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Saudi Journal of Kidney Diseases and Transplantation
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ORIGINAL ARTICLE Table of Contents   
Year : 2005  |  Volume : 16  |  Issue : 1  |  Page : 33-39
Sexual Dysfunction in Male Patients Undergoing Hemodialysis in Morocco

Nephrology Department, Ibn Rochd Hospital, Casablanca, Morocco

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Sexual dysfunction impairs the quality of life of patients undergoing hemodialysis (HD). The aim of this study was to evaluate the prevalence and the nature of sexual dysfunction in a Moroccan cohort of patients with chronic renal failure (CRF) on HD. This cross-sectional study was carried out with a questionnaire in 86 patients undergoing hemodialysis. Clinical and biological investigations were done. The mean age of our patients was 46.27 ± 15.68 years old. 81.4% of the cases suffered from a decrease in sexual activity after the onset of HD. The decrease or the loss of libido was noted in 59.3% of the cases. Total impotence was present in 22.1% of the cases and 36% reported partial impotence. Ejaculation was present in 86% of the cases. The comparison between the group of patients who had no sexual dysfunction (group I) and the group of those who had this problem (group II) showed significant differences of age, social status and sexual life before HD. Other significant differences were found regarding frequency of intercourses and sexual satisfaction. Group II was divided into 2 subgroups: IIA included patients who had sexual dysfunction before HD and IIB: those who developed it after. The comparison of this subgroups showed that differences were significant regarding age, weight and vascular risk factors (diabetes mellitus, atherosclerosis). Sildenafil was more efficient in the patients of the subgroup IIB. This study suggested that HD was one of many factors causing sexual dysfunction in hemodialysed patients. After this clinical evaluation of sexual dysfunction, we emphasize the value of a global approach of this problem. The use of sildenafil seems to be more valuable in young patients with erectile dysfunction which appeared after long dialysis duration.

Keywords: Sexual dysfunction, Impotence, Chronic renal failure, Hemodialysis.

How to cite this article:
Zamd M, Gharbi MB, Ramdani B, Zaid D. Sexual Dysfunction in Male Patients Undergoing Hemodialysis in Morocco. Saudi J Kidney Dis Transpl 2005;16:33-9

How to cite this URL:
Zamd M, Gharbi MB, Ramdani B, Zaid D. Sexual Dysfunction in Male Patients Undergoing Hemodialysis in Morocco. Saudi J Kidney Dis Transpl [serial online] 2005 [cited 2022 Jan 20];16:33-9. Available from: https://www.sjkdt.org/text.asp?2005/16/1/33/32949

   Introduction Top

Sexual dysfunction is frequent in patients with chronic renal failure (CRF) and seriously impairs their quality of life. Hemodialysis (HD) improves relatively this disturbance. [1],[2] The aim of this study was to perform a clinical analysis of the sexual dysfunction in male patients undergoing hemodialysis. We studied the type, prevalence and factors involved in this disturbance.

   Material and Methods Top

A cross-sectional study was performed with a questionnaire. All the adult males with CRF who were undergoing HD in our unit were included in the study. A free and enlightened consent was obtained from all the patients before the study. Patients under 18 years of age were excluded. Clinical and biological data were collected. Sexual activity evaluation before and after HD were investigated too with a "subjective" estimation of HD effect on sexual performances. The presence of sexual dysfunction was defined as a disturbance of one or more stage of sexual response (desire, erection, ejaculation and orgasm) that impaired the sexual life of patients and induced a sexual dissatisfaction. The patients were interviewed and examined by the same physician (MZ). The efficiency and the safety of sildenafil was tested in patients with erectile dysfunction.

   Statistical Analysis Top

Data were analysed by Epi-Info 5.01 software. Results were expressed in means ± standard error for quantitative variables, in percentages for qualitative variables. Differences between qualitative variables were tested by the x² test and for the quantitative variables by the Student test. Non-parametric tests were used if necessary. Significance threshold was fixed at 5% (p less than 0.05).

   Results Top

Eighty six male patients were included in this study. Their mean age was 46.27 ± 15.68 years (yrs). All of them had a sexual partner before and after HD. The causes of CRF were chronic glomerulonephritis and diabetes mellitus in 30.2% and 10.5% of cases respectively. In 33.7% of cases the underlying cause could not be determined. The patients were treated by HD for 78.84 ± 40.68 months, generally 5 hours twice a week (88.4% of cases). The cellulose acetate membrane was the most frequently used (61.6% of cases). The mean level of haemoglobin was 8.85 ± 1.79 g/dl without erythropoietin (previously or during the study). Arterial hypertension was present in 69.6% of cases. The use of medications that interfere with the different sexual functions has been noted in 18.6% of cases especially central anti-hypertensive drugs (alphamethyl­dopa, clonidine) in 31.3% and cimetidine in 25% of cases. Occasional alcoholism was noted in 39 patients, chronic tobacco addiction in 41 patients. Surgery or endoscopic interventions on the pelvis has been noted in 4.7% of cases.

Sexual Activity

Eighty one patients (94.2% of cases) have had a sexual activity before the start of hemo­dialysis. 48.8% had, 2-3 sexual intercourses per week. After hemodialysis, the persistence of a sexual activity was reported by 69.8% of patients but with a reduction of frequency in 81.4% of them. Analysis of the frequency of intercourses showed that less than one sexual intercourse per month was performed by 51.2% of cases and any intercourse has been achieved during the last 6 months before the interview in 43% of cases [Figure - 1].

The Sexual Dysfunction and Satisfaction

Fifty patients (60.9% of cases) declared a total sexual dissatisfaction or a poor satisfaction. Libido was preserved in 47.7% of cases and absent in 11.6% of cases. The conservation of erection has been noted in 77.9% of cases. A spontaneous erection has been reported by 45.3% of cases, a wake up erection in 57% of cases and a reactive erection (to erotic stimulation) in 75.6% of cases. Complete erection (sufficient rigidity to perform inter­course) was present in 41.9% of cases. It was incomplete in 36% of patients. Close to 3/4 of patients reported the conservation of ejaculation either during their sexual activity (conscious ejaculation: 72.1% of cases) or during sleep (unconscious ejaculations on the basis of an observation at the wakening: 86.0% of cases). Orgasm was reached during a sexual activity in only 70.4% of patients.

Clinical Examination

We noted the absence of secondary sexual characters in 3.5% of cases with a female morphology in 9.3% of cases. Testicular atro­phy (testicles less than 4 cm in its great axis) has been noted in 15.1% of cases. Perineal sensitivity was absent in 3.5% of cases and decreased in 8.1% of cases.

The patients were divided on the basis of their own "subjective" evaluation of the sexual activity in 2 groups:

- Group I consisted of 21 patients (24.4% of cases) without sexual dysfunction and who are satisfied with their sexual life.

- Group II consisted of 65 patients (75.6% of cases) with one or more sexual dysfunction (SD). Within this last group, and according to the date of appearance of SD, we distin­guished 2 subgroups of patients:

  • Subgroup IIA: 10 cases (11.6%) who pre­sented with sexual dysfunction before starting hemodialysis with a mean duration of 16.56 ± 12.7 months. Their sexual dys­function remained after the commence­ment of dialysis
  • Subgroup IIB: 55 cases (64%), who pre­sented with sexual dysfunction after the onset of hemodialysis after a mean duration of 27.18 ± 31.72 months.

Comparison of groups I and II

The comparison between group II and group I revealed significant difference in age (50 ± 15.5 years vs. 34 ± 8.0 years, p=0.00005), sexual activity before HD (100% vs. 76.2%, p=0.0006, more frequent sexual intercourse (55.3% with 2-3 intercourse/week vs. 33.3%, p=0.0005). We noted more diabetic and vas­cular nephropathies in patients in group II (21.5% vs. 4.7%, p = 0.02). We did not note significant differences between the Group I and II regarding HD regimen, clinical exami­nation findings, biologic parameters or the presence or absence of other causes of sexual dysfunction (comorbidity, drug use and pelvic surgery) except a more frequent alcohol ingested in the Group II (52.3% vs. 23.8%, p=0.02).

Comparison of subgroups IIA and IIB

The comparison between patients presenting with sexual dysfunction before (Group IIA) and after starting HD (IIB group), did not reveal significant differences regarding the different parameters of sexual activity, SD frequency, HD regimens, the use of tobacco or drugs affecting sexual function. On the other hand, patients of group IIA, were more recently dialysed (3.4 ± 1.6ys vs 6.7 ± 3.1 vs, p=0.0005). They were significantly older than those of group IIB (62.3 ± 12.6 vs 48.0 ± 15.1 vs, p=0.009), heavier (70.1 ± 16.8 kg vs 60.4 ± 8.6 kg, p=0.04). They had more frequently a female morphology (30.0% vs 5.5%, p=0.04). The diabetic or vascular nephropathies were more frequently present in group IIA (70.0% vs 12.7%, p=0.003), and they had significantly more co-morbidity: hypertension, heart disease, (83.3% vs 20.7%, p=0.01). The performance of a surgical or endoscopic intervention on the pelvis was more frequently seen in group IIA (20% vs 3.6%, p=0.04). The clinical exami­nation revealed a significantly more frequent reduction of perineal sensitivity (30.0% vs 12.7%, p =0.04).

We introduced sildenafil (50 mg tablet half hour before sexual intercourses), randomly, in 10 patients of group II (5 from subgroup IIA and 5 from subgroup IIB) if there was no contraindication to the use the drug. We noted the subjective improvement in all the patients. The efficiency of the drug was, how­ever, different in the 2 subgroups (all the patients of subgroup IIB improved their erectile function vs. 1 patient of the subgroup IIA). We didn't note any side effect of the drug in these 10 patients especially hypotension or headache.

   Discussion Top

Several definitions have been proposed for sexual dysfunction according to its different causes (endocrinological, urological, psycho­logical and neurological). [3] Segraves [4] affirms the absence of operational and clear criteria for definition. Others [5] reserve the term of sexual dysfunction only to sexual behaviour of psychological origin. On the basis of these observations, we defined the sexual dysfunction as "all disturbances of one or more stages of the sexual response that results in a disturbance of the patient's sexual life". The subjectivity of this definition may be a source of imprecision; however, the studied problem is defined exten­sively by subjective elements in the literature. [6]

SD impairs significantly the quality of life of patients with CRF undergoing HD. [8] This is well documented. [1],[2],[7],[8],[9],[10] However, the data remain generally conflicting. According to Binik, [8] the available studies lack rigorous methodology (standardisation of definitions and technical measures). This explains the great variability in the reported prevalence of sexual dysfunction in these patients (20 to 100% of cases); but in most publications the rate exceeds 50% of cases. In our study, the sexual function has been evaluated using two complementary approaches:

The presence of sexual activity and the frequency of sexual intercourse before and after HD with a subjective comparison of these periods. The decrease of sexual activity has been noted in 81.4% of patients. This rate comes closer to those of Pach [10] and Brook: [11] (80% and 64% respectively). Salvatierra et al. reported that the frequency of sexual intercourse of more than once a week decreased from 55% of the cases before to 22% after HD. [12] In our study, the same frequency of sexual intercourse decreased from 74.4% to 30.2% after HD. The absence of any sexual activity in hemodialyzed patients vary from 40% to 57.1% in previous studies. [13] It was 30.2% in our study.

Sexual satisfaction in HD and the presence of sexual dysfunction. These two parameters complement each other and reflect the impact on the patient in things like to self esteem that and relationship with partners. Milde [14] found 65% of HD patients as being sexually In our study, 60.9% of the patients had reduced or totally absent sexual satisfaction under HD. Rodger [15] and Weizman, [16] noted the presence of SD in 79% and 50% of their patients respectively. Our rate was 75.6% of cases.

The significant differences between group I and II, regarding the social and demographic data and of sexual life before HD, would suggest the influence of these factors on the perception of SD. Patients with SD (group II) were older and more active before sexually HD. This finding has not been reported previously in the literature.

Libido disorders in HD patients have been reported by several authors. Their prevalence varies from 12.5 to 65% of cases. [7],[9],[12],[15],[18],[19] In our study 52.3% of patients had a low or absent libido. Orgasm was little studied in patients undergoing HD in previous reports. [1],[9],[10] It was absent in 29.6% of our patients, either by absence sexual activity (21 cases) or by real inorgasmia (3 cases). The erectile dysfunction is the most studied sexual dysfunction. It is present in variable prevalence. The previous reports estimate the prevalence to be from 40 to 82.3% of cases [7],[9],[16],[18],[20],[21],[22],[23],[24] Several

parameters of erection have been considered in the previous studies: degree or percentage of tumescence, length and angle of erection. [24] The features considered in our study were the presence or the absence of erection and its complete or incomplete character. In patients who had no sexual activity, the erectile capacity evaluation has been assessed on the basis of the presence of waking up or spontaneous erection (73.1% among them had waking up erections and 58.3% maintained spontaneous erections). The absence of this type of erection, would be caused by organic pathology of erectile dysfunction. Thirty six percent of cases presented with incomplete and short-lived erections. The significance of this type of erection has not been addressed by the pre­vious publications, outside of the hypothesis that it is consequent to venous leakage. [25]

In the literature, [1],[17] disorders of ejaculation were, the most studied in view of investigating the causes of infertility. Semiologic abnormal­ities of ejaculation were studied in a few reports. Some authors reported the notion of "dry ejaculation" (decrease of volume with a particularly increased viscosity of the semen). [1],[21] The conservation of capacities to ejaculate can be verified on the basis of ejacu­lation in sexual activity (conscious ejaculation) or during the sleep (unconscious ejaculation). In our study, ejaculation was preserved in 86% of our patients. It was rarely reported by authors and its significance was not commented on. [25],[26],[27] The absence of ejaculation during sexual activity has been noted in 24 patients (28%), but half of these had nocturnal ejaculation.

The time of SD appearance has been studied by different authors. [9],[16],[28] Indeed, most authors report the fact that sexual dysfunction occur before the start of HD. HD improves them slightly only and sometimes aggravates them. [9],[16] On the other hand, Procci [25] noted stabilisation and even improvement with HD. In our study, 10 patients (11.6%) improved before the onset of HD. This group of patients (IIA) defers from group IIB by the same factors which are incri­minated in the development of sexual dys­function in the general population. This would lead one to think that HD is only another factor causing SD among many other factors present in these patients such as degenerative vascular disease.

Regarding the pathogenesis of SD, several factors have been generally incriminated. [10] The age seems to be one of the most important factors involved in the HD population. Initial nephropathy, especially diabetic nephropathy and the systemic hyper­tension, have to be considered in the patho­genesis of this disturbance. Alcohol intake is also incriminated in SD development. CRF associated diseases, drugs taken and HD regimens do not seem to be risk factors in the development of SD in our study.

Sildenafil was used with success to treat erectile dysfunction in patients undergoing hemodialysis. [29] Our experience showed differ­ent responses according to the timing of the onset of the disturbance. In fact the patients who had erectile dysfunction before starting hemodialysis showed bad response. This result was predicable as the main cause of erectile dysfunction in these patients was advanced atherosclerosis. Although, many side effects of this drug were noted in hemodialysis patients. [29] We did not note any side effect in our study.

   Conclusion Top

We can conclude that SD in HD patients is a heterogeneous entity. In fact, some patients had already the SD before HD or just after its onset. Those patients had generally vascular abnormalities and the CRF was the result of the evolution of diabetic or vascular nephro­pathy. The HD in this case was only a facili­tating factor. On the other hand, some young patients had developed SD after long duration under HD and it results generally from compli­cations of CRF and HD. Each etiological factor has its importance in the development of SD but the importance of each one differs from one patient and the other. The efficiency of sildenafil seems to be variable and the most important factor of variability of response which should be considered is the moment of the onset of the sexual dysfunction.

   Acknowledgements Top

Dr. Chakib NEJJARI from Biostatistics and Epidemiology Laboratory for his help in statistical analysis.

   References Top

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2.Palmer BF. Sexual Dysfunction in Uremia. J Am Soc Nephrol 1999;10:1381-8.  Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Impotence. NIH Consens statement. 1992 Dec 7-9; 10(4):1-31.  Back to cited text no. 3    
4.Segraves RT. Definitions and classification of male sexual dysfunction. Int J Impot Res 1998; 10Suppl 2:S54-8; discussion S77-9.  Back to cited text no. 4    
5.American Psychiatric Association. Diagnostic and statistical manual of mental disorders (DSM-IV). Fourth edition. Washington, American Psychiatric Association, 1995.  Back to cited text no. 5    
6.Feldman HA, Goldstein I, Hatzichristou DG, Krane RJ, Mckinlay JB. Impotence and its medical and psychosocial correlates: results of the Massachusett Male Aging Study. J Urol 1994;151(1):54-61.  Back to cited text no. 6    
7.Etcheverry M, Tignol J. Sexual dysfunction in males in Long-term hemodialysis. Acta Urol Belg 1989;20(1):207-12.  Back to cited text no. 7    
8.Binik YM, Mah K. Sexuality and end-stage renal disease: research and clinical recommendations. Adv Ren Replace Ther 1994;1(3):198-209.  Back to cited text no. 8    
9.Druecke T. Endocrines disorders in chronic hemodialysis patients. In Hamburger J Adv Nephrol 1981:346-7.  Back to cited text no. 9    
10.Pach J, Waniek W, Hartmann HG. Changes in male sexual function during hemodialysis and after renal transplantation under psy­chiatric aspects. Med Klin 1977;72(6):216-20.  Back to cited text no. 10    
11.Brook AC, Johnston DG, Ward MK, Watson MJ, Cook DB, Kerr DN. Absence of therapeutic effect of zinc in the sexual dysfunction of hemodialysed patients. Lancet 1980;2(8195 Part 1):618-20.  Back to cited text no. 11    
12.Salvatierra O Jr, Fortmann JL, Belzer FO. Sexual function of males before and after renal transplantation. Urology 1975;5(1):64-6.  Back to cited text no. 12    
13.Massry SG, Goldstein DA, Procci WR, Kletzky OA. On the pathogenesis of sexual dysfunction of the uraemic male. Proc Eur Dial Transplant Assoc, 1980;17:139-45.  Back to cited text no. 13    
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15.Rodger RS, Fletcher K, Dewar JH, et al. Prevalence and pathogenesis of impotence in one hundred uremic men. Uremia Invest 1984-85;8(2):89-96.  Back to cited text no. 15    
16.Weizman R, Weizman A, Levi J, et al. Sexual dysfunction associated with hyper­prolactinemia in males and females under­going hemodialysis. Psychosom Med 1983; 45(3):259-69.  Back to cited text no. 16    
17.Alleyne S, Dillard P, McGregor C, Hosten A. Sexual function and mental distress status of patients with end-stage renal disease on hemodialysis. Transplant Proc 1989;21(6): 3895-8.  Back to cited text no. 17    
18.Lawrence IG, Price DE, Howlett TA, Harris KP, Feehally J, Walls J. Correcting impotence in the male dialysis patient experience with testosterone replacement and vacuum tumescence therapy. Am J Kidney Dis 1998;31(2):313-9.  Back to cited text no. 18    
19.Rodriguez Rodriguez R, Burgos Revilla FJ, Gomez Dosantos V, et al. Endocrine changes and sexual dysfunction in kidney transplantation and hemodialysis : compa­rative study. Actas Urol Esp 1996;20(8): 697-701.  Back to cited text no. 19    
20.Altman JJ. Sex hormones in chronic renal failure of the diabetic. Ann Endocrinol Paris 1988;49(4-5):412-7.  Back to cited text no. 20    
21.Breza J, Reznicek J, Pribylincova V, Zvara P. Erectile dysfunctions in patients treated with hemodialysis and kidney transplantation. Bratisl Lek Listy 1993;94(9):489-93.  Back to cited text no. 21    
22.Kaufman JM, Hatzichristou DG, Mulhall JP, Fitch WP, Goldstein I. Impotence and chronic renal failure : a study of the hemodynamic pathophysiology. J Urol 1994;151(3):612-8.  Back to cited text no. 22    
23.Blumberg A, Wildbolz A, Descoeudres C, et al. Influence of 1,25 dihydroxycholecalciferol on sexual dysfunction and related endocrine parameters in patients on maintenance hemo­dialysis. Clin Nephrol 1980;13(5): 208-14.  Back to cited text no. 23    
24.Verma KK, Khaitan BK, Singh OP. The frequency of sexual dysfunction in patients attending a sex therapy clinic in north India. Arch Sex Behav 1998;27(3):309-14.  Back to cited text no. 24    
25.Procci WR, Martin DJ. Effect of mainte­nance hemodialysis on male sexual per­formance. J Nerv Ment Dis 1985;173:366-72.  Back to cited text no. 25  [PUBMED]  
26.Lawrence IG, Price DE, Howlett TA, Harris KP, Feehally J, Walls J. Erythro­poietin and sexual dysfunction. Nephrol Dial Transplant 1997;12(4):741-7.  Back to cited text no. 26    
27.Zofkova I, Sotornik I, Kancheva RL. Adenohypophyseal-gonadal dysfunction in male hemodialyzed patients before and after subtotal parathyroidectomy. Nephron 1996; 74(3):536-40.  Back to cited text no. 27    
28.Bonomini V, Orsoni G, Sorrentino MA, Todeschini P. Hormonal changes in hemodialysis. Blood Purif 1990;8(2):54-68.  Back to cited text no. 28    
29.Seibel I, Poli De Figueiredo CE, Teloken C, Moraes JF. Efficacy of oral sildenafil in hemodialysis patients with erectile dys­function. J Am Soc Nephrol 2002;13(11): 2770-5.  Back to cited text no. 29    

Correspondence Address:
Benyounes Ramdani
Service de Néphrologie, CHU Ibn Rochd, Casablanca
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