Sexual function in ICU survivors more than 3 years after major trauma

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1 Intensive Care Med (2008) 34: DOI /s ORIGINAL Atle Ulvik Reidar Kvåle Tore Wentzel-Larsen Hans Flaatten Sexual function in ICU survivors more than 3 years after major trauma Received: 3 September 2007 Accepted: 26 October 2007 Published online: 28 November 2007 Springer-Verlag 2007 Electronic supplementary material The online version of this article (doi: /s ) contains supplementary material, which is available to authorized users. A. Ulvik ( ) R. Kvåle H. Flaatten Haukeland University Hospital, Department of Anaesthesia and Intensive Care, 5021 Bergen, Norway atle.ulvik@helse-bergen.no Tel.: Fax: A. Ulvik H. Flaatten University of Bergen, Section for Anaesthesiology and Intensive Care, Department of Surgical Sciences, Bergen, Norway T. Wentzel-Larsen Haukeland University Hospital, Centre for Clinical Research, Bergen, Norway Abstract Objective: To study sexual function in trauma patients 3 8 years after discharge from an ICU and to assess determinants of poor sex life. Design and setting: A postal questionnaire survey was conducted in 2006 on a cohort of 325 consecutive adult ICU trauma patients admitted to a university hospital during Patients: Of 210 eligible patients 156 (74%) answered the questionnaires. Mean age was 46 years, and 124 were males. Measurements and results: Sexual function was assessed by a self-report measure, and patients were asked to describe sexual life both currently and prior to trauma. The International Index of Erectile Function evaluated erectile function in males. At follow-up 50% reported sexual function to be unchanged, 41% impaired, and 9% to be better than preinjury status; 34% reported that the trauma impaired current sex life. Erectile dysfunction was found in 27% of men younger than 40 years and 51% of men 40 years or older. Age, being single, Injury Severity Score, and depression were associated with poor sexual function. Of 17 patients experiencing breakdown of a regular relationship 71% reported the trauma to be a significant contributor. Conclusions: At follow-up more than 3 years after injury one-third of our ICU trauma patients reported that the trauma impaired sexual function. Erectile dysfunction was significantly more frequent among men younger than 40 years than found in studies of the normal population. Evaluation of sexual function should be part of long-term outcome assessment after major trauma. Keywords Trauma patients Intensive care Sexual function Erectile dysfunction Long-term outcome Introduction Sexual dysfunction is highly prevalent in the community, ranging from 10% to 52% of men and 25% to 63% of women [1, 2], and has been found to impact significantly on interpersonal functioning and overall quality of life [2]. Although patients report sexual function to be important [3], symptoms of sexual dysfunction after major illness are seldom sought by medical practitioners [4]. Measuring quality of life has been recommended for evaluation of long-term outcome in critically ill patients [5], but the available knowledge concerning sexual problems after intensive care is limited [6]. A recent study found that symptoms indicating sexual dysfunction are common in patients recovering from critical illness [7]. Almost one-half of the patients were not satisfied with their sex life the first year after discharge from an intensive care unit (ICU). Thus a complete assessment of quality of life should perhaps include sexual functioning when evaluating long-term outcome after intensive care. The aim of the present study was to examine whether sexual function was impaired in ICU trauma patients 3 8 years after injury. If a reduction in sexual function was found, a further aim was to assess possible patient-,

2 448 ICU-, and trauma-related determinants of poor sex life. In addition, the relationship between sexual life and anxiety/depression at the time of follow-up was assessed. Some of the results were recently published in abstract form [8]. Patients and methods Setting and study population This study was performed in a mixed 10-bed ICU in a university hospital. The cohort comprised 325 consecutive trauma patients above 18 years of age admitted to our ICU in the period Foreign citizens (n = 16) were not included due to difficulty with follow-up. Detailed analyses of survival, quality of life, and functional status for this cohort of trauma patients have been described elsewhere [9, 10, 11]. A postal questionnaire survey among survivors was conducted in December The study was approved by the regional ethics committee. Scoring systems and questionnaires To evaluate sexual function we used a questionnaire (see Electronic Supplementary Material, ESM, Table E1) based on a sexual dysfunction screening questionnaire developed by Quinlan et al. [6, 7]. The patients were asked to describe their current sex life and, retrospectively, their sex life prior to trauma choosing one of five possible responses; poor, not very good, quite good, good, or very good. We also asked whether they considered the trauma had altered their current sex life. In addition, our questionnaire covered marital status, the need felt by the patient to discuss sexual problems with a physician, and whether any physician had sought information or given advice regarding sexual function after injury. Male sexual function was also evaluated by assessment of erectile function at followup. We used the International Index of Erectile Function (IIEF, see ESM, Table E2), a multidimensional self-report instrument [12]. Erectile dysfunction (ED) is defined as the persistent inability to achieve or maintain an erection sufficient for satisfactory sexual performance [13]. According to standard IIEF definitions ED was classified into five categories: severe, moderate, mild to moderate, mild, and no ED. The Hospital Anxiety and Depression Scale (HADS) is a questionnaire that is widely used to measure anxiety and depression in somatic and psychiatric patients as well as in general populations [14, 15]. The HADS consists of 14 items, 7 for anxiety (HADS-A subscale) and 7 for depression (HADS-D subscale). Each item is scored from 0 to 3. Anxiety disorder was defined as a HADS-A score of 8 or higher and depression was defined as a HADS-D score of 8 or higher. The Sequential Organ Failure Assessment (SOFA) score assesses the function of six different organ systems: respiratory, cardiovascular, renal, hepatic, neurological, and hematological [16]. During the ICU stay each organ system is evaluated daily and given a score from 0 (normal function) to 4 (most abnormal). Total maximum SOFA score, a measure of overall organ dysfunction/failure, is the sum of the highest score achieved in each of the six organ systems during the ICU stay. The Simplified Acute Physiology Score (SAPS) II is a scoring system that stratifies severity of illness within the first 24 h after ICU admission [17]. The Injury Severity Score (ISS) is an anatomical description of injury [18]. Data collection The baseline characteristics of age, gender, SOFA score, SAPS II, and length of stay in the ICU were retrieved from our prospectively collected ICU database. Missing values were filled in from patient records as required. The ISS has not been part of the routine ICU database, and was therefore calculated in retrospect using the 1990 version (update 1998) of the Abbreviated Injury Scale (AIS). Severe head injury was defined as a head AIS score 4. Survival data were found in the Norwegian Population Registry. At follow-up in December 2006, 241 patients were still alive (Fig. 1). Twenty-three patients were excluded from the study: 14 because they were not able to participate due to sustained injury, 8 due to severe chronic psychiatric disorders or dementia, and one due to imprisonment. Eight patients were lost to follow-up, leaving 210 patients eligible for the study. A letter with information about the study underlining voluntary participation, accompanied the questionnaires. A reminder was sent twice to nonresponders. At follow-up 3 8 years (median 69 months) after injury 210 patients were eligible for the study, and 156 (74%) answered the questionnaire (Fig. 1). The injuries were due mainly to traffic accidents (58%) and falls (33%). Severe head injury was found in 44 patients, pelvic trauma in 27, and 9 patients had a spinal cord injury. Table 1 compares baseline characteristics in the 156 responders and the 54 nonresponders; responders were older and had a higher SAPS II than nonresponders while there was no statistically significant difference between responders and nonresponders with respect to gender, length of ICU stay, SOFA score, or ISS. Statistical analysis Baseline characteristics of responders and nonresponders were compared using the exact χ 2 test and the exact Mann Whitney test. Patient evaluation of sex life prior to and 3 8 years after injury were compared by a marginal homogeneity test. The following variables were investigated as possible determinants of poor sex

3 449 Fig. 1 Patients included in/excluded from the study Table 1 Baseline characteristics of trauma patients treated in the intensive care unit (SOFA, Sequential Organ Failure Assessment; ISS, Injury Severity Score; SAPS, Simplified Acute Physiology Score) Responders (n = 156, 74%) Nonresponders (n = 54, 26%) p Male/female 124/32 49/ a Mean age at follow-up, years (range) 46 ± 16 (22 88) 40 ± 16 (22 87) b Mean length of ICU stay, days (range) 5.1 ± 5.6 ( ) 3.3 ± 4.0 ( ) b Mean total max. SOFA (range) 6 ± 4 (0 17) 6 ± 4 (1 14) b Median ISS (range) 25 (4 54) 22 (9 45) b Mean SAPS II (range) 31 ± 14 (6 65) 27 ± 14 (6 62) b a Exact χ 2 test, b Exact Mann Whitney test life (as reported by the patients on a five-point Likert scale) at follow-up: specific types of injury, age, gender, marital status, time since trauma, SOFA score, length of stay in ICU, ISS, depression, and anxiety. The exact Mann Whitney test was used for univariate analyses of the relationship between evaluation of current sex life and severe head injury, pelvic trauma, and spinal cord injury. The relationship between patients rating of their current sex life and age, gender, marital status, time since trauma, total maximum SOFA score, length of stay in ICU, ISS, depression, or anxiety was analyzed by ordinal logistic regression (adjusted for rating of sex life prior to trauma). Ordinal logistic regression was also performed to analyze the association between erectile dysfunction (ED) and age. The relationship between ED and satisfaction with current sex life was investigated by the exact Jonckheere Terpstra test. Statistical analyses were performed using SPSS 14 (SPSS, Chicago, IL, USA) and R (The R Foundation for Statistical Computing, Vienna, Austria). A p value less than 0.05 determined statistical significance, and all confidence intervals (CI) are 95%. Results Table 2 shows the distribution of patients evaluations of their sex life at the time of follow-up and prior to trauma. Overall 41% of patients (n = 60) reported a lower rating of their sex life at follow-up than prior to the trauma ( p < 0.001). However, 9% rated their current sex life

4 450 higher, and 50% reported no change. In 34% (n = 50) there was no evident reduction in sex life related to the trauma; 3% considered that the trauma had made their sex life better, while 18% had an altered sex life caused by the trauma but neither worse nor better. Of the 50 patients who experienced impaired sex life caused by the trauma 19 reported this to be caused by physical factors, 7 by psychological factors, and 24 as a result of both physical and psychological factors of the trauma. Table 3 shows erectile function evaluated in the male patients using the IIEF questionnaire. Of the 124 men participating in the study 120 completed this questionnaire. Eighteen men reported no sexual activity during the last 4 weeks, of whom 12 also reported low or very low confidence in achieving an erection. These 12 were therefore classified as having severe ED. The other six men reporting no sexual activity could not be further evaluated by the IIEF questionnaire, leaving 114 men for complete ED evaluation. Rating of current sex life was not found to be significantly related to severe head injury, pelvic trauma, or spinal cord injury. Assessed by HADS, 64% (n = 96) had no anxiety disorder or depression at follow-up, while 12% had anxiety, 5% had depression, and 19% had both anxiety and depression. Table 4 shows the relationship between quality of sex life at follow-up and various demographic and traumarelated variables. Patient age was associated with quality of sex life in that the odds for a poor sex life increased 1.66 times per 10 years increase in age. Single marital status increased the risk of poor sex life by a factor of ISS increased the odds for a poor sex life by 4% per point. Depression was strongly related to a lower rating of present sex life, and increased the odds of poor sex life 3.39 times. No association was found between evaluation of sex life and gender, time since trauma, SOFA score, length of ICU stay, or anxiety. Erectile function was significantly related to age (p < 0.001). A 10-year increase in age increased the odds of ED by 64%. Erectile function was also significantly related to evaluation of sex life at follow-up (p < 0.001). Of the 82 patients reporting no or mild ED 14 described their sex life as very good, 32 as good, 22 as quite good, 10 as not very good, and four as poor. Of the 21 patients reporting moderate or severe ED one described his sex life as good, two as quite good, seven as not very good, and 11 as poor. Table 5 shows marital status at the time of trauma and at follow-up. Of the 17 patients experiencing breakdown of a regular relationship already established at the time of Table 2 Trauma patients evaluations of sex life before and 3 8 years after injury. There was a significant reduction in patients rating of their sex life after injury (p < 0.001, marginal homogeneity test) Table 3 Erectile function in male patients 3 8 years after major trauma (ED, erectile dysfunction; IIEF, International Index of Erectile Function) Table 4 Determinants of poor sex life 3 8 years after major trauma At follow-up Poor Not very Quite Good Very good Prior to trauma good good Marginal Poor (6%) Not very good (9%) Quite good (23%) Good (41%) Very good (21%) Marginal 19 (13%) 29 (20%) 36 (25%) 43 (30%) 18 (12%) 145 ED evaluated by IIEF % < 40 years of age (n = 55) % 40 years of age (n = 59) No ED Mild ED 9 14 Mild to moderate ED 9 8 Moderate ED 4 5 Severe ED 5 24 Odds ratio (95% CI) a Gender (male vs. female) 1.52 ( ) Age (per 10 years) 1.66 ( ) < Single marital status vs. married/cohabitant 2.85 ( ) Time since trauma (years) 0.89 ( ) Total maximum SOFA score 0.99 ( ) Length of stay in ICU (days) 0.96 ( ) ISS 1.04 ( ) Depression 3.39 ( ) Anxiety 1.27 ( ) p a Low vs. high rating for sex life after trauma; proportional odds ordinal logistic regression, with adjustment for evaluation of pretrauma sex life

5 451 Table 5 Marital status and breakdown of relationships after major trauma: number of positive answers/total number of answers to the question Married/cohabitant at the time of trauma 73/149 (49%) Breakdown of relationship after trauma 17/73 (23%) Breakdown of relationship partly caused by the trauma 10/14 (71%) a Married/cohabitant at follow-up 84/152 (55%) a Of the 17 patients who were in a regular relationship at the time of trauma and experienced a breakdown of that relationship 3 did not report whether the trauma was a significant contributor to the breakdown trauma six were involved in a new relationship at followup. A total of 27 patients established a new regular relationship postinjury. Nine percent of the patients answered that they felt the need to discuss sexual problems with a physician postinjury. Five percent reported that a physician had questioned them about symptoms of sexual problems after the trauma. Discussion The literature specifically addressing sexual problems after intensive care is scarce [6, 7], although sexual function has been studied after injuries of the brain [19, 20], spinal cord [21], and pelvis [22] and after burns [23]. To evaluate sexual function is not simple. What is meant by sexual life or sexual function may vary considerably between individuals. The evaluation of sex life may therefore be very subjective. In this study three different approaches were used to assess sexual function in ICU survivors 3 8 years after major trauma. First, the patients were asked to rate their sex life at follow-up and, retrospectively, prior to trauma. According to the answers, there was a significant reduction in sexual function after injury. Using the same rating scale questions Griffiths et al. [7] found that 43.6% of patients were less satisfied with their sexual function up to 1 year after discharge from a general ICU. Second, to reveal whether a long-term reduction in sexual function was actually a consequence of the trauma we also asked the patients whether they considered that the trauma had altered their current sex life. One-third of patients reported that they had impaired sexual function caused by the trauma. Thus our findings are in accordance with earlier observations that satisfaction with sex life decreases after major trauma [19, 20, 21, 23]. Third, in male patients erectile function was assessed by the IIEF questionnaire, a more objective and consistent measure of sexual function than merely a general rating of sexual life [12]. Erectile dysfunction is the main reason for impaired male sexual activity [24]. In our study there was a strong relationship between erectile function and selfevaluation of sex life, although sexual function may also be reduced in patients with normal erectile function. Almost all men with moderate or severe ED rated their sex life as poor or not very good. We also found that 27% of men younger than 40 years reported some degree of ED. This is a much higher prevalence than the 1 9% found in population-based studies [25, 26] (p < by χ 2 test for comparison with a 9% population prevalence). Thus ED may be a substantial problem for younger men several years after major trauma. One-half of the men aged 40 years or more had ED, and this is in accordance with the prevalence reported in the normal population by the Massachusetts Male Aging Study [27]. In a Norwegian study of ED in men above 40 years, 20% reported moderate dysfunction, and 13% had complete ED [28]. Although ISS was associated with poor sex life, we found no relationship between poor sexual function and specific types of injury. The latter may be explained by the limited number of patients in our study. It has been found that after traumatic brain injury patients report somatic and psychological problems with negative impact on sexual interest and activity [20]. A study of 63 patients with spinal cord injuries found that only 44% of women and 38% of men were satisfied with their sex life [21]. Age was a determinant of poor sex life in the present study. Low sexual interest and erection problems are age-dependent disorders, possibly resulting from physiological changes associated with the aging process [1]. After traumatic brain injury older age has been shown to be a predictor of sexual difficulties [20]. An interesting finding in our study was the occurrence of possible anxiety disorder and depression. As many as 36% of the patients reported symptoms consistent with mental disorders. In comparison, the 1-year prevalence of anxiety and depression in the United States has been estimated at 14.9% [29], and in a Norwegian study of the general population depression was found in 11% [30]. Our finding suggests that mental disorders may be a problem for several years after major trauma. Moreover, we also found depression to be strongly related to poor sexual function. A relationship between depression and sexual dysfunction has been found after traumatic brain injury [20], and in a study of ICU survivors sexual dysfunction was associated with symptoms of posttraumatic stress disorder [7]. In addition, depression has been demonstrated in a number of studies to be associated with ED [27, 31]. Seventeen (23%) of the 73 patients who were in a regular relationship at the time of trauma experienced breakdown of the relationship within 3 8 years. In the majority of these cases the trauma was reported as a significant contributor to the breakdown. Major trauma may result in significant stress for both the patient and family members, and

6 452 divorce rates among head injury patients has been reported as high as 40% [19]. Thus information after major trauma should also aim to help patients and partners cope with psychological and marital problems. In our study a total of 27 patients established a new regular relationship after injury, and being married/cohabitant was strongly associated with better quality of sexual life. The response rate in the present study was 74%. Responders were older and had a higher SAPS II than nonresponders. These differences may have biased the results towards a lower rating of current sex life and higher prevalence of ED. To reveal a possible impairment in sexual function after major trauma the ICU trauma patients were used as their own controls. Such rating of sex life in retrospect potentially introduces recall bias. Regarding prevalence of ED the trauma patients were compared with available data from the normal population. This is not an optimal comparison. A large population-based study found that trauma patients had more preexisting morbidity than the general noninjured population [32]. A further limitation in our study is that the long follow-up time makes confounding from other causes of sexual dysfunction possible. In conclusion, at follow-up more than 3 years after injury one-third of our ICU trauma patients reported that the trauma impaired sexual function. ED was significantly more frequent among men younger than 40 years than in the normal population. Assessment of sexual function should be included in the long-term follow-up after major trauma. References 1. Laumann EO, Paik A, Rosen RC (1999) Sexual dysfunction in the United States: prevalence and predictors. JAMA 28: Rosen RC (2000) Prevalence and risk factors of sexual dysfunction in men and women. Curr Psychiatry Rep 2: Read S, King M, Watson J (1997) Sexual dysfunction in primary medical care: prevalence, characteristics and detection by the general practitioner. 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