| Abstract|| |
Sexual dysfunction impairs the quality of life of patients undergoing hemodialysis (HD). The aim of this study was to evaluate the prevalence and the nature of sexual dysfunction in a Moroccan cohort of patients with chronic renal failure (CRF) on HD. This cross-sectional study was carried out with a questionnaire in 86 patients undergoing hemodialysis. Clinical and biological investigations were done. The mean age of our patients was 46.27 ± 15.68 years old. 81.4% of the cases suffered from a decrease in sexual activity after the onset of HD. The decrease or the loss of libido was noted in 59.3% of the cases. Total impotence was present in 22.1% of the cases and 36% reported partial impotence. Ejaculation was present in 86% of the cases. The comparison between the group of patients who had no sexual dysfunction (group I) and the group of those who had this problem (group II) showed significant differences of age, social status and sexual life before HD. Other significant differences were found regarding frequency of intercourses and sexual satisfaction. Group II was divided into 2 subgroups: IIA included patients who had sexual dysfunction before HD and IIB: those who developed it after. The comparison of this subgroups showed that differences were significant regarding age, weight and vascular risk factors (diabetes mellitus, atherosclerosis). Sildenafil was more efficient in the patients of the subgroup IIB. This study suggested that HD was one of many factors causing sexual dysfunction in hemodialysed patients. After this clinical evaluation of sexual dysfunction, we emphasize the value of a global approach of this problem. The use of sildenafil seems to be more valuable in young patients with erectile dysfunction which appeared after long dialysis duration.
Keywords: Sexual dysfunction, Impotence, Chronic renal failure, Hemodialysis.
|How to cite this article:|
Zamd M, Gharbi MB, Ramdani B, Zaid D. Sexual Dysfunction in Male Patients Undergoing Hemodialysis in Morocco. Saudi J Kidney Dis Transpl 2005;16:33-9
|How to cite this URL:|
Zamd M, Gharbi MB, Ramdani B, Zaid D. Sexual Dysfunction in Male Patients Undergoing Hemodialysis in Morocco. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2020 Jun 6];16:33-9. Available from: http://www.sjkdt.org/text.asp?2005/16/1/33/32949
| Introduction|| |
Sexual dysfunction is frequent in patients with chronic renal failure (CRF) and seriously impairs their quality of life. Hemodialysis (HD) improves relatively this disturbance. , The aim of this study was to perform a clinical analysis of the sexual dysfunction in male patients undergoing hemodialysis. We studied the type, prevalence and factors involved in this disturbance.
| Material and Methods|| |
A cross-sectional study was performed with a questionnaire. All the adult males with CRF who were undergoing HD in our unit were included in the study. A free and enlightened consent was obtained from all the patients before the study. Patients under 18 years of age were excluded. Clinical and biological data were collected. Sexual activity evaluation before and after HD were investigated too with a "subjective" estimation of HD effect on sexual performances. The presence of sexual dysfunction was defined as a disturbance of one or more stage of sexual response (desire, erection, ejaculation and orgasm) that impaired the sexual life of patients and induced a sexual dissatisfaction. The patients were interviewed and examined by the same physician (MZ). The efficiency and the safety of sildenafil was tested in patients with erectile dysfunction.
| Statistical Analysis|| |
Data were analysed by Epi-Info 5.01 software. Results were expressed in means ± standard error for quantitative variables, in percentages for qualitative variables. Differences between qualitative variables were tested by the x² test and for the quantitative variables by the Student test. Non-parametric tests were used if necessary. Significance threshold was fixed at 5% (p less than 0.05).
| Results|| |
Eighty six male patients were included in this study. Their mean age was 46.27 ± 15.68 years (yrs). All of them had a sexual partner before and after HD. The causes of CRF were chronic glomerulonephritis and diabetes mellitus in 30.2% and 10.5% of cases respectively. In 33.7% of cases the underlying cause could not be determined. The patients were treated by HD for 78.84 ± 40.68 months, generally 5 hours twice a week (88.4% of cases). The cellulose acetate membrane was the most frequently used (61.6% of cases). The mean level of haemoglobin was 8.85 ± 1.79 g/dl without erythropoietin (previously or during the study). Arterial hypertension was present in 69.6% of cases. The use of medications that interfere with the different sexual functions has been noted in 18.6% of cases especially central anti-hypertensive drugs (alphamethyldopa, clonidine) in 31.3% and cimetidine in 25% of cases. Occasional alcoholism was noted in 39 patients, chronic tobacco addiction in 41 patients. Surgery or endoscopic interventions on the pelvis has been noted in 4.7% of cases.
Eighty one patients (94.2% of cases) have had a sexual activity before the start of hemodialysis. 48.8% had, 2-3 sexual intercourses per week. After hemodialysis, the persistence of a sexual activity was reported by 69.8% of patients but with a reduction of frequency in 81.4% of them. Analysis of the frequency of intercourses showed that less than one sexual intercourse per month was performed by 51.2% of cases and any intercourse has been achieved during the last 6 months before the interview in 43% of cases [Figure - 1].
The Sexual Dysfunction and Satisfaction
Fifty patients (60.9% of cases) declared a total sexual dissatisfaction or a poor satisfaction. Libido was preserved in 47.7% of cases and absent in 11.6% of cases. The conservation of erection has been noted in 77.9% of cases. A spontaneous erection has been reported by 45.3% of cases, a wake up erection in 57% of cases and a reactive erection (to erotic stimulation) in 75.6% of cases. Complete erection (sufficient rigidity to perform intercourse) was present in 41.9% of cases. It was incomplete in 36% of patients. Close to 3/4 of patients reported the conservation of ejaculation either during their sexual activity (conscious ejaculation: 72.1% of cases) or during sleep (unconscious ejaculations on the basis of an observation at the wakening: 86.0% of cases). Orgasm was reached during a sexual activity in only 70.4% of patients.
We noted the absence of secondary sexual characters in 3.5% of cases with a female morphology in 9.3% of cases. Testicular atrophy (testicles less than 4 cm in its great axis) has been noted in 15.1% of cases. Perineal sensitivity was absent in 3.5% of cases and decreased in 8.1% of cases.
The patients were divided on the basis of their own "subjective" evaluation of the sexual activity in 2 groups:
- Group I consisted of 21 patients (24.4% of cases) without sexual dysfunction and who are satisfied with their sexual life.
- Group II consisted of 65 patients (75.6% of cases) with one or more sexual dysfunction (SD). Within this last group, and according to the date of appearance of SD, we distinguished 2 subgroups of patients:
- Subgroup IIA: 10 cases (11.6%) who presented with sexual dysfunction before starting hemodialysis with a mean duration of 16.56 ± 12.7 months. Their sexual dysfunction remained after the commencement of dialysis
- Subgroup IIB: 55 cases (64%), who presented with sexual dysfunction after the onset of hemodialysis after a mean duration of 27.18 ± 31.72 months.
Comparison of groups I and II
The comparison between group II and group I revealed significant difference in age (50 ± 15.5 years vs. 34 ± 8.0 years, p=0.00005), sexual activity before HD (100% vs. 76.2%, p=0.0006, more frequent sexual intercourse (55.3% with 2-3 intercourse/week vs. 33.3%, p=0.0005). We noted more diabetic and vascular nephropathies in patients in group II (21.5% vs. 4.7%, p = 0.02). We did not note significant differences between the Group I and II regarding HD regimen, clinical examination findings, biologic parameters or the presence or absence of other causes of sexual dysfunction (comorbidity, drug use and pelvic surgery) except a more frequent alcohol ingested in the Group II (52.3% vs. 23.8%, p=0.02).
Comparison of subgroups IIA and IIB
The comparison between patients presenting with sexual dysfunction before (Group IIA) and after starting HD (IIB group), did not reveal significant differences regarding the different parameters of sexual activity, SD frequency, HD regimens, the use of tobacco or drugs affecting sexual function. On the other hand, patients of group IIA, were more recently dialysed (3.4 ± 1.6ys vs 6.7 ± 3.1 vs, p=0.0005). They were significantly older than those of group IIB (62.3 ± 12.6 vs 48.0 ± 15.1 vs, p=0.009), heavier (70.1 ± 16.8 kg vs 60.4 ± 8.6 kg, p=0.04). They had more frequently a female morphology (30.0% vs 5.5%, p=0.04). The diabetic or vascular nephropathies were more frequently present in group IIA (70.0% vs 12.7%, p=0.003), and they had significantly more co-morbidity: hypertension, heart disease, (83.3% vs 20.7%, p=0.01). The performance of a surgical or endoscopic intervention on the pelvis was more frequently seen in group IIA (20% vs 3.6%, p=0.04). The clinical examination revealed a significantly more frequent reduction of perineal sensitivity (30.0% vs 12.7%, p =0.04).
We introduced sildenafil (50 mg tablet half hour before sexual intercourses), randomly, in 10 patients of group II (5 from subgroup IIA and 5 from subgroup IIB) if there was no contraindication to the use the drug. We noted the subjective improvement in all the patients. The efficiency of the drug was, however, different in the 2 subgroups (all the patients of subgroup IIB improved their erectile function vs. 1 patient of the subgroup IIA). We didn't note any side effect of the drug in these 10 patients especially hypotension or headache.
| Discussion|| |
Several definitions have been proposed for sexual dysfunction according to its different causes (endocrinological, urological, psychological and neurological).  Segraves  affirms the absence of operational and clear criteria for definition. Others  reserve the term of sexual dysfunction only to sexual behaviour of psychological origin. On the basis of these observations, we defined the sexual dysfunction as "all disturbances of one or more stages of the sexual response that results in a disturbance of the patient's sexual life". The subjectivity of this definition may be a source of imprecision; however, the studied problem is defined extensively by subjective elements in the literature. 
SD impairs significantly the quality of life of patients with CRF undergoing HD.  This is well documented. ,,,,, However, the data remain generally conflicting. According to Binik,  the available studies lack rigorous methodology (standardisation of definitions and technical measures). This explains the great variability in the reported prevalence of sexual dysfunction in these patients (20 to 100% of cases); but in most publications the rate exceeds 50% of cases. In our study, the sexual function has been evaluated using two complementary approaches:
The presence of sexual activity and the frequency of sexual intercourse before and after HD with a subjective comparison of these periods. The decrease of sexual activity has been noted in 81.4% of patients. This rate comes closer to those of Pach  and Brook:  (80% and 64% respectively). Salvatierra et al. reported that the frequency of sexual intercourse of more than once a week decreased from 55% of the cases before to 22% after HD.  In our study, the same frequency of sexual intercourse decreased from 74.4% to 30.2% after HD. The absence of any sexual activity in hemodialyzed patients vary from 40% to 57.1% in previous studies.  It was 30.2% in our study.
Sexual satisfaction in HD and the presence of sexual dysfunction. These two parameters complement each other and reflect the impact on the patient in things like to self esteem that and relationship with partners. Milde  found 65% of HD patients as being sexually In our study, 60.9% of the patients had reduced or totally absent sexual satisfaction under HD. Rodger  and Weizman,  noted the presence of SD in 79% and 50% of their patients respectively. Our rate was 75.6% of cases.
The significant differences between group I and II, regarding the social and demographic data and of sexual life before HD, would suggest the influence of these factors on the perception of SD. Patients with SD (group II) were older and more active before sexually HD. This finding has not been reported previously in the literature.
Libido disorders in HD patients have been reported by several authors. Their prevalence varies from 12.5 to 65% of cases. ,,,,, In our study 52.3% of patients had a low or absent libido. Orgasm was little studied in patients undergoing HD in previous reports. ,, It was absent in 29.6% of our patients, either by absence sexual activity (21 cases) or by real inorgasmia (3 cases). The erectile dysfunction is the most studied sexual dysfunction. It is present in variable prevalence. The previous reports estimate the prevalence to be from 40 to 82.3% of cases ,,,,,,,, Several
parameters of erection have been considered in the previous studies: degree or percentage of tumescence, length and angle of erection.  The features considered in our study were the presence or the absence of erection and its complete or incomplete character. In patients who had no sexual activity, the erectile capacity evaluation has been assessed on the basis of the presence of waking up or spontaneous erection (73.1% among them had waking up erections and 58.3% maintained spontaneous erections). The absence of this type of erection, would be caused by organic pathology of erectile dysfunction. Thirty six percent of cases presented with incomplete and short-lived erections. The significance of this type of erection has not been addressed by the previous publications, outside of the hypothesis that it is consequent to venous leakage. 
In the literature, , disorders of ejaculation were, the most studied in view of investigating the causes of infertility. Semiologic abnormalities of ejaculation were studied in a few reports. Some authors reported the notion of "dry ejaculation" (decrease of volume with a particularly increased viscosity of the semen). , The conservation of capacities to ejaculate can be verified on the basis of ejaculation in sexual activity (conscious ejaculation) or during the sleep (unconscious ejaculation). In our study, ejaculation was preserved in 86% of our patients. It was rarely reported by authors and its significance was not commented on. ,, The absence of ejaculation during sexual activity has been noted in 24 patients (28%), but half of these had nocturnal ejaculation.
The time of SD appearance has been studied by different authors. ,, Indeed, most authors report the fact that sexual dysfunction occur before the start of HD. HD improves them slightly only and sometimes aggravates them. , On the other hand, Procci  noted stabilisation and even improvement with HD. In our study, 10 patients (11.6%) improved before the onset of HD. This group of patients (IIA) defers from group IIB by the same factors which are incriminated in the development of sexual dysfunction in the general population. This would lead one to think that HD is only another factor causing SD among many other factors present in these patients such as degenerative vascular disease.
Regarding the pathogenesis of SD, several factors have been generally incriminated.  The age seems to be one of the most important factors involved in the HD population. Initial nephropathy, especially diabetic nephropathy and the systemic hypertension, have to be considered in the pathogenesis of this disturbance. Alcohol intake is also incriminated in SD development. CRF associated diseases, drugs taken and HD regimens do not seem to be risk factors in the development of SD in our study.
Sildenafil was used with success to treat erectile dysfunction in patients undergoing hemodialysis.  Our experience showed different responses according to the timing of the onset of the disturbance. In fact the patients who had erectile dysfunction before starting hemodialysis showed bad response. This result was predicable as the main cause of erectile dysfunction in these patients was advanced atherosclerosis. Although, many side effects of this drug were noted in hemodialysis patients.  We did not note any side effect in our study.
| Conclusion|| |
We can conclude that SD in HD patients is a heterogeneous entity. In fact, some patients had already the SD before HD or just after its onset. Those patients had generally vascular abnormalities and the CRF was the result of the evolution of diabetic or vascular nephropathy. The HD in this case was only a facilitating factor. On the other hand, some young patients had developed SD after long duration under HD and it results generally from complications of CRF and HD. Each etiological factor has its importance in the development of SD but the importance of each one differs from one patient and the other. The efficiency of sildenafil seems to be variable and the most important factor of variability of response which should be considered is the moment of the onset of the sexual dysfunction.
| Acknowledgements|| |
Dr. Chakib NEJJARI from Biostatistics and Epidemiology Laboratory for his help in statistical analysis.
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Service de Néphrologie, CHU Ibn Rochd, Casablanca
[Figure - 1]