Abstract
Background
Over three-quarters of stroke survivors experience disruption of sexual functioning. Studies reporting poststroke sexual function of Nigerian patients are few.
Objectives
This survey reports sexual dysfunction in Nigerian stroke survivors, and determines the influence of sociodemographic, clinical and psychological factors on the dysfunction.
Methods
Participants were 77 stroke survivors (60 males; 17 females) recruited consecutively from a teaching hospital. Participants completed the Beck Depression Inventory, Stroke Specific Quality of Life Scale and post-stroke sexual function questionnaire. Participants' motor ability was rated on the Modified Motor Assessment Scale. Data were analysed using Chi square test and Mann-Whitney U test (alpha level set at 0.05).
Results
Participants were aged 55.2±10.8 (28–79) years. Most (94.8%) participants reported a dysfunction in sexual function. Decline in libido and coital frequency were reported by >70% and in erection, ejaculation and orgasm by >60% of participants. Participants' with erectile dysfunction were significantly older than those without (U=267.0; p=0.02). Depression, quality of life, willingness to have sex, general attitude to sex and ability to express sexual feelings had significant influence on sexual dysfunction reported by participants (p<0.05).
Conclusion
Our findings suggest that sexual dysfunction is common among Nigerian stroke survivors and it is mostly associated with psychological factors.
Keywords: Stroke-Survivors, Sexual dysfunction, Psychological factors, Quality of life
Introduction
Stroke is a major cause of long-term disability worldwide, as it results in considerable impairment of sensory, motor, mental, perceptual and language functions1. It is a leading cause of morbidity and mortality in adults in the productive ages2. Stroke was believed to be rare in the Black Africans five decades ago3, but is known to be common in developing countries such as Nigeria as in the Western world4.
Sexuality is an integral part of normal life in men and women of all ages. A marked decline in sexuality has been reported after stroke. It has been reported that as many as three-quarters of stroke survivors experience disruption of sexual functioning. According to Buzzelli et al 5 and Korpelainen et al6, post-stroke decline in sexual function was predominantly due to psychological rather than physiological causes. However, other authors have identified the causes to include anatomical lesion in the brain, pre-morbid medical conditions (diabetes, hypertension, cardiac disease), and several interpersonal factors5,7. The most commonly reported post-stroke sexual problems include decline in libido and coital frequency, reduced vaginal lubrication and orgasmic ability in women, and poor or absent erection and ejaculation in men as well as decreased enjoyment and satisfaction with sexual life. In cultures where it is more or less a taboo to discuss sexuality publicly, discussing sexuality with individuals with neurologic disabilities is difficult and thus makes its rehabilitation difficult8. This is probably the reason for the negligent attitude shown by professionals towards the effect of stroke on sexuality and the sexual health of stroke survivors9.
Studies reporting sexual dysfunction among stroke survivors in Nigeria are not common. The only study from Nigeria reported decline in sexual function in a small sample of male stroke survivors with hemiparesis, attending a hospital in Northern Nigeria10.
The aims of the present study were to survey sexual dysfunction among stroke survivors attending a hospital in Southwestern Nigeria, and to determine the influence of socio-demographic, clinical and psychological factors on the dysfunction.
Methods
The study protocol was approved by the University of Ibadan and University College Hospital, Ibadan Research Ethics Committee. Participants were 77 stroke survivors attending physiotherapy out-patient department of the University College Hospital, Ibadan, Nigeria. They were recruited consecutively over a period of 9 months (October, 2008 to July, 2009). Only male and female Nigerians who have had stroke for at least three months, who were married and/or were living with their spouse(s) and who gave informed consent participated in this study.
Participant's socio-demographic and clinical information (age, gender, duration of stroke, presence and side of hemiparesis/hemiplegia) were collected through interview and from participants' hospital files. Their motor ability was rated on the Modified Motor Assessment Scale11 by one of the authors. Participants then completed 3 questionnaires which were the Stroke Specific Quality of Life Scale (SS-QOL)12, the Beck Depression Inventory13 and a questionnaire on sexual dysfunction in stroke survivors adapted from a previous study6. The order of administration of the questionnaire was randomized using fish bowling method. The questionnaire on post-stroke sexual dysfunction included seven sexual functions (libido, coital frequency, erection, ejaculation vaginal lubrication, orgasm and satisfaction with sexual life). Two sexual functions (erection, ejaculation) were specific to males and one (vaginal lubrication) was specific to females. Participants were asked to rate each sexual function based on their post-stroke sexual state relative to their pre-stroke sexual state on a 4 or 5 point likert scale 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) once 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. The questionnaire also included five psychological factors which were: General attitude towards 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.
Sexual dysfunction was defined in terms of response options as follows: Libido dysfunction-diminished, markedly diminished and no libido; coital frequency dysfunction-once or twice a month, less than once a month and no coitus; penile erection, ejaculation, vaginal lubrication orgasm dysfunction-slightly diminished, markedly diminished and none; dissatisfaction with sexual life - moderately dissatisfied and completely dissatisfied. Prior to data collection, each of the 3 questionnaires was translated into Yoruba (the indigenous language of the southwestern Nigeria) by two language experts, who later produced a consensus translation which was taken through the process of back translation and review by an expert panel 14. This ensured the participation of stroke-survivors who were not literate in English
Data were summarized using frequency, percentage, median, mean and standard deviation. Inferential statistics of Chi Square test and Mann-Whitney U test were used to analyze data. The alpha level was set at 0.05.
Results
A total of seventy seven stroke survivors comprising 60 males (77.9%) and 17 females (22.1%) participated in the study. Their age ranged from 28 to 79 years with a mean of 55.2+ 10.8 years. The mean age for the males was 57.0±10.0 (38 to 79) years and that of the females was 48.4±10.2 (28 to 65) years. Thirty-three (43.4%) had right hemiparesis and 43 (56.6%) had left hemiparesis. Participants have had stroke for 3–84 months (median of stroke duration was 13.5 months. Participants had a mean depression score of 13.1±8.3 (out of a maximum obtainable score of 63) and a mean quality of life score of 181.0±30.5 (out of a maximum obtainable score of 245). Sixty three (81.9%) of the participants regarded sex as important and 52 (67.5%) could express sexual feelings to their spouses and 48 (62%) expressed unwillingness to have sex. Thirty-nine participants (50.6%) had fear of another stroke episode and 31 males (60%) had fear of impotence.
Seventy-three (94.8%) reported a dysfunction in one or more of the 7 sexual activities (libido, coital frequency, vaginal lubrication, erection, ejaculation, orgasm, satisfaction with sexual life) considered in this study (table 1). More than 70% of participants reported dysfunctions in libido and coital frequency and over 60% reported dysfunction in erection, ejaculation and orgasm. The least frequently reported sexual dysfunction was dissatisfaction with sexual life which was expressed by 30 (39%) of participants (table 1). Table 2 shows the frequency distribution of participants with or without dysfunction by gender, clinical and psychological variables.
Table 1.
Frequency distribution of participants with and without Sexual dysfunction post stroke
| Variables | n | Without dysfunction |
With dysfunction | ||
| F | % | F | % | ||
| Libido | 77 | 23 | 29.9 | 54 | 70.1 |
| Coital frequency | 77 | 18 | 23.3 | 59 | 76.7 |
| Erection | 60 | 23 | 38.3 | 37 | 61.7 |
| Ejaculation | 60 | 22 | 36.7 | 38 | 63.3 |
| Vaginal lubrication | 17 | 9 | 52.9 | 8 | 47.1 |
| Orgasm | 77 | 28 | 36.4 | 49 | 63.6 |
| Sexual satisfaction | 77 | 47 | 61.0 | 30 | 39.0 |
|
Any sexual dysfunction |
77 | 4 | 5.2 | 73 | 94.8 |
Table 2.
Frequency distribution of participants with or without sexual dysfunction by Gender, Clinical and Psychological variables
| Variable | LB | CF | ER | EJ | VL | OR | SS | |||||||
| ND | D | ND | D | ND | D | ND | D | ND | D | ND | D | ND | D | |
| Gender | ||||||||||||||
| Male | 37 | 23 | 26 | 34 | 23 | 37 | 22 | 38 | - | - | 22 | 38 | 37 | 23 |
| Female | 10 | 7 | 9 | 8 | - | - | - | - | 9 | 8 | 6 | 11 | 10 | 7 |
| Side of Hemiparesis | ||||||||||||||
| Right | 18 | 15 | 13 | 20 | 9 | 16 | 8 | 17 | 5 | 3 | 11 | 22 | 18 | 15 |
| Left | 29 | 14 | 22 | 21 | 14 | 21 | 14 | 21 | 4 | 4 | 17 | 26 | 29 | 14 |
| Attitude to Sex | ||||||||||||||
| Important | 42 | 21 | 33 | 30 | 20 | 29 | 21 | 28 | 8 | 6 | 27 | 36 | 42 | 21 |
| unimportant | 5 | 9 | 2 | 12 | 3 | 8 | 1 | 10 | 1 | 2 | 1 | 13 | 5 | 9 |
| Fear of Impotence | ||||||||||||||
| No | 24 | 14 | 17 | 21 | 16 | 22 | 13 | 25 | - | - | 15 | 23 | 24 | 14 |
| yes | 13 | 9 | 9 | 13 | 7 | 15 | 9 | 13 | - | - | 7 | 15 | 13 | 9 |
| Fear of another stroke | ||||||||||||||
| No | 25 | 13 | 17 | 21 | 14 | 19 | 13 | 20 | 3 | 2 | 16 | 22 | 25 | 13 |
| yes | 22 | 17 | 18 | 21 | 9 | 18 | 9 | 18 | 6 | 6 | 12 | 27 | 22 | 17 |
| Express sexual feelings | ||||||||||||||
| Yes | 35 | 17 | 31 | 21 | 18 | 22 | 19 | 21 | 6 | 6 | 22 | 30 | 35 | 17 |
| No | 12 | 13 | 4 | 21 | 5 | 15 | 3 | 17 | 3 | 2 | 6 | 19 | 12 | 13 |
| Unwilling to have sex | ||||||||||||||
| Yes | 16 | 13 | 11 | 18 | 20 | 19 | 21 | 18 | 5 | 4 | 7 | 22 | 16 | 13 |
| No | 31 | 17 | 24 | 24 | 3 | 18 | 1 | 20 | 4 | 4 | 21 | 27 | 31 | 17 |
LB - Libido CF-Coital Frequency ER-Erection EJ - Ejaculation VL-Vaginal Lubrication ND-No Dysfunction D-Dysfunction
During data collection, many of the stroke survivors opined that it was the first time any healthcare professional was asking them questions relating to sexual function, an area of importance to them. They also expressed a desire for proper counseling on this aspect of their lives and suggested that sexual counseling be made a part of stroke rehabilitation.
Discussion
The mean age of stroke survivors in the present study is slightly lower than the mean age of those in previous stroke studies from Nigeria, which ranged from 60.6±12.4years to 62±13years15–17. There was a preponderance of male in the ratio 3.5:1 in this study. This is similar to the findings of previous studies from Nigeria and other parts of the world6,7,15–17,18.
Almost all (95%) the participants in this study reported at least one sexual dysfunction. This suggests that sexual dysfunction is common among Nigerian stroke survivors, as it is with stroke survivors from other parts of the world 5–7. Dysfunction in coital frequency was the most frequently reported sexual dysfunction, followed by dysfunction in libido, orgasm, and erection. This is in line with the findings of Monga et al 19 in which a 79% to 61% dysfunction in sexual activities was reported. The decline in libido, coital frequency, orgasm and satisfaction with sexual life reported by participants in this study are also similar to the findings of Korpelainen et al 6, Kimura et al 7 and Cheung20.
It is surprising that only 30 (40%) of participants in this study reported dissatisfaction with sexual life. This is in spite of the fact that more participants reported sexual dysfunction in libido, coital frequency, erection, ejaculation and orgasm. In previous studies, higher proportions of participants (49–71%) were reported to be dissatisfied with sexual life6,7,20. In the Nigerian cultural context, ability to have children is perceived as a major determinant of satisfaction with sexual life. This cultural perception might have influenced participants' response to satisfaction with sexual life. Unfortunately, we did not survey how many of the participants had or did not have children and this is regarded as a limitation of this study.
The results of this study revealed that psychological factors (willingness to have sex, general attitude to sex and ability to express sexual feelings) have a negative influence on sexual function (libido, erection, coital frequency, ejaculation, orgasm and satisfaction with sexual life) post stroke. This agrees with previous reports 5,6,18. The finding suggests that psychological factors play a crucial role in determining sexual function and satisfaction after stroke. Gender had no influence on the sexual function common to both gender (libido, orgasm, coital frequency and satisfaction with sexual life). This is similar to the findings of Buzzelli et al 5 and Choi-Kwom and Kim21. Participants' sexual function was also not affected by the side of hemiparesis, however two psychosocial factors (fear of impotence and fear of another stroke episode) had no significant influence on sexual function. Boldrini et al22 reported that clinical features had no significant association with changes in sexual life.
Findings from this study showed that there was no significant difference between the motor assessment score of those with sexual dysfunction and those without sexual dysfunction in all the sexual activities assessed in this study. Buzzelli et al 5 and Choi-Kwon et al 21 also reported that motor disability has no effect on sexual activities post stroke. Kimura et al7 on the other hand, reported that physical disability is an important factor influencing post stroke sexual function.
The mean age of participants with erectile dysfunction (59.4±9.49years) was found to be significantly higher than the mean age of those who reported none (53.1±9.87years) in this study, supporting the finding of Giaquinto et al 18. This could be explained by the fact that sexual function appears to decline with age 23. The depression scores of those with ejaculation dysfunction were significantly higher than the scores of those who reported no dysfunction in their sexual activities. Also, the depression score of participants who reported dissatisfaction with their sexual life was significantly higher than that of those who were satisfied with their sexual life. This supports the findings of Goddess et al24, Buzzelli et al5, Korpelainen et al 25 and Kimura et al 7 who reported that sexual dysfunction was closely associated with the degree of depression post stroke. On the other hand, Buzzelli et al5 found no significant association between depression and sexual variations. However, we observed that participants with sexual dysfunction in penile erection, ejaculation, and satisfaction with sexual life had significantly higher quality of life scores. It is not impossible that the cultural tendency of Nigerians not to arrogate negative things to themselves might have influenced the participants' response to items on the stroke specific quality of life scale.
Conclusion
The findings of this study suggest that decline in sexual function is common among Nigerian stroke survivors. Age, depression and psychological factors (attitude to sex, ability to express sexual feelings, unwillingness to have sex) have negative influence on sexual function of Nigerian stroke survivors. The implication of these findings is that assessment of sexual function and sexual counseling should be incorporated into the management of stroke survivors in Nigeria. This will necessitate training healthcare professionals involved in the care of stroke survivors in sex life counselling. Longitudinal studies will be necessary to ascertain the causes of sexual dysfunction among stroke survivors in Nigeria. However, this study has some limitations as regards the participants recruited. All were attending physiotherapy and so all were likely to have had mobility and/or upper limb disabilities. The participants were also married and/or lived with their spouse(s) or partner(s) leaving out single stroke survivors who masturbate and may use paid sexual service or have occassional sexual encounters. We suggest that these areas be looked into in future longitudinal studies.
Table 3.
Association between sexual dysfunctions and gender, clinical, psychological variables
| Variable | LB | CF | ER | EJ | VL | OR | SS | |||||||
| χ2 | P-value | χ2 | P-value | χ2 | P-value | χ2 | P-value | χ2 | P-value | χ2 | P-value | χ2 | P-value | |
| Gender | ||||||||||||||
| Male | 0.306 | 0.580 | 0.493 | 0.483 | - | - | - | - | - | - | 0.011 | 0.917 | 0.045 | 0.832 |
| Female | ||||||||||||||
| Side of Hemiparesis | ||||||||||||||
| Right | 0.000 | 0.995 | 1.041 | 0.308 | 0.099 | 0.753 | 0.402 | 0.526 | 0.254 | 0.614 | 0.309 | 0.579 | 1.316 | 0.251 |
| Left | ||||||||||||||
| Attitude to Sex | ||||||||||||||
| Important | 0.582 | 0.445 | 6.705 | 0.010* | 0.697 | 0.404 | 4.411 | 0.036* | 0.562 | 0.453 | 6.314 | 0.012* | 4.615 | 0.032* |
| unimportant | ||||||||||||||
| Fear of Impotence | ||||||||||||||
| No | 0.208 | 0.649 | 0.083 | 0.773 | 0.624 | 0.430 | 0.269 | 0.604 | - | - | 0.352 | 0.553 | 0.097 | 0.755 |
| yes | ||||||||||||||
| Fear of another stroke | ||||||||||||||
| No | 1.741 | 0.187 | 0.016 | 0.901 | 0.519 | 0.471 | 0.235 | 0.628 | 0.142 | 0.707 | 1.609 | 1.301 | 0.712 | 0.399 |
| yes | ||||||||||||||
| Express sexual feelings | ||||||||||||||
| Yes | 3.400 | 0.065 | 12.954 | 0.001* | 2.256 | 0.133 | 6.065 | 0.014* | 0.142 | 0.707 | 2.445 | 0.118 | 2.647 | 0.104 |
| No | ||||||||||||||
| Unwilling to have sex | ||||||||||||||
| Yes | 5.740 | 0.017* | 1.062 | 0.303 | 7.904 | 0.005* | 14.162 | 0.001* | 0.052 | 0.819 | 3.005 | 0.083 | 0.673 | 0.412 |
| No |
LB - Libido CF-Coital Frequency EF-Erection EJ - Ejaculation VL-Vaginal Lubrication OR-Orgasm SS- Satisfaction with Sexual Life
statistically significant at p<0.05 Chi2 = chi square value
Table 4.
Mean values of selected variables of participants With and Without Sexual dysfunction
| Variable | LB | CF | ER | EJ | VL | OR | SS | |||||||
| ND | D | ND | D | ND | D | ND | D | ND | D | ND | D | ND | D | |
| Age (years) | ||||||||||||||
| N | 53.8 | 55.6 | 54.5 | 55.5 | 53.1 | 59.4 | 53.4 | 59.1 | 45.9 | 51.3 | 54.8 | 54.6 | 55.3 | 55.9 |
| SD | 8.74 | 11.37 | 10.54 | 10.80 | 9.87 | 9.94 | 9.67 | 9.77 | 11.60 | 8.17 | 10.60 | 10.26 | 10.74 | 11.30 |
|
Stroke duration (months) |
||||||||||||||
| N | 21.10 | 21.8 | 22.30 | 21.00 | 19.50 | 22.10 | 19.70 | 22.00 | 28.80 | 16.8 | 23.10 | 20.70 | 23.40 | 18.80 |
| SD | 19.94 | 19.65 | 20.85 | 18.81 | 19.10 | 19.50 | 19.14 | 19.49 | 25.21 | 14.71 | 24.05 | 16.90 | 21.09 | 17.05 |
| Depression Score | ||||||||||||||
| N | 11.10 | 14.00 | 10.70 | 15.10 | 10.90 | 14.00 | 9.70 | 14.60 | 16.20 | 11.29 | 11.20 | 14.20 | 11.40 | 15.83 |
| SD | 5.82 | 9.09 | 6.12 | 9.34 | 7.34 | 8.71 | 7.40 | 8.34 | 10.58 | 3.90 | 6.07 | 9.21 | 7.33 | 9.12 |
| Motor Assessment Score | ||||||||||||||
| N | 33.00 | 33.40 | 34.60 | 32.20 | 32.30 | 35.40 | 35.20 | 31.60 | 32.90 | 36.00 | 33.60 | 33.10 | 34.10 | 31.90 |
| SD | 9.31 | 11.26 | 10.90 | 10.44 | 9.23 | 11.60 | 9.05 | 11.43 | 10.03 | 12.14 | 10.87 | 10.63 | 10.75 | 10.52 |
| Quality of Life Score | ||||||||||||||
| N | 189.90 | 177.80 | 186.10 | 177.0 | 184,00 | 178.50 | 186.10 | 193.20 | 177.90 | 192.00 | 184.20 | 179.90 | 186.90 | 173.10 |
| SD | 24.05 | 32.22 | 28.85 | 31.35 | 26.50 | 35.22 | 28.85 | 29.77 | 25.72 | 20.43 | 25.24 | 32.98 | 27.99 | 32.37 |
LB - Libido CF-Coital Frequency ER-Erection EJ - Ejaculation VL-Vaginal Lubrication OR-Orgasm SS-Satisfaction with Sexual Life ND-No Dysfunction D-Dysfunction N-Number of Participants SD-Standard Deviation
Table 5.
Mann Whitney U Test for selected variables of participants with and without sexual dysfunction
| Variable | LB | CF | ER | EJ | VL | OR | SS |
| U* P-value | U* P-value | U* P-value | U* P-value | U* P-value | U* P-value | U* P-value | |
| Age (years) | 558.00 0.482 | 698.50 267.00 | 267.00 0.016** | 291.00 0.051 | 26.00 0.370 | 672.00 0.882 | 656.50 0.612 |
| Stroke duration (months) | 596.50 0.883 | 714.00 1.000 | 367.50 0.535 | 350.50 0.437 | 25.50 0.321 | 625.00 0.692 | 610.00 0.395 |
| Depression Score | 514.50 0.336 | 524.00 0.065 | 305.50 0.111 | 236.50 0.010 ** | 25.00 0.536 | 551.00 0.283 | 454.50 0.021** |
| Motor Assessment Score | 577.00 0.713 | 611.00 0.267 | 371.00 0.504 | 339.50 0.290 | 28.50 0.481 | 652.00 0.829 | 589.00 0.322 |
| Quality of life Score | 491.50 0.182 | 626.50 0.361 | 390.00 0.790 | 264.00 0.033** | 24.00 0.277 | 660.50 0.991 | 494.50 0.038** |
LB-Libido CF-Coital Frequency ER-Erection EJ-Ejaculation VL-Vaginal Lubrication OR-Orgasm SS-Satisfaction with Sexual Life U*= Mann Whitney U value
statistically significant at p<0.05
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