Symptomatic arthritis of the hip has been shown to interfere with sexual activity.3,4,12 Pain, deformity, stiffness, immobility, and negative body image all may contribute to sexual dysfunction in patients with arthritis of the hip. Successful THA has been shown to improve sexual function in most patients.1,3,12,13
Despite the fact that 89% of patients have been reported to desire more information regarding return to sexual activity after THA, the data from this study show that most experienced hip surgeons surveyed rarely or never discuss sex after THA with their patients. For those who discuss a return to sexual activity with their patients, most spend less than 5 minutes. In this study, the performance of a high volume of hip arthroplasties correlated with an increased frequency of discussion with patients regarding return to sexual activity. In the United States, most THAs are done by surgeons doing far fewer than the number of procedures done by this selected sample of surgeons. Therefore, it is highly likely that these issues rarely are discussed with most patients having hip arthroplasties in this country. In a study by Stern et al,12 less than 10% of patients surveyed reported discussing return to sexual activity with their surgeon preoperatively. One reason for the paucity of discussion between patient and surgeon may be the patient’s reluctance to verbalize concerns regarding sexual issues.2 In addition, the physician or other healthcare professional may lack information on appropriate guidelines or may be unprepared or uncomfortable providing specific instructions in this area.
In our study surgeons were more likely to discuss return to sexual activity with married patients than with single patients. Surgeons whose practices included a larger proportion of younger patients (younger than 65 years) also were more likely to discuss sex with their patients. The reason for this discrepancy is unknown, however, it may be attributable to the surgeons’ general perceptions of the patients’ sexual activities rather than any knowledge of individual patient’s practices.
In our study, 20% of surgeons surveyed were aware of at least one patient who had a hip dislocation during sexual activity. Delay in return to sexual activity after THA allows for wound, pericapsular tissue, and muscular healing, thereby improving comfort and reducing the risk of hip instability. Dislocation after THA is a relatively common major complication, occurring in 0.6%5 to 7% of patients.10 Two percent to 3% of primary THAs will dislocate, and 59% of THA dislocations are reported to occur within the first 3 months postoperatively.15 Despite differences in relative risk of dislocation for anterior and posterior approaches, posterior dislocation with flexion and adduction is a considerable risk after THA with the anterior and posterior approaches, and patients having THA through either approach routinely should be counseled to avoid this position. No attempt was made to determine details such as timing of or hip position during dislocation, therefore conclusions specific to hip dislocation during sexual activity cannot be made. Nevertheless, our study calls attention to dislocation as a potential problem, and underscores the importance of proper instruction in the timing and mechanism of return to sexual activity in the patient who has had a THA.
Most surgeons in our study (67%) advocated return to sexual activity 1–3 months after surgery, however, 31% allowed return at 4 weeks or less. Surgeons recommended, on average, a slightly longer period after revision versus primary THA (p < 0.0001). There are several potential reasons for recommending a longer period of abstinence after revision surgery, including allowing for more time for pericapsular and muscular healing, which may be relatively compromised in the revision setting. Additionally, a longer period of protection might be warranted in a revision setting, given the slightly higher rate of reported instability.9
Of the 12 sexual positions shown in the survey, five positions for men and three positions for women were considered acceptable in patients who have had THAs by greater than 90% of respondents (Fig 2). Recommended positions most often were those in which the patient avoided extremes of hip flexion, adduction, and internal rotation.
Further limitations of our study include an incomplete response rate and the potential limitations of respondent recall. In this study the response rate of 31% is fairly typical of voluntary surveys not providing monetary incentive, and represents an almost identical response rate to that obtained in a previously published survey of this same population of surgeons.8 Another limitation relates to the fact that the surveys were anonymous and as such the validity of the data cannot be independently verified. However, given the relatively sensitive nature of the study, ensuring the anonymity of the respondents was important in encouraging the highest possible response rate and greatest possible level of candor. These limitations are unlikely to have any influence on the validity of the main conclusion of this study, which is that discussions by surgeons with patients regarding return to sexual activity after THA occur infrequently and are touched on only briefly when discussed, despite the importance of these issues to patients. This study has documented a relative lack of communication between patients and surgeons regarding return to sexual activity after THA even when in the hands of experienced high-volume practitioners. This study also provides guidelines for the timing and mechanism of safe return to sexual activity after THA based on the consensus opinions obtained from this large sample of experienced joint replacement surgeons. Each surgeon should consider individual patient and surgical factors when discussing return to sexual activity with his or her patients, and modify the discussion accordingly.
We thank Charles Rowland, MS, from the Mayo Clinic, Department of Statistics, for assistance with statistical analysis.
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