,4.

Epidemiology of sex and stroke

Stroke can have an impact on sexual frequency, and post-stroke 33 to 64 per cent of patients have ceased sexual intercourse^4,5 and 72 to 83.3 per cent report decreased sexual frequency^3,6. Decreased libido also occurs in 57 to 79 per cent of all patients and in up to 79 per cent of males and 66 per cent of females^4,5.

In male patients, erectile function is diminished or absent in 29 to 75 per cent⁷. However, Hawton found that the majority of men regain erectile function post-stroke⁸. In females, 46 per cent have diminished or absent vaginal lubrication and 55 per cent have diminished or absent orgasmic ability^4,9. In regard to sexual satisfaction there is increased dissatisfaction with sexual life frequently observed in up to 49 per cent of patients and 31 per cent of partners^1,3,4,10,11.

However, enhanced sexual activity has occurred post-stroke and between 3.2 and 11.1 per cent of patients experience enhanced sexual activity and increased libido^{3, 4, 5,11}. Findings of the key studies on stroke and sexuality are highlighted in Table 1.

Table 1. Summary of key papers

Authors	Year	Number of patients	The main positive findings
Murray CD Harrison B¹	2004	10 patients	Highlighted emotional findings post-stroke, particularly social withdrawal and increased pressure in maintaining/forming relationships.
Giaquinto S Buzzelli S Di Francesco L Nolfe G³	2003	68 patients	Sexual decline and arousal in the post-stroke period. A negative impact on sexual activity was observed for physical disability. 3.2 per cent experienced enhanced sexual activity.
Korpelainen JT Nieminen P Myllyla V	1999	192 patients, 94 partners	Patients and partners reported decline in libido, coital frequency, and sexual satisfaction. Sexual dysfunction was related to depression and functional disability. 19 subjects showed increased libido. Psychological factors played an important role in the decline.
Kimura M Murata Y Shimoda K Robinson RG¹⁰	2001	100 patients	Demonstrated decline in libido and sexual satisfaction post-stroke in males and females. Post-stroke sexual dysfunction was related to the existence and severity of depressive disorder and activities of daily living. Sexual dysfunction in males was related to left hemisphere lesions.
S Buzzelli L Francesco S Giaquinto G Nolfe	1997	86 patients	Sexual decline observed post-stroke. Length of marriage had a negative impact on sexual function. Psychological factors influence sexual decline.
Greenburg E Treger I Ring H	2004	120 patients	Sexual dysfunction was reported in three per cent.
Sjogren K Fugl Meyer AR¹⁴	1982	110 patients	Dependence, causing changes in roles of post-stroke patients is a predictor of sexual activity.
Hawton K	1984	50 male patients	Physical disability had been a problem in resuming sexual activity. A man’s sexual response is not usually chronically impaired following stroke. Some partners experienced lack of desire, and fear of another stroke and poor communication added to this.

Factors affecting sexuality after stroke

Many factors have been suggested that may affect the sexual function of a stroke patient and these include demographic, physical and psychosocial factors^5,12.

Demographic factors affecting sexuality after stroke

These demographic factors include gender, marital status, age and education. These factors were not found to be significant by many authors in determining sexual function of a patient after a stroke^3,4,11,13. However, a study by Buzzelli et al¹¹, found that the length of marriage had a negative impact on the patient’s level of sexual function post-stroke.

Physical factors affecting sex after stroke

Site of lesion

Left sided lesions were found to be in a significantly higher frequency among a group of males with sexual dysfunction, in comparison to a group of males with no sexual dysfunction¹⁰. This has also been demonstrated by other authors^5,15,16. The right hemisphere has also been suggested to be dominant to sexual function¹⁷. Coslett et al found that right hemisphere stroke led to found that right hemisphere stroke led to major sexual dysfunction in comparison to left hemisphere stroke in a study of 26 men with unilateral strokes¹⁷. In addition, damage to the dominant hemisphere has been implicated in causing sexual decline, with damage to the nondominant hemisphere causing sexual excitation¹³. These results are conflicting and other studies show no correlation^3,4,8.

Physical disability

Physical disability was found to have a negative impact on sexual activity^3,6,18. Hawton⁸ found that of the 50 men included in his study, the majority experienced difficulties due to physical disability. In spite of this, difficulties were overcome by two thirds of the men by trying new sexual positions⁸. Dependence of a stroke patient on their partner has been implicated in causing changes in sexuality⁶.

Medication

Whilst the majority of patients are on a wide variety of pharmacological agents, as a whole they have not been implicated in affecting sexual function other than antidepressants and antihypertensives^4,11,19.

Psycho-social factors affecting sex after stroke

Depression

Post-stroke sexual dysfunction has been shown to be closely related to the degree of depression shown with the Geriatric Depression Scale^4,10. Conversely other authors have indicated no relationship between sexual dysfunction and depression^3,11.

Psychological fears

Many psychological fears may affect the sexual function of an individual. Salvatore et al³ found that 25 per cent of male partners and 21 per cent of female partners feared relapse in their partners (the patient) that contributed to sexual dysfunction. Korpelainen et al⁴ discusses other fears that patients have, regarding sexuality, impotence and functional disability. Patients often have reduced self-esteem concerning their desirability to others, in both married and single patients¹ . Lack of communication between the patient and their partner also presents a problem^4,8.

High level of pre-morbid sexual activity

It has been suggested that a high level of premorbid sexual activity is indicative of maintained sexual activity post-stroke in males⁸, but this has not been supported elsewhere³.

Based on the perceived factors influencing the impact of stroke on sexuality, a variety of assessment tools have been used in considering sexual function in post-stroke patients:

Semi-structured interviews^1,8
Questionnaires – including detail of pre-stroke and post stroke sexual function⁴
Assessment of depression, e.g. using the Geriatric Depression Scale⁴, Hamilton Rating Scale for Depression¹⁰, Beck Scale and Centre for Epidemiologic Studies Depression Scale³
Assessment of physical disability, e.g. using the Rankin Scale⁴ and Functional Independence Measure¹¹.

Inclusion of data from partners of patients has also been reported by some authors (partners completing questionnaires on their sexual activity separately to the patient)^3,4. The impact on the partner post-stroke Partners experienced reduced desire, fear of relapse of the patient, and anxiety at having sexual intercourse with an unwell person, as well as experiencing decreased libido (in up to 65 per cent), sexual activity and satisfaction^3,4,8. In addition, 27 per cent of spouses are said to have ceased sexual intercourse post-stroke³. Breakdown of marriage due to a reduction in sexual intercourse is an extreme outcome but has been described¹.

Management

Management of altered sexuality following stroke is difficult particularly as there is no consensus agreement about the risk factors involved. It is important to screen patients for contributing psychological problems. e.g. depression as well as rehabilitating physically. Most studies suggest that counselling should form part of the ‘routine’ management of patients who have suffered a stroke to facilitate discussion within a couple to address interpersonal problems^1,3,4,8,13. In one study approximately half of the patients and spouses displayed an interest in sexual counselling⁴. In the first instance, there must be a greater awareness and acknowledgement of this problem among physicians and other members of the multidisciplinary team, particularly as patients may be reluctant to discuss symptoms relating to sexuality.

Conclusion

Sexual dysfunction following stroke is a prevalent problem for both patients and their partners but is under recognised by the multidisciplinary stroke team. It has been demonstrated repeatedly that patients have experienced loss of libido, decreased frequency of intercourse, decreased arousal and decreased satisfaction with their sexual health. Factors that may be implicated in this decline are many and at present there are no conclusive answers; it is likely to be combination of the physical and psycho-social factors identified. Counselling of a couple as part of the rehabilitation programme may help to focus on some of their concerns.

Nia O’Doherty

Dr Dylan Harris

Dr Bella Richard

Dr Pradeep Khanna

References

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Korpelainen JT, Nieminen P, Myllyla VV. Sexual functioning among stroke patients and their spouses. Stroke 1999; 30(4): 715-9
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