Stroke is a leading cause of mortality and disability (ABS 2008). It is estimated that one in six people worldwide will suffer a stroke in their lifetime – in 2012, 50,000 new stroke or recurrent strokes occurred in Australia (NSF 2013), and 795,000 in the USA (CDC 2014). In the same year there were over 420,000 people in Australia and over 7,000,000 people in the USA living with the effects of stroke (NSF 2013; CDC 2014). The burden of disease and economic impact of stroke upon stroke survivors, their caregivers (often family members) and on society is substantial, with lifetime costs per patient ranging from USD 11,787 to USD 3,3035,671 in the USA (Palmer 2005) and annual national costs of AUD 5 billion in Australia (NSF 2013).
Description of the condition
One of the most common but least talked about effects of stroke is sexual dysfunction with 50% or more of stroke survivors suffering a degree of sexual decline post-stroke (Korpelainen 1999; Giaquinto 2003; Tamam 2008; Schmitz 2010). Sexual dysfunction is often multifactorial in origin and contributing causes can broadly be divided into the following categories.
Primary causes where stroke directly affects sexual function, for example, decline in libido and coital frequency for both genders, decline in vaginal lubrication and orgasm in females and in erection and ejaculation in males (Monga 1986; Giaquinto 2003; Tamam 2008).
Secondary causes where the stroke results in sensorimotor problems, such as hemiplegia or spasticity, pain, bowel or bladder dysfunction, which in turn affect sexual function due to issues such as the loss of ability to position oneself during sexual activity.
Tertiary causes such as psychological adjustment issues, or cognitive or behavioural issues or both.
Psychological adjustment issues may include body image changes, loss of self-esteem, anxiety, stress, depression, fear of new stroke and marital conflict (changes in roles, fear that able-bodied partner will leave, difficulties stemming from the spouse having a dual role of lover as well as carer) (Korpelainen 1999; Giaquinto 2003).
Cognitive or behavioural issues, or both, may include poor judgement, egocentricity, emotional lability, disinhibition, low tolerance for delayed gratification and poor memory.
Issues may not only relate to the stroke survivor but also to his or her spouse with up to 88% stating they would not like to have sexual activity with a "sick person" (Giaquinto 2003).
Description of the intervention
Types of interventions for sexual dysfunction include:
pharmacological interventions such as phosphodiesterase-5 inhibitors, intracavernosal injections, intraurethral suppositories and hormonal therapy (Vecchio 2010);
mechanical devices (such as vacuum pumps, penile implants, penile prostheses and lubricating gels);
psycho-educational interventions (such as counselling and psychotherapy);
physical therapy (such as physiotherapy for bed mobility) (Miles 2007);
complementary medicine interventions such as gingko biloba and ginseng (Miles 2007).
Interventions are not mutually exclusive and may be used in combination. An example of a comprehensive intervention for sexual dysfunction following stroke is sexual rehabilitation. Rehabilitation is defined as "a problem-solving educational process aimed at reducing disability and handicap (participation) experienced by someone as a result of disease or injury" (Wade 1992). The specific aims of stroke sexual rehabilitation are to assess existing sexual issues, provide information on concerns and support safe return to sexual activity after a stroke (Byrne 2014). Sexual rehabilitation is tailored according to individual needs and delivered, in a co-ordinated manner, by medical staff together with one or more disciplines (physiotherapy, occupational therapy, social work, psychologist, nursing). Sexual rehabilitation is designed to be person-centred, time-based, functionally-oriented and aims to maximise activity and participation (social integration) using a biopsychosocial model. Counselling may form a large (and potentially only) component of sexual rehabilitation and may address sexual performance concerns, issues related to medication and co-morbid conditions that may affect sexual function and specific psychological or interpersonal factors (Lue 2004). Counselling may be delivered in a one-on-one or group setting. In addition to counselling, sexual rehabilitation may involve other aspects of physical rehabilitation such as mobility training by the physiotherapist to optimise bed mobility for sexual positioning and transferring in and out of bed, and the management of spasticity such as using a bolster between the knees for adduction spasticity. It may also include the prescription of medications such as phosphodiesterase-5 inhibitors. Sexual rehabilitation may be provided by a range of appropriately trained health professionals within the multidisciplinary team and may involve the stroke survivor or his/her partner alone or the stroke survivor together with his or her partner. A range of formats may used in sexual rehabilitation, including oral information, visual information, written materials, audiovisual and practical training. Sexual rehabilitation may be short-term (such as once-off counselling or a medication prescription) or longer-term, for example providing cognitive behavioural therapy targeting psychological and physical aspects of sex and intimacy (Song 2011), or physiotherapy to achieve mobility goals.
At present, a number of international guidelines recommend that assessment and management of sexual function be made following stroke (NSF 2010; RCP 2012; CSN 2014). However, these guidelines are largely based on consensus and do not address types of intervention or their relative effectiveness.
How the intervention might work
Pharmacological interventions such as phosphodiesterase-5 inhibitors, intracavernosal injections, and intraurethral suppositories assist with erectile function by increasing blood flow to the penis to achieve and maintain erection. Mechanisms of action vary with each medication: phosphodiesterase-5 inhibitors prevent the breakdown of cyclic guanidine monophosphate (cGMP), which results in enhancement of penile erection, while intracavernosal injections cause vasodilatation of the penis. Hormonal treatment, such as testosterone, treat testosterone deficiency resulting in improved libido and erectile function.
The range of non-pharmacological interventions is broad. Mechanical devices such as vacuum pumps and penile implants/penile prostheses treat erectile dysfunction by using an external pump with a band to obtain and maintain an erection and surgically implanting a prosthesis within the corpora cavernosa of the penis respectively. Lubricating gels reduce friction between body parts, or between body parts and other objects during sexual activity. Psycho-educational interventions (such as counselling and psychotherapy) may reduce anxiety related to sexual problems and provide reassurance around fears related to sexual activity precipitating another stroke resulting in an increase in confidence in sexual abilities. Other therapies may work by providing practical guidance such as ideal timing (sexual activity in the morning when the person is not tired), management of bladder and bowel issues and working around weakness (physical support with pillows) to help stroke survivors and their partners address problems common after a stroke that affect sexuality.
Complementary medicine interventions such as gingko biloba and ginseng may increase nitric oxide levels leading to improved erectile function.
Why it is important to do this review
Sexual activity is an integral part of life and the importance of addressing sexual health after stroke is well accepted (NSF 2010). Despite this, a recent Australian National Stroke Audit Rehabilitation Services Report showed that of 2789 post-stroke adults audited across 111 Australian public and private hospitals, only 17% received information on sexuality (NSF 2012). In addition, although current guidelines recommend the assessment and management of post-stroke sexual dysfunction (NSF 2010), little is known about what type of interventions should be provided and how effective these interventions are. Although some clinical studies and reviews (including Cochrane reviews) have explored the role of these interventions for sexual dysfunction in conditions such as cancer (Miles 2007), chronic kidney disease (Vecchio 2010), and diabetes (Vardi 2007), the effectiveness and safety of these interventions in stroke survivors have not yet been studied thoroughly. This review therefore aims to identify the existing evidence for interventions for sexual dysfunction in stroke survivors, and identify gaps in current knowledge with the purpose of informing health professionals, stroke survivors and their partners, and policy makers about the effectiveness of different interventions.