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Sexual dysfunction common in patients with inflammatory arthritis
Sexual dysfunction is highly prevalent among men and women with inflammatory arthritis, with diseases-related factors impacting fluctuations in sexual function and reduced sexual desire, according to data published in Arthritis Care & Research.
“Sexual health and family planning are important considerations not only for individuals living with [inflammatory arthritis] but also for the health practitioners who treat them, yet these issues are rarely comprehensively addressed in clinical practice,” Laura Restoux, BPT, of Curtin University in Perth, Western Australia, and colleagues wrote. “Earlier research has shown that 36% to 70% of people with rheumatoid arthritis experience impaired sexual health associated with their disease, however, the majority have not discussed this with a health professional.”
“The impact of [inflammatory arthritis] on sexual health has been investigated previously, however systematic reviews published to date have important limitations,” they added, stating that other studies have focused on women’s sexual function only, and have been disease-specific without including contemporary evidence.
To evaluate the effects of inflammatory arthritis on sexual function and intimate relationships, Restoux and colleagues conducted a systematic literature review of quantitative and qualitative studies that included both men and women who had been diagnosed with a variety of specific conditions. Searched databases included Ovid Medline, Ovid PsycINFO, Ovid EMBASE and EBSCO CINAHL.
The researchers focused their search on studies of patients aged 16 years and older with diseases including, but not limited to, RA, seronegative arthritis, systemic lupus erythematous, systemic scleroderma and sclerosis, ankylosing spondylitis, psoriatic arthritis, connective tissue disease, vasculitis, Sjogren’s syndrome, spondyloarthritis, autoimmune arthritis and juvenile idiopathic arthritis. In addition, the researchers sought out studies in which participants with inflammatory arthritis expressed concerns, thoughts, beliefs and opinions regarding their condition’s impact on their intimate relationships and sexual function.
The researchers identified 55 eligible studies for inclusion in their final analysis. These included 49 quantitative and five qualitative studies. Sample sizes ranged from 10 to 1,272 participants in quantitative studies, and from 8 to 57 participants in qualitative studies.
According to the researchers, among studies that reported Female Sexual Function Index score, all inflammatory arthritis groups demonstrated mean scores of 26.55 or lower, denoting sexual dysfunction. In studies that reported International Index of Erectile Function scores, all groups with inflammatory arthritis diseases reported mean scores of 25 or less, which indicates erectile dysfunction.
Comments from patients with inflammatory arthritis conditions, collected in qualitative studies through interviews and focus groups, expressed themes of impaired sexual function and compromised intimate relationships. Major subthemes included diseaserelated pain and fatigue, erectile dysfunction, diminished sexual desire and changes in sexual function based on disease activity.
“Sexual dysfunction is prevalent in female and male populations diagnosed with various forms of [inflammatory arthritis],” Restoux and colleagues wrote. “Sexual dysfunction in [inflammatory arthritis] is associated with pain, reduced sexual desire, erectile dysfunction, fatigue and mobility restrictions. As sexual health is an important component of wellbeing, raising clinician and patient awareness of sexual dysfunction associated with [inflammatory arthritis] could facilitate the provision of more holistic care.” – by Jason Laday
Disclosure: The researchers report no relevant financial disclosures.
Perspective
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This study reiterates the importance of addressing the sexual health of patients. While this study assesses specifically patients with inflammatory arthritis (IA), patients with other rheumatic conditions may be experiencing similar concerns. It can be difficult for patients and providers to initiate conversations regarding the patient’s sexual health. Both may feel uncomfortable broaching this sensitive topic and patients may feel unsure if this is something that they should discuss with their rheumatology team, often leaving the topic unaddressed.
Providers may feel pressed for time due to so many other topics to address at a visit such as disease activity, medication response/side effects, and discussion of the treatment plan, leaving the topic of a sexual health unaddressed. However, the results of this study indicate that sexual health is indeed a concern for patients who are diagnosed with inflammatory arthritis. The rheumatology team can play a pivotal role in assessing a patient’s sexual health given that factors identified affecting the patient’s sexual health include pain, fatigue, as well as disability. First and foremost, the team needs to learn to become comfortable asking the sensitive questions of patients about their sexual health and how their IA may be having an impact.
Secondly, it is imperative that the rheumatology team provides safe space, nonjudgmental place for patients to express their concerns, validating their concerns. Lastly, asking the patient how they perceive their sexual health is affecting their partner is also important. In this study, some patients indicated their partners had a good understanding of how their condition affected their sexual performance while others felt their partners possessed little understanding, creating tension and even fear. Treating the “whole” patient includes physical, spiritual, emotional health. Addressing their sexual health should be included in routine care and patients may depend on us to ask the hard questions, opening the door to feel comfortable discussing this sensitive yet important topic.
Perspective
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I think rheumatic disease is frequently associated with divorce; throughout my practice, I have seen many rheumatic disease patients, both female and male, who have ended their marriage in divorce court. Divorce is common in the United States and it is possible that we are seeing a cross-section and by chance, divorce will be seen in our rheumatic patients.
The study from Restoux and colleagues addresses an area that most rheumatologists probably do not delve into: With all the data required by the electronic health record, obtaining a history of intimate relationships and sexual problems would not be high on our list. I think we surmise that this may be the case if our patient is in pain, taking opioids, is fatigued, and cannot enjoy life and ends up in a divorce, but we never really get into those details.
The researchers, who are from Australia, performed a systematic review of the literature on the impact of inflammatory arthritis on intimate relations and sexual function. They found that sexual function was affected by pain, reduced sexual desire, erectile dysfunction, mobility limitations and fatigue, but was also influenced by stress, including financial stressors, which are prevalent in the community. Of course, financial stress is also an issue for inflammatory arthritis as patients miss work and if poorly controlled, end up on disability.
Not surprisingly, patients with inflammatory arthritis changed the position previously used for intercourse and were more passive in intercourse to reduce pain. Flares of inflammatory arthritis were a significant problem and the evening was a worse time than daytime, following the normal cycle of inflammatory arthritis pain and fatigue.
Erectile dysfunction was the major problem for males. Some couples adjusted to the lack of sexual intercourse by being more caring and less physical. In other couples, the loss of the physical aspect of the marriage was poorly understood by the partner without inflammatory arthritis causing tension in the relationship; some females felt pressured to maintain their intimate relationships despite their pain and fatigue.
The researchers recommend that patients be treated holistically and that providers should obtain a history of sexual health. I think many of us in rheumatology would be concerned that this conversation may occupy a lot of care time for an area other than the patient’s arthritis that we are not trained to treat; however, simply being aware that this is a problem in our patients might help us seek out referral sources for this problem.