Changes in Sexual Behavior After Orthopedic Replacement of Hip Or Knee in Elderly Males Ð a Prospective Study

Changes in sexual behavior after orthopedic replacement of hip or knee in elderly males Ð a prospective study

T Nordentoft1*, J Schou2 and J Carstensen3

1Department of Orthopedic Surgery, Herlev Hospital, University of Copenhagen, Denmark; 2Urology, Herlev Hospital, University of Copenhagen, Denmark; and 3Department of Orthopedic Surgery, Koege Hospital, Denmark

The aim of this study was to investigate two questions: Does arthroplastic surgery affect the patient's status as being sexually active; and if patients are sexually active, does surgery affect their erectile function? The study was designed prospectively and the patients ®lled in a questionnaire concerning sexuality and erectile function before and 6 months after alloplastic hip- or knee surgery. Ninety-nine males were included, mean age 70.6 y. The results demonstrate that 17% of patients lost a sexual activity that they had preoperatively, and no one regained sexual activity after surgery. A correlation between increasing age and risk of losing sexual activity was demonstrated. 26.1% lost a normal erectile function they had preoperatively, while 6.7% regained normal erections. A similar correlation between increasing age and increased risk was demonstrated. From this study of elderly males undergoing orthopaedic alloplastic surgery it is concluded that the risk of losing sexual activity and erectile capability is increased after surgery, and especially in the group where sexual functions are already impaired. International Journal of Impotence Research (2000) 12, 143±146.

Keywords: sexual activity; erectile dysfunction; arthroplasty; surgery; age

Introduction After informed consent, all patients ®lled in a questionnaire before and 6 months after surgery. Patients suffering from osteoarthrosis in hip or knee experience a decrease in all aspects of quality of life Questionnaire including sexual function.1±5 There has been little investigation of the in¯uence of arthroplasty on the sexual function as a whole and no studies have been At the time of the study, there was no international made to evaluate the in¯uence of arthroplasty on validated and accepted questionnaire such as The erectile function. Only a few publications exist on International Index for Erectile Function.6 Further- the in¯uence of general surgery on sexual activity or more, no questionnaire in Danish existed. Therefore, erectile function. The purpose of this investigation a questionnaire was devised for this study. On the was prospectively to estimate changes in sexual front page of the questionnaire the patient could behavior in elderly males undergoing total hip or state either if they had no sexual activity at all knee replacement because of osteoarthrosis. (including any libido, erection, masturbation or coitus), or if they did not want to participate in the study. If the patient agreed to participate, and still Patients and study design had remaining sexual activity, he ®lled in the questionnaire which consisted of the following questions concerning erectile function. Study population A. `Do you experience dif®culties in obtaining full erection when you want it', and B. `Do you experience dif®culties in maintaining an erection Patients suffering from osteoarthrosis in hip or knee until orgasm during sexual intercourse' (Possible scheduled for elective total hip or knee replacement. answers: 1. Never; 2. Occasionally (less than 25% of the times); 3. Approximately 50% of the times; 4. Often (75% of the times); 5. Always). Before using the questionnaire in the study, it was *Correspondence: T Nordentoft, Department of Surgery, Glostrup Hospital, University of Copenhagen, Ndr. Ringvej, tested on 10 elderly patients to see if anything was 2600 Glostrup, Denmark. unclear. After some corrections it was re-tested and Received 3 September 1999; accepted 2 February 2000 found to be satisfactory. Orthopedic replacement of hip or knee T Nordentoft et al 144 Patients Table 2 Sexual activity pre- and postoperatively

Sexual 7 Sexual During a one year period 99 consecutive patients Pre=postoperative activity postop. activity postop. Total were recruited from four departments of orthopedic sexual activity preop. 30 (56.6%) 9 (17.0%) 39 surgery in the Copenhagen area. Exclusion criteria: 7 sexual activity preop. 0 (0%) 14 (26.4%) 14 age < 45 y, active malignant disease, incapacity to Total 30 23 53 ®ll in the form (blindness, dementia). Preoperatively only one patient had to be excluded increased, 7 decreased sexual activity. (concomitant malignant disease). Of the remaining 98 patients, 27 did not want to participate. activity revealed how many patients regarded Six months later similar questionnaires were themselves as being sexually active at all (including mailed to 71 patients and 59 replies were obtained any libido, erection, masturbation or coitus) pre- (answering percent: 81.9%). Six patients had to be and postoperatively, and if any changes for the excluded (two deaths, two would not ®ll in second individual patient were registered. This calculation form and two for other reasons), but 53 answered the was based on the patient's statement on the front second time. For demographic data see Table 1. page of the questionnaire. The patients' erectile function were categorized pre- and postoperatively to see if there was any Control group change. This was based on the questions concerning erectile function. Since there was no generally accepted de®nition of normal erection it was No control group was included, but in a study of de®ned as `the ability to obtain and maintain an elderly men in Copenhagen it was found that 3% erection until orgasm in at least 75% of the times spontaneously developed erectile dysfunction dur- desired'.7 This means that to be classi®ed as having ing a period of 6 months.6 a normal erectile function, the patients had to answer 1 or 2 in both questions (see questionnaire in study design). Statistics

Students t-test were used for comparison of groups. Sexual activity

The data show that 17.0% lost a sexual activity they Ethics had preoperatively, while no patients being sexually inactive preoperatively regained any activity. A total The study design was approved by the local ethics of 83% were unchanged in that 56.6% still had a committees. sexual activity postoperatively while 26.4% remained inactive. The group of patients without any sexual activity (n 14) was signi®cantly older Results than the patients with a sexual activity pre- and postoperatively (n 30) (P < 0.01). The group who lost their sexual activity (n 9) was also signi®- The data were analysed regarding sexual activity as cantly older than the group who remained sexually well as erectile function. The analysis of the sexual active (n 30) (P < 0.01). See Table 3.

Table 1 Demographic data: age of the subpopulations in the study Erectile function

First questionnaire Mean age (y) The results above outline two interesting subpopu- Did you want to participate (n 27) 69.9 Excluded, ®rst questionnaire (n 1) 79.1 lations for further study, namely the nine patients Included (n 72) 70.0 Included, no sexual function (n 21) 73.8 Table 3 Mean age (range) related to sexual activity pre- and Included, preserved sexual function (n 51) 68.3 postoperatively Second questionnaire Sexual ± Sexual Lost to follow-up (n 13) 67.1 activity postop. activity postop. Returned questionnaire (n 59) 70.6 Excluded, second questionnaire (n 6) 74.3 Sexual activity preop. 67.0 (48 ± 84) 75.2 (70 ± 79) From these no sexual function (n 23) 74.4 7 Sexual activity preop. ± 74.0 (64 ± 85) From these preserved sexual function (n 30) 67.0 increased, 7 decreased sexual activity.

International Journal of Impotence Research Orthopedic replacement of hip or knee T Nordentoft et al 145 losing their sexual activity and the 30 patients and women (average age 65 y, range 20 ± 79 y) remaining sexually active. It was calculated how suffering from arthrosis of the hip joint Wiklund many of these patients who had normal erections and Romanus showed that total hip arthroplasty had pre- and postoperatively according to the de®nition bene®cial effect on all functions concerning quality (see Table 4). of life including sexual function.13 After this classi®cation, the data show that 26.1% To our knowledge the in¯uence of hip or knee lost a normal erectile function they had preopera- replacement speci®cally on erectile function has tively, while 6.7% (one patient) regained normal never been investigated. erections. The patients with unchanged abnormal Some surgical procedures on the pelvic organs erections (n 15) were signi®cantly older than the have been demonstrated to increase the risk of patients with normal erections pre- or=and post- erectile dysfunction (ie TURP, operation for rectal operatively (n=24) (P < 0.001). Again, the group of cancer)14 ± 17 probably due to neurovascular damage patients who lost their normal erectile function and various studies show that increasing age (n 6) were signi®cantly older than the patients enlarges this risk: Burniham et al 16 found in a who continued with normal erectile function group of males who had undergone rectal excision, (n 17) (P < 0.02) (see Table 5). that the risk of developing erectile dysfunction after the operation was much higher among older patients (more than 45 y-old) than among the younger patients. Libman et al 18 demonstrated that the Discussion negative impact of TURP on sexual function and erectile function was more pronounced in a group older than 65 y compared with a group less than It is well-known that patients suffering from osteo- 65 y-old. Linder et al 19 have found similar results. arthrosis in hip or knee experience a decreases in Whether any major surgery unrelated to the quality of life.5,8 Total hip or knee replacement pelvic organs in¯uences the erectile function has increases quality of life for these patients.8,9 ± 13 only been scarcely investigated. It is more probable Part of the decrease in quality of life is related to that especially elderly males or others with a decreased sexual function or other sexual weakening erectile function are more likely to problems.1±5 experience problems after such events. The in¯uence of arthroplasty on the sexual Libman et al 20 compared the in¯uence of TURP function has been investigated in the following versus inguinal hernia repair on sexual function in studies. Currey showed, in a retrospective study of elderly males, and found that the groups experi- younger patients with osteoarthrosis of the hip, enced a similar reduction in sexual function and some bene®cial effect of hip replacement on sexual erectile function, indicating that the deterioration life2 and Todd et al 3 showed in a retrospective was due to an aging process and surgery in general. study of middle-aged (average 60 y) patients with In a prospective study of 115 heart-transplanted osteoarthrosis of the hip decreased sexual problems men (average age 47.9 y, range 24 ± 64 y), Mulligan after Charnley arthroplasty. In another retrospective et al 21 found that libido increased after operation study of 86 patients (average age 57 y, range 20 ± but the risk of developing erectile dysfunction 70 y) who had a successful total hip replacement, increased. This risk was positively correlated to Stern et al found that 46% had sexual dif®culties old age. In a study of the impact of limb amputation preoperatively whereas only 1% experienced this on sexual function, Williamson and Walters22 found postoperatively.4 In a prospective study of 55 men that high age was related to negative impact on sexual function. In this study, we have demonstrated a negative Table 4 Normal=abnormal erectile function pre- and postoperatively impact on sexual activity and especially on erectile function in elderly males undergoing total hip or Postop. Postop. Changes knee replacement. These changes cannot be ex- normal abnormal Total (%) plained as an effect of time (increasing age) since Preop. normal 17 6 23 26.1% 26.1% of the studied patients lost a preexisting Preop. abnormal 1 15 16 6.7% erectile function and only 3% were expected to do Total 19 20 39 so during the observation period.7 The loss of erectile function cannot be explained physiologi- cally from the current knowledge. Maybe the loss of Table 5 Mean age (range) related to normal=abnormal erectile erectile function can be explained from a still function pre- and postoperatively unknown physiological mechanism, but from this Postop. normal Postop. abnormal and other studies20 it seems likely that any major operation might decrease the erectile function at Preop. normal 62.8 (50 ± 74) 72.2 (60 ± 78) Preop. abnormal 78.0 (1 patient) 74.5 (59 ± 85) elderly men who already have a vulnerable erectile function.

International Journal of Impotence Research Orthopedic replacement of hip or knee T Nordentoft et al 146 Sexual function after hip replacement has pre- 2 Currey HLF. Osteoarthrosis of the hip joint and sexual viously been studied as described above. In contrast function. Ann Rheum Dis 1970; 29: 488 ± 492. 3 Todd RC et al. Low friction arthroplasty of the hip joint and to the present study, most of these studies show an sexual activity. Acta Ortop Scand 1973; 44: 690 ± 693. improved sexual function after the operation.2,3,4,13 4 Stern-SH et al. Sexual function after total hip arthroplasty. This difference might be explained by various Clin Orthop 1991; 269: 228 ± 235. reasons. First, this study has been made on an older 5 Wright JG, Rudicel S, Feinstein AR. Ask patients what they want. Evaluation of individual complaints before total hip population than in the former studies. Second, most replacement. J Bone Joint Surg Br 1994; 76: 229 ± 234. of the earlier studies have been made retrospec- 6 Rosen CR et al. The International Index of Erectile Function tively. Third, the term `sexual function' is not well (IIEF): a multidimensional scale for assessment of erectile de®ned, neither in general nor in the refereed dysfunction. Urology 1997; 49: 822 ± 830. studies, which introduces many problems when 7 Schou J. Prostatectomy and impotence. PhD thesis. 1995, Copenhagen University, Denmark. comparing studies on sexual function. 8 Borstlap M, Zant JL, Van-Soesbergen M, Van-der-Korst JK. In contrast to `sexual function', erectile func- Effects of total hip replacement on quality of life in patients tion=dysfunction is easier to de®ne, and thus more with osteoarthritis and in patients with rheumatoid arthritis. substantial to investigate. In the present study, we Clin Rheumatol 1994; 13: 45 ± 50. found a negative impact of hip- or knee replacement 9 O'Boyle CA et al. Individual quality of life in patients undergoing hip replacement. Lancet 1992; 339: 1088 ± 1091. on erectile function in elderly males. Furthermore, 10 Pitson D et al. Effectiveness of knee replacement surgery in we ®nd that the risk of losing sexual activity and= arthritis. Int J Nurs Stud 1994; 31: 49 ± 56. or normal erectile function after the operation, 11 Laupacis A et al. The effect of elective total hip replacement increases with age. This topic has never been on health-related quality of life. J Bone Joint Surg Am 1993; 75: 1619 ± 1626. investigated before but, as described above, previous 12 Cleary PD et al. Using patient reports to assess health-related studies indicate that major surgery decreases quality of life after total hip replacement. Qual Life Res 1993; erectile function in elderly males.20 ± 22 2: 3 ± 11. From the results of the present study and the 13 Wiklund I, Romanus B. A comparison of quality of life before and after arthroplasty in patients who had arthrosis of the hip refereed literature we conclude that males who are joint. J Bone Joint Surg Am 1991; 73: 765 ± 769. having an increased risk of developing erectile 14 Bennet AE, Melman A. The epidemiology of erectile dysfunc- dysfunction because of age, further increase this tion. Urol Clin North Am 1995; 22: 699 ± 709. risk by undergoing total hip or knee replacement. It 15 Levectis J et al. Bladder and erectile dysfunction before and is likely that any major surgery may have the same after rectal surgery for cancer. Br J Urol 1995; 76: 752 ± 756. 16 Burnham WR, Lennard-Jones JE, Brooke BN. Sexual problems effect on elderly males. among married ileostomists. Gut 1977; 18: 673 ± 677. 17 Boemers TM, van Gool JD, de Jong TD. Tethered spinal cord: the effect of neurosurgery on the lower urinary tract and male sexual function. Br J Urol 1995; 76: 747 ± 751. Acknowledgements 18 Libman E et al. Transurethral prostatectomy: differential effects of age category and pre-surgery sexual function on We would like to thank the departments of ortho- postprostatectomy sexual adjustment. J Behav Med 1989; 12: pedic surgery at Herlev, Glostrup, Koege and 469 ± 485. Hilleroed hospitals for their participation in the 19 Lindner A et al. Effects of prostatectomy on sexual function. recruitment of patients. Urology 1991; 38: 26 ± 28. 20 Libman E et al. Prostatectomy and inguinal hernia repair: a comparison of the sexual consequences. J Sex Marit Ther 1991; 17: 27 ± 34. References 21 Mulligan T et al. Sexual function after heart transplantation. J Heart Lung Transplant 1991; 10: 125 ± 128. 22 Williamson GM, Walters AS. Perceived impact of limb 1 Hamilton A. Sexual problems in arthritis and allied condi- amputation on sexual function: a study of adult amputees. tions. Int Rehab Med 1981; 1: 38 ± 41. J Sex Res 1996; 33: 221 ± 230.

International Journal of Impotence Research