Sexual Functioning Among Stroke Patients
and Their Spouses
Juha T. Korpelainen, MD, PhD; Pentti Nieminen, PhD; Vilho V. Myllylä, MD, PhD
Downloaded from http://stroke.ahajournals.org/ by guest on June 18, 2017
Background and Purpose—The aim of this study was to assess effects of stroke on sexual functioning of stroke patients
and their spouses and to study the associations of clinical and psychosocial factors with poststroke changes in
sexual functions.
Methods—One hundred ninety-two stroke patients and 94 spouses participating in stroke adjustment courses sponsored by
the Finnish Stroke and Aphasia Federation completed a self-administered questionnaire concerning their prestroke and
poststroke sexual functions and habits. The main outcome measures were (1) libido, (2) coital frequency, (3) sexual
arousal, including erectile and orgastic ability and vaginal lubrication, and (4) sexual satisfaction.
Results—A majority of the stroke patients reported a marked decline in all the measured sexual functions, ie, libido, coital
frequency, erectile and orgastic ability, and vaginal lubrication, as well as in their sexual satisfaction. The most important
explanatory factors for these changes were the general attitude toward sexuality (odds ratio [OR] range, 7.4 to 21.9; logistic
regression analysis), fear of impotence (OR, 6.1), inability to discuss sexuality (OR range, 6.8 to 18.5), unwillingness to
participate in sexual activity (OR range, 3.1 to 5.4), and the degree of functional disability (OR range, 3.2 to 5.0). The spouses
also reported a significant decline in their libido, sexual activity, and sexual satisfaction as a consequence of stroke.
Conclusions—Sexual dysfunction and dissatisfaction with sexual life are common in both male and female stroke patients
and in their spouses. Psychological and social factors seem to exert a strong impact on sexual functioning and the quality
of sexual life after stroke. (Stroke. 1999;30:715-719.)
Key Words: cerebrovascular disorders n sexuality n stroke
C
erebrovascular diseases are the third leading cause of
death and one of the major causes of long-term disability
in western countries.1 Despite this high prevalence, little
information is available on sexual functioning and sexual
satisfaction in stroke patients.2
Most previous studies3–7 have involved either a small
sample size or only included subjects younger than 60 years,
although 2 studies8,9 have focused on the physiological
aspects of sexual behavior rather than on attitudes or psychosocial functioning, which may be important elements in
determining the quality of poststroke sexual life.
The most common sexual problems that have been identified
after stroke include decline in libido and coital frequency,
decline in vaginal lubrication and orgasm in women, and poor or
failed erection and ejaculation in men.6,7 The observed decline in
sexual functions appears to be multifactorial in nature. In
addition to neurological and cognitive deficits, the quality of
poststroke sexual life may be impaired because of previous
diseases, medication, or various psychosocial factors.2,10 However, the value of these factors influencing sexual behavior after
stroke is not carefully outlined, nor do we know the value of
sexual counseling and other management approaches.2
Little information is available about the consequences of
stroke on the sexual behavior and attitudes of the spouses of
stroke patients, although they are very important persons in
terms of the well-being of stroke patients. Previous studies7,11,12
suggest that spouses experience negative changes in the quality
of their sexual life similar to those of stroke patients, but there is
a lack of detailed information regarding the changes in their
libido, sexual activity, and satisfaction with sexual life.
A clear understanding of the effects of stroke on sexual
behavior would be useful for physicians in planning sexual
counseling for stroke patients and their spouses during
rehabilitation. We therefore designed the present study to
assess the impact of stroke on sexual functioning among
stroke patients and their spouses. We particularly aimed to
study the associations between the changes in sexuality and
the various clinical and psychosocial features of stroke
patients and to clarify the complex and multifactorial etiology
of poststroke sexual dysfunction.
Subjects and Methods
The series consisted of 192 stroke patients (117 men and 75 women;
mean age, 59.1 [SD 10.2] years; range, 32 to 79 years) and 94
spouses (21 men and 73 women; mean age, 57.6 [SD 10.7] years;
range, 30 to 79 years) who were recruited from inpatient adjustment
courses sponsored by the Stroke and Aphasia Federation in 1997.
The total number of patients participating in the courses was 213, of
Received November 20, 1998; final revision received January 15, 1999; accepted January 15, 1999.
From the Department of Neurology, University of Oulu (Finland).
Correspondence to Juha T. Korpelainen, MD, Department of Neurology, University of Oulu, Kajaanintie 52, 90220 Oulu, Finland. E-mail
[email protected]
© 1999 American Heart Association, Inc.
Stroke is available at http://www.strokeaha.org
715
716
Sexual Functions After Stroke
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whom 192 (90%) were able and willing to participate in the study.
Ninety-four (90%) of the total of 105 spouses agreed to participate in
the study. Fifteen patients and 11 spouses who refused to answer the
questions, as well as 6 aphasic patients who did not understand the
questions, were excluded.
Of the 192 patients, 135 had suffered a brain infarction, 45 had an
intracerebral hemorrhage, and 12 had a subarachnoid hemorrhage
(93% first-ever strokes). The focal lesion was located in the
dominant hemisphere in 100 cases, in the nondominant hemisphere
in 58 cases, in the brain stem in 5 cases, and in the cerebellum in 8
cases. Twenty-one patients had multiple brain lesions. The median
time from the onset of the first stroke was 23 months. Fifty-one of
the 192 patients were previously healthy, while 141 patients had
previous diseases, the most common being arterial hypertension (81
patients), diabetes mellitus (42 patients), and coronary artery disease
(39 patients). Fifty-four patients suffered from poststroke epilepsy.
The majority (159) of the patients were taking medication: 50
b-adrenergic blocking agents, 37 calcium entry blockers, 34 angiotensin-converting enzyme inhibitors, 31 diuretics, 11 digitalis, 23
nitroglycerin, 32 oral diabetes medication, 11 insulin, 7 tricyclic
antidepressants, 43 serotonin reuptake inhibitors, and 54 anticonvulsive medication. There were 149 married patients and 43 unmarried,
of whom 20 were divorced and 11 widowed.
During the courses, all the patients and their spouses independently completed a questionnaire that included their prestroke and
poststroke sexual functions and habits. Dysphasic patients with
difficulties in writing (n521) were assisted by a nurse. Because a
validated questionnaire for poststroke sexual functions is not available, we used questions described by Monga et al6 with minor
modifications. They were 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) one 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. We also asked about
the following: General attitude toward 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. The degree of disability of the patients was scored with the
use of the Rankin Scale,13 and the degree of depression was scored
with the Geriatric Depression Scale.14 This scale was chosen after a
pilot study because it is simple enough for dysphasic patients.
The data were analyzed with SPSS for Windows software. The
main response variables, reflecting consequences of stroke on sexual
functions, were change in libido, frequency of sexual intercourse,
and satisfaction with sexual life. Various clinical factors such as age,
gender, diagnosis, location of the lesion, degree of disability,
presence and side of hemiparesis, spasticity, hemisensory symptoms,
presence and severity of aphasia, previous diseases, and medication,
as well as several psychosocial factors such as marital status,
presence and degree of depression, ability to discuss sexuality with
spouse, fear of having another stroke or fear of impotence, and
general attitude toward sexuality, were used to explain the observed
alterations in sexual functions (explanatory variables). The statistical
significance of factors associated with the measures of sexual
functions was evaluated with the x2 test and multivariate analysis.
The response variables were dichotomously divided as follows:
(1) decreased libido (answers 3 to 5) versus increased or unchanged
libido (answers 1 to 2), (2) coital frequency less than once a month
(answers 4 to 5) versus coital frequency more than once a month
(answers 1 to 3), and (3) dissatisfaction with sexual life (answers 3
to 4) versus satisfaction with sexual life (answers 1 to 2). Logistic
regression analysis, which demonstrates the effect of the explanatory
variable on the response variable in such a manner that the other
variables can be regarded as adjusted and standardized, was used to
test which variables best describe and discriminate patients and their
spouses with altered sexual functioning. The stepwise regression
procedure of the SPSS statistical package was used. The final models
were reported using odds ratios (ORs) and their 95% CIs. The
agreement between the answers of the patients and their spouses was
analyzed by the marginal homogeneity test, and the Kruskal-Wallis
test was used to analyze associations between the degree of depression and changes in sexual functions. The protocol of the study was
approved by the ethics committee of the medical faculty, and
informed consent of the patient was obtained in each case.
Results
Stroke caused a marked decrease in libido among both the
patients and their spouses, with more than half of the patients
(57%) and of the spouses (65%) reporting a diminished poststroke libido compared with their prestroke libido. The statistically most essential explanatory variables for the decrease were
the general attitude toward sexuality (unimportant: OR, 21.9;
fairly important: OR, 7.4), fear of impotence (OR, 6.1), and
functional disability (severe: OR, 4.2; mild: OR, 3.2) (Table 1).
The majority of patients (79%) and spouses (84%) reported an
active prestroke sexual life, including intercourse regularly at
least once a month. After the stroke, however, the number of
patients (45%) and spouses (48%) with an active sexual life had
markedly decreased. Thirty-three percent of patients and 27% of
the spouses reported having ceased sexual intercourse. The
decreased coital frequency associated most significantly with
the disability to discuss sexuality with the spouse (OR, 18.5), the
general attitude toward sexuality (unimportant: OR, 7.7; fairly
important: OR, 9.2), and unwillingness to participate in sexual
activity (OR, 5.4) (Table 2).
Table 3 shows the effects of stroke on penile erection of the
male patients and on vaginal lubrication and orgastic ability of
the female patients before and after the stroke. All of these
functions decreased markedly as a consequence of stroke, with
the majority (75%) of the male patients having a feeling of
diminished or absent poststroke erectile capacity and approximately half of the female patients reporting diminished or absent
vaginal lubrication (46%) and orgastic ability (55%).
Most of the patients (89%) and their spouses (93%) had
been satisfied with their prestroke sexual life. After the
stroke, however, dissatisfaction with sexual life increased
among both the patients and spouses, with 49% of the patients
and 31% of the spouses reporting a feeling of moderate or
complete dissatisfaction. The statistically most significant
explanatory variables for this reported dissatisfaction were an
inability to discuss sexuality (OR, 6.8), unwillingness to
participate in sexual activity (OR, 3.1), and functional disability (mild: OR, 5.0; severe: OR, 4.2) (Table 4).
We also found other significant associations between the
reported sexual disorders and various clinical factors, which,
however, were statistically nonsignificant after the selection
of the variables shown in Tables 1, 2, and 4 into the logistic
regression model. Erectile dysfunction both before and after
the stroke was more frequent among patients with diabetes
mellitus than among the other patients (x2 test, P50.004), and
disorders of erection (P50.007) and vaginal lubrication
(P50.006) were more common in patients with prior cardiovascular medication than in other patients. A statistically
significant association was found between the score of the
Geriatric Depression Scale and the poststroke libido
(Kruskal-Wallis test, P50.001), coital frequency (P50.038),
Korpelainen et al
April 1999
717
TABLE 1. Explanatory Variables Associated With Changes in Libido in Stroke
Patients (n5182)
Decreased
Libido
No Changes
in Libido
No.
%
No.
%
P*
Extremely important (reference)
29
34.1
56
65.9
,0.001
Fairly important
53
74.6
18
25.4
7.4 (3.0–18.3)
Unimportant
21
91.3
2
8.7
21.9 (4.1–118.3)
Explanatory Variables
OR (95% CI)
General attitude toward sexuality
1
Fear of impotence
,0.001
No (reference)
30
39.5
46
60.5
Yes
31
79.5
8
20.5
6.1 (1.85–20.0)
1
Cannot say
43
64.2
24
35.8
1.6 (0.6–4.0)
No disability (112) (reference)
10
31.3
22
68.8
Mild disability (3)
33
63.5
19
36.5
3.2 (1.0–9.8)
53
62.4
32
37.6
4.2 (1.4–12.8)
104
57.1
78
42.9
Rankin Scale
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Moderate or severe disability (415)
All patients
0.005
1
ORs and their 95% CIs are calculated by logistic regression.
*x2 test.
erectile capacity (P,0.001), vaginal lubrication (P50.003),
orgastic ability (P50.011), and satisfaction with sexual life
(P,0.001). Changes in sexual function after the stroke were
not related to the gender and marital status of the patients,
etiology of stroke, or location of the lesion.
We also analyzed the agreement between the answers of the
stroke patients and their spouses, considering the couple as a unit
of analysis. There was good agreement in the reported coital
frequency and the time to begin sexual activity after the stroke,
but the decrease in libido was markedly higher (P50.007)
among the spouses than among the patients, and the spouses
reported more dissatisfaction with their prestroke (P50.041) and
poststroke (P,0.001) sexual life than the patients.
Discussion
The results of the present study, aimed at assessing the effects of
stroke on sexual functioning, reveal a significant decline in
libido, coital frequency, sexual arousal, and satisfaction with
sexual life in both stroke patients and their spouses. The present
results also demonstrate that disorders of sexual functions are
TABLE 2. Explanatory Variables Associated With Coital Frequency in Stroke
Patients (n5187)
,1 per
month
Explanatory Variables
No.
%
.1 per
month
No.
%
P*
OR (95% CI)
General attitude toward sexuality
Extremely important (reference)
23 27.1
62
72.9 ,0.001
Fairly important
58 78.4
16
21.6
9.2 (3.7–22.8)
Unimportant
20 80.0
5
20.0
7.7 (2.1–27.9)
Yes, with ease (reference)
33 39.8
50
60.2 ,0.001
Yes, with trouble
18 45.0
22
55.0
0.9 (0.3–2.5)
No
33 89.2
4
10.8
18.5 (4.1–82.3)
Cannot say
19 70.4
8
29.6
2.6 (0.7–10.5)
23.1 ,0.001
1
Ability to discuss sexuality with the spouse
1
Unwillingness to participate in sexual activity
No (reference)
30 76.9
9
Yes
24 32.4
50
Cannot say
All patients
5.4 (1.6–17.6)
2.1 (0.8–5.6)
49 66.2
25
33.8
103 55.1
84
44.9
ORs and their 95% CIs are calculated by logistic regression.
*x2 test.
1
67.6
718
Sexual Functions After Stroke
TABLE 3. Erectile Ability in Male Patients (n5117) and Vaginal Lubrication and
Orgastic Ability in Female Patients (n575) Before and After Stroke
Erection
Lubrication
Orgasm
Before
After
Before
After
Before
After
Normal
73 (62%)
26 (22%)
35 (47%)
18 (24%)
36 (48%)
12 (16%)
Slightly diminished
28 (24%)
29 (25%)
15 (20%)
13 (17%)
14 (19%)
11 (15%)
Markedly diminished
11 (9%)
43 (37%)
7 (9%)
13 (17%)
3 (4%)
17 (23%)
None
3 (3%)
15 (13%)
3 (4%)
9 (12%)
6 (8%)
13 (17%)
Cannot say
2 (2%)
4 (3%)
15 (20%)
22 (29%)
16 (21%)
22 (29%)
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most significantly associated with various psychosocial factors,
such as patients’ general attitude toward sexuality, fear of
impotence, and ability to discuss sexuality, as well as with the
degree of poststroke functional disability. Moreover, sexual
dysfunction was related to the presence and degree of depression, diabetes mellitus, and cardiovascular medication. The
etiology or location of the stroke and the gender or marital status
of the patients were not associated with changes in poststroke
sexuality in patients in the present study.
A few previous studies3– 8 suggest that cerebrovascular diseases may commonly result in sexual dysfunction, leading to a
marked decrease in sexual activity. In their study, performed in
113 stroke patients, Monga et al6 reported diminished or ceased
poststroke libido in 79% of male and 66% of female stroke
patients. Disorders of erection (62%), ejaculation (78%), vaginal
lubrication (61%), and female orgastic ability (77%) were also
frequently encountered after the stroke. They also reported that
sexual activity, measured as frequency of intercourse, had
decreased markedly as a consequence of stroke. Sixty-four
percent of their male and 54% of their female patients reported
no coital activity after stroke. Significantly decreased poststroke
libido,5,8 coital frequency,3,7,8 and erectile and orgastic ability4,5
have also been reported by other authors.
The results of the present study generally agree with the
previous studies,3– 8 but the number of patients who completely stopped having sexual intercourse after the stroke was
markedly lower (33% of patients, 27% of spouses) than
previously reported.5,6 Moreover, the number of patients
satisfied with their poststroke sexual life decreased less in our
patients (89% before stroke, 49% after stroke) than reported
previously6 (male: 95%, 26%; female: 76%, 37%, respectively). The different findings of these studies are likely to be
related to discrepancy in the basic characteristics of the
patients, ie, age, previous diseases, and prestroke sexual
habits, but they may also reflect different attitudes toward
sexuality in different cultures and societies.
Sexual dysfunction in stroke patients is known to be
complex and multifactorial. Monga and Ostermann2 suggested in their review that sexual problems in these patients
are never a consequence of stroke alone; rather, they may be
due to a variety of associated medical conditions and psychosocial factors. Although other authors5–7,11 have also suggested that psychological and social factors may significantly
affect poststroke sexual functioning, none of these factors has
been systematically investigated, and some suggested factors
would seem to conflict with each other. In the present study,
TABLE 4. Explanatory Variables Associated With Satisfaction With Sexual Life in Stroke
Patients (n5176)
Dissatisfied
Explanatory Variables
No.
%
Satisfied
No.
%
P*
,0.001
OR (95% CI)
Ability to discuss sexuality with spouse
Yes, with ease (reference)
28
34.1
54
65.9
Yes, with trouble
18
45.0
22
55.0
1.3 (0.5–3.1)
1
No
28
84.8
5
15.2
6.8 (2.2–21.7)
Cannot say
12
57.1
9
42.9
1.1 (0.3–4.1)
No (reference)
25
64.1
14
35.9
Yes
20
27.4
53
72.6
3.1 (1.2–8.2)
Cannot say
41
64.1
23
35.9
3.4 (1.4–8.4)
Unwillingness to participate in sexual activity
,0.001
1
Rankin Scale
No disability (112) (reference)
7
22.6
24
77.4
Mild disability (3)
29
55.8
23
44.2
5.0 (1.5–16.1)
Moderate or severe disability (415)
42
50.6
41
49.4
4.2 (1.3–13.1)
86
48.9
90
51.1
All patients
ORs and 95% CIs are calculated by logistic regression.
*x2 test.
0.009
1
Korpelainen et al
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we have for the first time demonstrated that psychosocial
factors play a crucial role in determining sexual drive,
activity, and satisfaction after stroke, and their influence is
even stronger than that of medical factors. On the other hand,
recruiting patients from adjustment courses may overemphasize the role of sexual dysfunction, because stroke patients
willing to participate in the courses may have more psychosocial adjustment problems than stroke patients in general. It
is also possible that in some patients psychosocial disorders
are a cause of poststroke sexual dysfunction instead of being
a consequence of sexual problems.
In patients in the present study, poststroke sexual dysfunction was also closely related to the degree of depression
measured by the Geriatric Depression Scale, which is also a
novel finding. Antidepressant medication, which may sometimes cause sexual disorders, did not explain this finding,
because sexual functions were similar in the patients with and
without antidepressant medication. Actually, only 7 of our
patients used tricyclic antidepressants, which are known to
frequently cause sexual disorders, while 43 patients used
serotonin reuptake inhibitors and 1 patient used moclobemide, which seldom cause decline in sexual activities.
Our results agree with the previous suggestions that other
diseases and medication, such as antihypertensives and antidepressants, may modify the effects of stroke on the sexual
behavior of patients and their spouses.2,10,15–17 Sjögren and
Fugl-Meyer18 reported that stroke patients with previously
known arterial hypertension, myocardial infarction, or diabetes mellitus changed their sexual behavior relatively little
compared with those without these diseases, reflecting the
likelihood of a prestroke decline in their sexual functions. We
found a similar association between disorders of erection and
the presence of diabetes mellitus in the male patients and
between disorders of sexual arousal and previous cardiovascular medication in both genders.
Another interesting finding in the present study was that 19
of our 192 patients, but none of the spouses, reported
increased libido after the stroke in comparison with the
prestroke libido. These patients were younger (mean age,
50.7 years) than the other patients (60.0 years), but the side
and location of the cerebral lesion, clinical deficits, and other
diseases or medication of the patients did not differ from
those of the other patients. There is also a previous description19 of 3 stroke patients who demonstrated hypersexuality
and deviant sexual behavior appearing 3 months after the
stroke and remaining stable for years. All 3 patients had
temporal lobe lesions and had a history of poststroke seizure
activity. Recently, hypersexuality has also been described as
a reversible side effect of antidepressant treatment (moclobemide) in 2 patients with ischemic stroke.20
A minor limitation of the present study is that only the Rankin
Scale was used to score the degree of disability of the patients.
Because different stroke and disability scales are used in various
Finnish hospitals and rehabilitation centers, we were not able to
compare the severity of stroke using these scales. Moreover, the
reported 90% satisfaction with prestroke sexual life among the
patients and spouses is surprisingly high and must be regarded
with caution. Although these high figures may partly be related
April 1999
719
to the retrospective behavior of the present study, the decline of
satisfaction, particularly among the spouses, is remarkable and is
likely caused by the stroke itself.
Approximately half of the stroke patients and spouses in the
present study reported an interest in sexual counseling and
regarded it as an essential part of stroke rehabilitation, but only
a few of them had received it. Although there may be a lack of
highly trained sexual counselors, the attitudes toward intimate
sexual questions among rehabilitation professionals may also
reduce discussion of this topic. The present results, however,
suggest that a need clearly exists for sexual counseling after
stroke, and we recommend that such counseling be included in
the basic information given to stroke patients and their spouses.
Acknowledgments
This study was supported by grants from the Maire Taponen
Foundation, the Medical Reseach Foundation in Oulu, and the
Biomedical Engineering Program of the University of Oulu (Finland). We thank the field workers of the Stroke and Aphasia
Federation for assisting in the data collection.
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Sexual Functioning Among Stroke Patients and Their Spouses
Juha T. Korpelainen, Pentti Nieminen and Vilho V. Myllylä
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Stroke. 1999;30:715-719
doi: 10.1161/01.STR.30.4.715
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Copyright © 1999 American Heart Association, Inc. All rights reserved.
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