Timing and Holistic Measure of Sexual Function in Patients with IBD After Proctectomy

In the article titled “Sexual function after proctectomy in patients with inflammatory bowel disease (IBD): a prospective study,” Gklavas et al. measured sexual function before and 6 months after proctectomy in adult male and female patients with IBD. The authors sought to determine if surgery affected sexual function of patients with IBD. They concluded that undergoing proctectomy did not significantly affect sexual function in men or women with IBD.¹

The authors noted that previous studies regarding sexual function in patients with IBD, who underwent surgery, only measured sexual function after the procedure. We commend the authors of this study for measuring sexual function of the participants before and after surgery. Additionally, making the surgeon and the surgical technique used for each procedure control variables strengthened the study’s methodology. It is not clear if the surgeon was aware of the study and whether this knowledge had an impact on the surgical procedures and study outcomes.

Although the authors attempted to determine participants’ baseline sexual function before surgery, we question if measuring sexual function in the immediate pre-operative period gives the same baseline understanding than a more comprehensive sexual history at various time points such as pre-IBD diagnosis, throughout non-surgical IBD treatment, pre-surgical treatment, post-surgical treatment longitudinally. Leenhardt et al. indicated that sexual dysfunction in patients with IBD has not been associated directly with the severity of disease, rather with factors such as depression and quality of life. The number of years with IBD, support systems, and current relationship status are other factors that can affect the quality of life. Collecting these data may have strengthened the measure of sexual function. A longitudinal study including data on patients’ months or years prior to requiring surgical intervention, as well as a more frequent interval of measuring of sexual function post operatively, may have strengthened the findings considering that pain, body image, and new bowel habits can affect sexual function over time.

Although the authors noted the limitation that the questionnaire used for women was more extensive (men’s questionnaire only measured erectile function and women’s questionnaire measured desire, arousal, lubrication, orgasm, pain, and satisfaction), a broader approach is needed to evaluate sexual function. The questions used in this study only focus on some anatomical factors and do not consider relationship status, fertility, or body image. In a review of sexual dysfunction in men with IBD, Park and Kim² included multiple measures of sexual function that have been used for patients with IBD, most notably the European Organization for Research and Treatment of Cancer Study Group (EORTCSG) tool, which assessed sexual function in patients with colorectal cancer. Like patients with IBD, some colorectal cancer patients have ostomies. The EORTCSG tool took into account how these changes affect body image and feelings of attraction, which can affect sexual function beyond erection and arousal. As mentioned previously, the study did not address fertility. Erection and arousal may be unaffected, but patients may have dysfunction with procreation secondary to medications.²

In Gklava et al.’s study, most of the surgical procedures involved ileostomy take-downs as a part of restoring bowel continuity for the patients.¹ We question if the sexual function in patients who received permanent ileostomies differed from those who did not, particularly since body image, feelings of attraction, and status of relationships can impact sexual function. The authors noted that all ileostomies were reversed within 3 months of the initial procedure, but the sexual function data were collected 6 months after the procedure. Including a rationale for the timing of the data collection at 6 months instead of 9 or 12 months would have possibly helped determine optimal times between surgery and establishment of new sexual norms.

Finally, we recommend a discussion on the statistical significance versus clinical significance of the results presented in this study. For women, 66.7% of the participants had abnormal sexual function pre- and postoperatively, while for men, 43.7% and 48.7% had some degree of ED pre- and postoperatively, respectively. While these results were not statistically significant, the presence of sexual dysfunction may be clinically significant for patients and should be addressed. In their review article, Leenhardt et al. highlighted that in a study of 69 gastroenterologists, only 16% asked IBD patients about their sexual health despite previous evidence indicating that IBD patients expect their doctors to ask about their sexual health.³ As such, routine sexual health screening should be the standard of care postoperatively for IBD patients in colorectal offices. Although Gklavas et al. found that sexual function after proctectomy was not significantly affected in male and female patients with IBD, sexual function may be more complex for these patients than what was highlighted in their study.¹

According to the World Health Organization, sexual health is defined as a state of physical, emotional, mental, and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction, or infirmity.⁴ Although longitudinal studies are challenging to conduct, they may provide a more accurate picture of sexual function in IBD patients who undergo proctectomy, particularly with the inclusion of expansive sexual health screening beyond anatomy and physiology to include body image, support systems, relationship status, and fertility. Using a biopsychosocial approach to sexual health screening is key since sexual function is multifaceted and experienced differently in patients across their lifespan.

Funding Statement

The authors declared that this study has received no financial support.