Chronic renal failure is a chronic illness reported to result in the development of sexual dysfunction in women and men that might have severe negative effects on patients’ lives and quality of life 1. The prevalence of sexual problems is about 9% before the start of dialysis, increasing to about 60–70% in male and female patients undergoing dialysis 2. Renal transplantation has been the most preferred treatment of choice and is a cost-effective treatment compared with hemodialysis. It has been shown to be superior to the quality of life on dialysis 3. Although a successful renal transplantation might improve sexual functions in comparison with dialysis, in many women, some degree of sexual dysfunction might persist 4. There are relatively few studies in the literature investigating sexual dysfunction in renal transplanted patients, and among these, very few included women and very few were carried out among Egyptian women who had undergone transplantation. This study aimed to retrospectively determine the effect of renal transplantation on sexual function of end-stage renal disease (ESRD) women in comparison with the general female population.
Materials and methods
A total of 100 female patients including 50 women that underwent renal transplantation within the last 2 years, with a mean age 32.71±7.34 years, and 50 age-matched normal control were enrolled in this study.
The study was carried out in collaboration with Renal Transplant and Nephrology Unit in Kasr Al Aini Medical School, Cairo University. All patients were given triple immunosuppression including tacrolimus or cyclosporine, mycophenolate mofetil or azathioprine or sirolimus, and steroids after transplantation. The study protocol was approved by the local ethical committee of the Andrology Department and an informed consent was obtained from all the women participating in the study. After determination of demographic characteristics, female sexual function was evaluated using a detailed 19-item questionnaire [Female Sexual Function Index (FSFI)] assessing sexual functions.
The demographic data, including age, number of children, educational level, occupational status, chronic disease, menstrual status, circumcision, neurological and psychological disorders, and medication that adversely affects sexual function the duration of dialysis in the transplant group were assessed. Exclusion criteria were; females younger than 18 years or older than 45 years of age, psychotic diseases, debilitating disease such as advanced cancer, liver, or cardiac failure, husband with erectile dysfunction, and pregnancy.
Female sexual function index
Assessment of female sexual function was performed using the FSFI, a validated 19-item questionnaire 5. The maximum score for this scale is 36. Sexual function was considered good if the score was 30 or above, intermediate if between 23 and 29, and poor if below 23. The 19 items are assigned to six separate domains of female sexual function. Four domains are related to the four major categories of sexual dysfunction: desire disorder, arousal disorder, orgasmic disorder, and sexual pain disorder. The fifth domain assesses the quality of vaginal lubrication, whereas the sixth domain is related to overall sexual and relationship satisfaction and is viewed as the ‘quality of life’ domain of the scale. Each domain is scored on a scale of 0 or 1–5, with a higher score indicating better function.
Logistic regression was used to determine the effect of risk factors on female sexual dysfunction (FSD). Differences were considered significant at P value less than 0.05. Data were analyzed using the statistical package for the social science (SPSS), version 20 (SPSS Inc., Chicago, Illinois, USA). Numerical data were expressed as means and SDs. Qualitative data were expressed as frequency and percentage. The χ2-test was used to examine the relationship between qualitative variables. For repeated quantitative two variables, the T-test was used for comparison. The relation between different numerical variables was tested using the Pearson correlation.
The results of demographic data are presented in Table 1. In terms of the fertility and menstrual status of patients, 18 patients with transplant had irregular cycles in comparison with four women in the control group. Ten of the renal transplant patients had amenorrhea during dialysis; in five of these women, their regularity of cycle was restored after transplantation. None of the renal transplant patients conceived after transplantation or during dialysis; two renal transplant women had a history of recurrent abortion. A total of 54% had an additional chronic disease such as diabetes and hypertension, for which they received the corresponding medications.
The results of the questionnaire are shown in Table 2.
FSFI scores were lower in cases of renal transplantation with a mean of 24.84±3.44 compared with the control group (28.1±4.1), with a significant difference. All questionnaire items showed a significant difference between both groups, except in the subdomains of desire level and pain. There was a significant decrease in the score of all domains, except in pain, between the renal transplant and control women Table 3. The mean desire score was 3.76±0.72 in the control group compared with the renal transplantation group (3.44±0.72), although statistically nonsignificant, whereas other domains showed lower scores in transplant patients with a statistical significance: arousal mean was 4.57±0.94, which decreased to 3.80±0.59; lubrication mean was 5.29±0.70, which decreased to 4.42±0.65; orgasm mean was 4.63±1.29, which decreased to 3.84±1.29; and satisfaction mean was 5.17±1.20, which decreased to 4.51±0.94.
Duration of dialysis had a significant negative correlation (P<0.05) with the arousal (r=−0.27) and satisfaction (r=−0.29) scores as well as the full scale score (r=−0.36). Other domains such as desire, lubrication, orgasm, and pain showed nonsignificant correlation with the duration of dialysis (Table 4).
Few areas of human behavior are as complex as sexuality. Sexual function is very sensitive to illness, psychological distress, and interpersonal relationships. Chronic illness is largely associated with diminished sexual activity because of malaise, fatigue, and changes in body image. It is difficult to define ‘normal’ sexual function or frequency of sexual activities because of the wide variation in sexual practices between different cultural groups and ethnicities 6. Sexuality is considered an important component of quality of life. Sexual dysfunction in men or women on hemodialysis or peritoneal dialysis was largely because of loss of sexual interest, subjectively ascribed to fatigue. Basok et al. 7 compared between female sexual functions in predialysis, dialysis, and transplant patients and found that predialysis patients had the worst FSFI scores, and the transplant patients had the highest FSFI scores. Therefore, transplantation seemed to be the proper treatment option for improvement in FSD. In comparison with our current study, the mean total FSFI scores were reduced in renal transplant patients (24.84±3.44) as compared with the control group (28.10±4.09), with a significant difference. Another study by Muehrer et al. 8 investigated sexuality among women recipients of a pancreas and kidney transplant in University of Wisconsin–Madison. They found that only 39% of the women had normal sexual function. The majority reported either some difficulty with sexual function (34%) or sexual dysfunction (27%). Schover et al.9 reported nonsignificant increase in sexual satisfaction after renal transplantation, despite a significant increase in sexual desire. Ozdemir et al. 10 examined the prevalence of sexual dysfunction, using the Arizona sexual experiences scale, in 98 men and women who had received a kidney transplantation in Turkey. The authors reported a high prevalence (69%) of sexual dysfunction in their sample. When the prevalence was examined by sex, 94% of women and 57% of men were classified as having a sexual dysfunction. The lack of an improvement following transplantation could be attributed to the lack of an effect or the concomitant comorbidities, especially as 26% of our patients had diabetes. Our result is supported by Diemont et al. 11, who found that 44.4% of women receiving renal transplantation had diabetes and hypertension for a number of years. Both of these conditions may influence sexuality. Kettas et al. 12 found that after renal transplantation surgery, women with no diabetes showed significant improvement in sexual function than women with diabetes. Several pharmacotherapies can increase the risk of FSD, and many of these drugs are used in the treatment of renal transplantation 13. The effect of some of these drugs and their interactions on genital and sexual function is still unclear. It could be an area of potential future studies.
The improvement in hormonal status and the restoration of menses positively influenced the sexual function of renal transplant women as discussed by Filocamo 14, in contrast to our results. Fifty-eight women with ESRD who received kidney transplantation were enrolled, 16 of 39 (41%) patients acknowledged having an active sexual life before transplant, as opposed to 34 of 39 (88%) after transplantation. The FSFI and Beck Depression Inventory questionnaires were filled out. The result of the study showed that women with renal transplant reported significantly higher sexual domains in comparison with dialysis patients. Desire became higher from 3.24 on dialysis to 4.48 on transplantation, which was highly significant; the scores on arousal, lubrication, orgasm, and satisfaction also increased, with an increase in the total score from 18.93 on dialysis to 27.64 on renal transplantation. A total of 64% of our patients regained regular menstrual cycles, which may indicate improvement in the hormonal status after transplantation. Our study has some limitations. Sexual function was not correlated with the level of function of the graft or the number of rejections if it occurred together with the hormonal status after transplantation. In addition, the effect of medications for immunosuppression needs further studies.
There was a significant decrease in the score of all FSFI score domains, except for pain, comparing between renal transplant and control women. Early evaluation and management of patients with chronic kidney disease may help avoid progression to ESRD and other complications such as sexuality problems. Women with renal transplantation must be informed about post-transplant sex life and the requirement for regular examinations by a gynecologist. Hence, close collaborations should be established between patients, sexologists, and nephrologists.
Conflicts of interest
There are no conflicts of interest.
1. Stewart M.Narrative literature review: sexual dysfunction in the patient on hemodialysis.J Nephrol Nurs2006;33:631–641.
2. Toorians AW, Janssen E, Laan E, Gooren LJ, Giltay EJ, Oe PL, et al..Chronic renal failure
and sexual functioning: clinical status versus objectively assessed sexual response.Nephrol Dial Transplant1997;12:2654–2663.
3. Liem YS, Bosch JL, Arends LR, Heijenbrok-Kal MH, Hunink MG.Quality of life assessed with the medical outcomes study short form 36-item health survey of patients on renal replacement therapy: a systematic review and meta-analysis.Value Health2007;10:390–397.
4. Camsari T, Cavdar C, Yemez B, Ozkahya M, Atabay G, Alkin T, Akçiçek F.Psychosexual function in CAPD and hemodialysis patients.Perit Dial Int1999;19:585.
5. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al..The Female Sexual Function Index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function.J Sex Marital Ther2000;26:191–208.
6. Davison SL, Bell RJ, LaChina M, Holden SL, Davis SR.Sexual function in well women: stratification by sexual satisfaction, hormone use, and menopause status.J Sex Med2008;5:1214–1222.
7. Basok EK, Atsu N, Rifaioglu MM, Kntarci G, Yildirim A, Tokuc R.Assessment of female sexual function and quality of life in predialysis, peritoneal dialysis, haemodialysis and renal transplant patients.Int Urol Nephrol2009;41:473–481.
8. Muehrer RJ, Keller ML, Powwattana A, Pornchaikate A.Sexuality among women recipients of a pancreas and kidney transplant.West J Nurs Res2006;28:137–150.
9. Schover LR, Novick AC, Steinmuller DR, Goormastic M.Sexuality, fertility, and renal transplantation
: a survey of survivors.J Sex Marital Ther1990;16:3–13.
10. Ozdemir C, Eryilmaz M, Yurtman F, Karaman T.Sexual functioning after renal transplantation
11. Diemont WL, Vruggink PA, Meuleman EJ, Doesburg WH, Lemmens WA, Berden JH.Sexual dysfunction after renal replacement therapy.Am J Kidney Dis2000;35:845–851.
12. Kettas E, Cayan F, Akbay E, Kiykim A, Cayan S.Sexual dysfunction and associated risk factors in women with end-stage renal disease.J Sex Med2008;5:872–877.
13. Soykan A, Boztas H, Kutlay S, Ince E, Nergizoglu G, Dilekoz AY, et al..Do sexual dysfunctions get better during dialysis? Result of a six-month prospective follow-up study from Turkey.Int J Impot Res2005;17:359–363.
14. Filocamo MT, Zanazzi M, Li Marzi V, Lombardi G, Del Popolo G, Mancini G, et al..Sexual dysfunction in women during dialysis and after renal transplantation
.J Sex Med2009;6:3125–3131.