Sexual activity is a normal part of life for most individuals. It has been reported that ⅔ of patients with osteoarthritis of the hip report sexual difficulty, most commonly attributable to hip pain and immobility.3 Similarly, 85% of women and 69% of men with rheumatoid arthritis report that increased disease activity is a major limiting factor for initiating sexual activity.4
Successful total hip arthroplasty (THA) has been reported to improve sexual satisfaction and performance in most patients.1,3,12,13
Stern et al12 surveyed 86 patients who had successful THAs and found that 89% desired more information regarding sexual activity after arthroplasty. Eighty-one percent of these patients reported that they had not been told when intercourse could safely be resumed after surgery. Data on surgeons’ attitudes and practices regarding sexual activity after THA are limited.
The purpose of this study is to report the results of a survey of experienced hip surgeons regarding their opinions on appropriate guidelines for safe return to sexual activity after THA. We specifically will address the frequency and the degree to which this information is provided to patients. Additionally, we will document surgeons’ preferences concerning the time of return to sexual activity and safety of various sexual positions.
MATERIALS AND METHODS
All members (821 orthopaedic surgeons) of the American Association of Hip and Knee Surgeons were sent an anonymous survey concerning their clinical experience and practice regarding return to sexual activity by patients after THA. Surgeons were asked what percentage of men and women who have had THA asked questions about sex after THA, and how frequently the surgeon or a member of their healthcare team discussed sex after THA with their patients. Questions regarding surgeons’ specific recommendations for return to sexual intercourse after THA also were asked. Information was obtained regarding surgeon and patient demographics. Surgeons also were asked whether, to their knowledge, a patient of theirs ever experienced a hip dislocation during sexual activity. Finally, sketches of 12 common sexual positions were provided (Fig 1) and surgeons were asked to deem each sexual position as either acceptable or unacceptable in a patient of each gender after THA.
The Wilcoxon signed-rank test14 was used to assess differences in an ordinal or continuous response for paired survey questions. Paired survey questions included those in which the respondent was asked to answer the same question once for men and once for women, or once for primary THA and once for revision THA. Fisher’s exact test6 was used to assess associations between pairs of categorical responses. Associations of an ordinal or continuous response between nonpaired groups were assessed with the Wilcoxon rank sum test when two groups were being compared or the Kruskal-Wallis test7 when more than two groups were being compared. Spearman’s rank correlation11 coefficient was used to assess the association of pairs of continuous responses. A significance level of 0.05 was used for all statistical tests.
Two hundred fifty-four surveys were returned (31% response rate). One hundred eighty-one surgeons (75%) reported doing greater than 50 THAs annually, and 189 (78%) had been in practice at least 10 years at the time of the survey. Seventy percent of respondents were either from the northeast, southeast, or east-central United States. Seventy-eight percent of surgeons belonged to a private single specialty or a multispecialty group, whereas 21% belonged to a university or teaching institution. Surgeons reported that men asked about sex after THA more frequently (p = 0.0008) than women. More than 80% of respondents stated that they rarely or never discussed sex with patients after THA. Of those who discussed sex with patients after THA, 96% reported spending 5 minutes or less in such discussions. Forty-five percent of surgeons surveyed provided written information regarding sex after THA to their patients, and of this group, 44% provided written information only to patients who specifically asked for it. Respondents were more likely (p < 0.0001) to discuss sex with married patients compared with unmarried patients. The number of THAs done annually was correlated with an increase in frequency with which healthcare team members discussed sex with patients, so that surgeons who did a higher number of THAs more frequently (p = 0.0001) discussed sex with patients. Furthermore, surgeons who did a higher number of THAs annually allowed return to sexual activity earlier (p = 0.02) after revision THA than surgeons who did fewer THAs per year. Most respondents (67%) recommended return to sexual activity 1–3 months postoperatively for patients who have had primary and revision THA (Table 1). The posterior approach was favored by 69% of respondents for primary THA and 68% of respondents for revision THA. Surgical approach used did not correlate with recommended time allowed before return to sexual activities. Additionally, surgical approach used did not correlate with the positions deemed acceptable by surgeons, nor with the reported cases of dislocation during sexual activity. Fifty-one respondents (20%) reported knowledge of at least one patient experiencing THA dislocation during sexual activity. Of the 12 sexual positions shown in the survey, five positions for men and three positions for women were considered acceptable for patients who have had THA by more than 90% of respondents. One position was considered acceptable by 90% of respondents when both individuals had THAs (Fig 2).
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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