Evaluation of sexual function during Crohn disease according to anoperineal lesions

sabbah meriam |

La tunisie chirurgicale - 2019 ; Vol 2019

Resumé

Few data exist on sexual dysfunction in patients with Crohn's disease with ano-perineal lesions, particularly in Tunisia, probably since sexuality remains a taboo subject in the doctor-patient relationship. The aims of our study were to evaluate the prevalence of sexual disorders in patients with Crohn's disease with ano-perineal lesions and to look for predictors of the occurrence of these disorders.

Methods: A cross-sectional prospective study including all patients with Crohn's disease with active sexuality followed in the Gastroenterology department of Habib Thameur Hospital between January and June 2018 was performed. All patients gave their oral informed consent before completing the questionnaires.Patients<18 years of age, with no active sexuality, or experienced sexual dysfunction prior to the diagnosis of Crohn's disease were not included in the study.Sexual dysfunction was assessed on the International Index of Erectile Function (IIEF) score in men and on Female Sexual Function Index (FSFI) in women. Prevalence of sexual dysfunction was compared in patients with Crohn's disease presenting active anoperineal lesions compared with controls without active anoperineal lesions.

Results: Thirty patients were included. Mean age was 45 years [18-65] and the sex ratio was 0.875 [M / F = 14/16]. Seven patients were single and 23 were married. Average duration of disease progression was 9.8 years [1-20]. Active ano-perineal manifestations were objectified in 9 patients (30%). Anxiety, a depression were objectified in respectively 7 and 9 patients. Mean fatigue score was 28.9 [9-55]. Erectile dysfunction was observed in 7 men (50%). It was mild (n = 1), mild to moderately severe (n = 3), moderately severe (n = 1), and severe (n = 2). In women, sexual dysfunction (FSFI score> 26.55 was observed in 100% of cases (n = 16) with a score <26.55 (mean 17.3 [2.6-24.4]). Comparing the prevalence of sexual disorders according to the presence of active ano-perineal lesions, we did not find any significant difference. Moreover, we did not find any predictors of the occurrence of sexual dysfunction in patients with Crohn with ano-perineal lesions.

Conclusion:Sexual dysfunction is common in Crohn's disease and probably underdiagnosed. It affects half of the men and all women in our study. An adapted medical and psychological management is necessary in these young patients in full sexual activity. However, the presence of anoperineal lesions does not seem to affect the occurrence of these disorders.

Mots Clés

sexual function

Introduction :

Quality of life of patients now occupies a central place in the global management of Crohn's disease. This concept associates several dimensions of the patient's life: physical, psychic, intimate, social, professional functioning, mental health, and perception of illness [1].

Sexuality is a major determinant of quality of life [2], especially in chronic inflammatory bowel disease (IBD), which is a chronic condition, affecting mainly adolescents or young adults in construction of their sexual identity. Thus, these patients often have an impairment of their body image related to either the side effects of drugs (especially corticosteroids) or surgery, or to the manifestations of the disease (ano-perineal lesions, dermatological lesions) [3].

Few data exist on sexual dysfunction in patients with Crohn's disease and especially in those with ano-perineal lesions. This subject has never been discussed in Tunisia, probably because the private life is still a taboo subject difficult to approach  in the doctor-patient relationship.

The aims of our study were to compare the prevalence of sexual disorders in patients with Crohn's disease according to the presence of anoperinal lesions and to identify the factors associated with sexual disorders in patients with Crohn's disease with active ano-perineal manifestations.

Article

METHODS

A prospective cross-sectional study over a period of 6-month (January - July 2018) in the Department of Gastroenterology of Habib Thameur Hospital of Tunis was conducted.

All patientspresenting Crohn's disease (diagnosis made on clinico-biological, endoscopic, morphological and histological arguments)were included. Patients were divided into two groups according to the presence or absence of active ano-perineal lesions: Group 1: absence of active ana-perineal lesions and Group 2: presence of active ano-perineal lesions

Patients younger than 18 years, without active sexual activity, with a previous sexual disorder were not included in the study.

For each patient the following scores were calculated: Harvey Bradshaw index, Perineal disease activity index, Fatigue severity score, Hospital anxiety and depression scale.

Evaluation of sexual function was based on the following scores: IIEF score (International Index of Erectile Function) in version 15 for men and FSFI score (Female sexual function index) which includes 19 questions for women.

Statistical analysis was carried out by SPSS software. Descriptive and analytic analysis were performed (univariate and multivariate) to investigate factors associated with sexual dysfunction.

All patients gave their oral informed consent prior to the completion of the study.

The personal data of the patients were protected by the realization of a pseudonymisation within the service. Only the principal investigator knew the identity of the patients.

Ethics Committee of Sahloul University Hospital Center approval was obtained for the realization of the study.

RESULTS

During the study period (January - June 2018), 30 patients were collected.

The average age was 45 years [ 18 - 65 years] and sex ratio was 0.875 [H / F = 14/16]. Our patients were either married (n = 24) or single (n = 6).Smoking was noted in 13 patients while alcohol consumption was observed in 7 patients.

The average duration of disease progression was 9.89 years [1-21]. Crohn's disease was ileal in 4 cases, colic in 9 cases and ileocolic in 13 cases. Ano-perineal manifestations (complex fistulas) were noted in 9 patients (30%) with complex fistulas. Fistulas were inter-sphincteric in 4 cases, trans-sphincteric in 3 cases and extra-sphincterial in 1 case.

Surgical history was observed in 23 patients (76.7%) mainly ileo-caecal resection (n = 15).

Thirteen patients (43%) were in remission and 17 patients (57%) had active disease.

Average Harvey Bradshaw Index was 4.75 [1-9].

In the 9 patients with active anoperineal lesions, the PDAI score was calculated. It averaged 5.28 [1-13].

Twelve patients were on TNF antagonist (mean duration of treatment 10 months [6-24 months]) while 15 received azathioprine.

Mean mean fatigue score was 3.21 [1-6,11].

A fatigue score greater than or equal to 5.5 was observed in 5 cases (16.7%)

A patent anxiety was present in 8 patients (27%).

A patent depression was present in 10 patients (33%).

Erectile dysfunction was objectified in half of the male patients (n = 7).

The severity of objectified erectile dysfunction in our patients is summarized in Figure 1.

In women, the average FSFI score was 17.38 [2.6-24.4]. Sexual disorders were observed in 100% of patients.

The results of the FSFI questionnaire are summarized in Figure 2.

 

Comparing the prevalence of sexual disorders with active ano-perineal lesions, we found no significant difference (Table 1). Similarly, the type of ano-perineal lesions (stenosis, fistula) and Parks' classification did not seem to influence the presence of sexual disorders in our series.

However, the PDAI score was higher in patients with active LAPs with sexual dysfunction compared with those without sexual dysfunction (5.29 versus 4.23 with p = 0.538).

Comparing patients with ano-perineal lesions with sexual disorders compared to those without, we identified the factors associated with the occurrence of sexual disorders during Crohn's disease. They are summarized in Table 2.

 

In our series, older age and status (married versus single) were associated with the occurrence of sexual disorders in patients with Crohn's disease with ano-perineal lesions. No independent predictors emerged in multivariate analysis.

DISCUSSION

Studies evaluating sexual function in patients with Crohn's disease are numerous [4-8], but those focusing specifically on patients with ano-perineal lesions are rarer.

A recent study dating from 2017 [9] from the University of Bordeaux included 97 patients with Crohn's disease with ano-perineal lesions and 238 controls without ano-perineal lesions. The primary endpoint was the existence of sexual dysfunction defined by an FSFI score <26.55 in women and IIEF <42.9 in men. This study concluded that there is an increase in the prevalence of sexual dysfunction in women with active anoperineal lesions compared to controls. This result was not found in men, although a trend appears. This study also demonstrated that obtaining ano-perineal remission may be associated with improvement of sexual function. Regarding patients with ano-perineal lesions, sexual dysfunction was found in 62% of women and 51% of men (compared to 66% of women and 30% of men with Crohn's disease without ano-perineal lesions).

Prevalence of sexual disorders in the literature has not been studied specifically for patients with anoperineal lesions but is quite variable according to the studies (between 25 and 83.6%). Most studies show a lower prevalence of sexual disorders in men than in women. This was found in our series. Indeed, in addition to decreased satisfaction, lack of interest, women have specific problems with lubrication, dyspareunia and vaginal infections. In addition, body image disorders appear to be accentuated in women [10]. Our study found a higher prevalence of these disorders according to the gender (in 50% of men and 100% of women). Prevalence of sexual disorders found in the literature is summarized in Table 3 [11].

Differences in the prevalence of sexual disorders in patients with Crohn's disease with ano-perineal lesions can be explained by several factors.

Indeed, LAPs can be complicated by candidiasis (especially vaginally in women) that can interfere with the sexual life of patients [11].

In addition, deleterious lesions observed during Crohn’s disease can cause a disturbance of the body image and negatively affect the overall quality of life of patients and more specifically sexual function [12-13].

In addition, patients with ano-perineal lesions are often on long-term immunosuppressive therapy (eg, azathioprine or anti TNF alpha) and these treatments may have an effect on sexual function (whether positive or negative) [14]. A special place is devoted to the anti-TNF alpha, very frequently used during the ano-perineal lesions of Crohn's disease and which seems to improve the quality of life of patients and in particular their sexual function. This was demonstrated in a study involving 26 patients with significant improvement at 12 months of quality of life and PDAI score [15], but also by other less recent studies [16-18].

Also, patients with Crohn disease are more likely to undergo heavy surgical procedures such as proctectomies or ileostomies. These interventions may alter not only the rectal and sensory innervation involved in sexual function but also body image. Thus, ostomate patients have specific fears related to their status: organic causes related to the involvement of peripheral nerves associated with psychogenic causes related to the alteration of body image, anxiety and stress, feelings depreciation, fatigue or loss of control function [19-20].

Finally, depression and anxiety rates are also higher in these patients and their influence on sexual disorders is well established [21-23]. The effect of depression would be multifactorial: somatic linked to hormonal imbalances caused by insomnia and eating disorders but also psychological related to a disorder of body image and a denigration of self-image.

Finally, it seems thatano-perineal manifestations during Crohn's disease increase sexual disorders through several mechanisms: psychological, sociocultural, infectious, medicated, surgical ... And although this effect was not found in our series, special care should be offered to these patients in order to early detect these disorders and offer them appropriate management [24].

Concerning predictors sexual disorders, these have also not been specifically studied in patients with anoperineallesions  in the literature. Depression is the most frequently identified independent predictor in the literature [11]. This factor was not isolated in our study, probably due to the small sample size. Predictors found in the literature are summarized in Table 4 [11].

Our study, although prospective, is limited by the small samplesize, making it difficult to generalize the statistical results.

In addition, sexuality remains a taboo subject related to our socio-cultural environment.

Another limitation of this study is the difficulty in diagnosing and treating sexual dysfunction in Crohn's disease and the lack of a specific assessment system [25]. Indeed, no specific scale of measurement of sexual function adapted to Crohn's disease has been used.

The FSFI measures desire, excitement, satisfaction, lubrication, orgasm and pain / discomfort while IIEF measures erectile function, sexual satisfaction, orgasmic function, sexual desire and overall satisfaction [26-28]. None of these scales take into account the particular elements related to Crohn's disease such as fear of fecal incontinence, embarrassment related to ano-perineal involvement or secondary inhibition to an ostomy pouch. Recently, a validated body image scale specially adapted for patients with Crohn's disease has been developed, which would accurately measure IBD-specific body image disorders [29]. Specific scales adapted to sexual function among Crohn disease patients should therefore be developed.

CONCLUSION

Sexual disorders are common but certainly undiagnosed during Crohn's disease. In our study, half of all men and women presented sexual troubles. However, no significant difference in the occurrence of sexual disorders was objectified according to anoperineal lesions in our cohort. Moreover, older age and marital status (married versus single) were associated with the occurrence of sexual disorders. Finally, chronic inflammatory bowel disease affects the quality of life, resulting in a negative impact on sexual function. It would be advisable to sensitize physicians on the importance of searching these disorders systematically, in order to detect them early and to propose a specialized care.

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Figures

 

 

 

Figure 1 : Severity of erectile dysfonction among men

 

Figure 2 : Severity of sexual disorders among women

Tables

Table 1 :Conmparison of sexual disorders according to anoperineal lesions

 

Active anoperineallesions

p

Group 1 : no (n=21)

Group2 : yes (n=9)

 

0,111

Sexualdisorders

16

7

No sexualdisorders

5

2

 

Table 2 :Associated factors to sexual disorders during Crohn disease with anoperineal lesions (univariate analysis)

 

Yes  (n=6)

No (n=3)

 

Epidemiological data

Meanage (years)

48,3

25

0,002

Sexe ratio H/F

1/5

1/2

0,346

Habits

Tobacco (n=)

Alcohol (n=)

Toxicomania (n=)

 

1

1

1

 

1

0

0

 

0,326

0,537

0,537

Marital status

Married/Single (n=)

 

5/1

 

0/3

 

0,035

Crohndisease data

Meanevolutionperiod (years)

10

7

0,238

Localization

Ileal/colic/ileocolic (n=)

 

1/0/5

 

1/1/1

 

0,069

Phenotype

Luminal/Fistulizing/Stenosing/ both (n=)

 

0/1/1/4

 

1/1/0/1

 

0,149

Surgery(n=)

6

2

0,346

Harvey Bradshaw Index (mean score)

5,4

5

0,882

Treatment

Corticosteroid (n=)

0

0

0,258

5ASA (n=)

0

0

0,594

Azathioprin(n=)

3

2

0,346

Anti TNF alpha (n=)

4

2

0,676

Scores

Fatigue score (mean)

4.3

1.72

0,112

Anxiety (n=)

3

2

0,855

Depression (n=)

2

1

0,299

 

Table3 : Prevalence of sexual disorders in patients with Crohn disease according to litterature

Author

Year

n

Prevalence of sexualdisorders

Ghosh

2007

5576 (europeanstudy)

40%

Timmer

2007

347

44%

Muller

2010

219

57,6%

Marin

2013

152

40%

Knowles

2013

77

83,6% of women

53,9% of men

Bel

2015

287

52% of women

25% of men

Boudhiaf

2017

335

66% of women

30% of men

Our Study

2018

30

 

100% of women

50% of men

 

Table4 :Predictors of sexual disorders in patients with Crohn disease according to litterature

Auteur

Année

n

Facteurs prédictifs de troubles sexuels

Timmer

2007

347

Depression

Timmer

2008

336

Depression

Activity of the disease

Smoking

 

Muller

2010

347

Femalegender

Surgery

Marin

2013

152

Depression

Biological therapy use

Diabetes

Knowles

2013

77

Femalegender

 

Bel

2015

287

Activity of the disease

Depression

Fatigue

Boudhiaf

2017

335

Female gender

Activity of the disease

Our study

2018

30

 

Age et maritalstatus