w w w . r e u m a t o l o g i a . c o m . b r
REVISTA
BRASILEIRA
DE
REUMATOLOGIA
Review
article
How
the
rheumatologist
can
guide
the
patient
with
rheumatoid
arthritis
on
sexual
function
夽
Pedro
Henrique
Tavares
Queiroz
de
Almeida
a,b,
Clarissa
de
Castro
Ferreira
c,∗,
Patricia
Shu
Kurizky
b,
Luciana
Feitosa
Muniz
d,
Licia
Maria
Henrique
da
Mota
baUniversidadeFederaldeSãoCarlos,SãoCarlos,SP,Brazil bUniversidadedeBrasília,Brasília,DF,Brazil
cHospitalRegionaldeCeilândia,Ceilândia,DF,Brazil
dHospitalUniversitáriodeBrasília,UniversidadedeBrasília,Brasília,DF,Brazil
a
r
t
i
c
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Articlehistory:
Received7December2013 Accepted17August2014 Availableonline14January2015
Keywords:
Sexualdysfunction Rheumatoidarthritis Sexuality
a
b
s
t
r
a
c
t
Sexuality,anintegralpartofhumanlifeandqualityoflife,isoneofthosefactors responsi-bleforindividualwelfare.Sexualdysfunctioncanbedefinedasachangeinanycomponent ofsexualactivity,whichmaycause frustration,pain anddecreasedsexualintercourse. Althoughitisknownthatchronicdiseases,suchasrheumatoidarthritis(RA),influence thequalityofsexuallife,sexualdysfunctionisstillunderdiagnosed,duetotworeasons:(i) patientsfailtoreportthecomplaintbecauseofshameorfrustrationand(ii)thissubjectis rarelycalledintoquestionbydoctors.Rheumatologistsareincreasinglywillingtodiscuss areaswhicharenotdirectlyrelatedtodrugtreatmentofjointdiseases,suchasqualityof life,fatigue,andeducationofpatients;however,sexualityisrarelyaddressed.Theaimof thisreviewistopresentsomeusefulconceptstoRheumatologistsfororientationoftheir patientswithRAwithrespecttosexualfunction/dysfunction,someconsiderations con-cerningtheroleoftheseprofessionalsinordertoinstructthepatient,generalnotionsabout sexualfunction,includingpracticalconceptsaboutthemoreappropriatesexualpositions forpatientswithRA,andamultidisciplinaryapproachtosexualdysfunction.
©2014ElsevierEditoraLtda.Allrightsreserved.
Como
o
reumatologista
pode
orientar
o
paciente
com
artrite
reumatoide
sobre
func¸ão
sexual
Palavras-chave:
Disfunc¸ãosexual Artritereumatoide Sexualidade
r
e
s
u
m
o
Asexualidade,parteintegrantedavidahumanaedaqualidadedevida,éumadas respon-sáveispelobem-estarindividual.Adisfunc¸ãosexualpodeserdefinidacomoalterac¸ãoem algumcomponentedaatividadesexualepodeacarretarfrustrac¸ão,dorediminuic¸ãodos intercursossexuais.Emborasesaibaquedoenc¸ascrônicas,comoaartritereumatoide(AR),
夽
WorkidealizedanddevelopedintheRheumatologyService,HospitalUniversitáriodeBrasília,Brasília,DF,Brazil.
∗ Correspondingauthor.
E-mail:[email protected](C.d.C.Ferreira).
http://dx.doi.org/10.1016/j.rbre.2014.08.008
influenciamaqualidadedavidasexual,adisfunc¸ãosexualaindaépoucodiagnosticada,o quesedeveadoismotivos:tantoospacientesdeixamderelataraqueixaporvergonhaou frustrac¸ãoquantoosmédicospoucoquestionamseuspacientesaesserespeito.Os reuma-tologistasestãocadavezmaisdispostosadiscutirdomíniosquenãoestãodiretamente relacionadoscomotratamentomedicamentosodasdoenc¸asarticulares,comoqualidade devida,fadigaeeducac¸ãodospacientes.Asexualidade,noentanto,émuitopouco abor-dada.Oobjetivodestarevisãoéapresentaralgunsconceitosúteisaoreumatologistapara orientac¸ãodopacientecomARquantoàfunc¸ão/disfunc¸ãosexual,considerac¸õesrelativas aopapeldesseprofissionalnosentidodeinstruiropaciente,noc¸õesgeraissobrefunc¸ão sex-ual,incluindoconceitospráticossobreposic¸õessexuaismaisadequadasparaportadores deAR,eabordagemmultidisciplinardadisfunc¸ãosexual.
©2014ElsevierEditoraLtda.Todososdireitosreservados.
Introduction
Sexuality,anintegralpartofhumanlifeandqualityoflife,is oneofthosefactorsresponsibleforindividualwelfare. Sexu-alitynotonlyreferstothesexualactitself,buttotheentire spectrumrangingfromself-imageandthevalorizationofself, totherelationshipwiththepartner.1
Sexual dysfunction can cause frustration, pain and decreased sexual intercourse.2 Although it is known that
chronicdiseasescaninfluencethequalityofsexuallife, sex-ualdysfunctionisstillunderdiagnosed,duetotworeasons: (i)patientsfailtoreportthecomplaintbecauseofshameor frustrationand(ii)thissubjectisrarelycalledintoquestionby doctors.3,4
Ourgrouphasstudiedtheprevalenceofsexual dysfunc-tioninwomenwithdiagnosesofvariousrheumaticdiseases, including systemic lupus erythematosus (SLE), rheumatoid arthritis(RA),systemicsclerosis(SSc),antiphospholipid syn-drome(APS),fibromyalgia,psoriasisandpsoriaticarthritis.5,6
Wehaveobservedthatoneofthecomponentsthatmay hinderanapproachofthesubjectwiththepatientand conse-quentlyasuitabletreatmentisthelackofguidanceonsexual functionbythephysician.Sexualfunctionisaneglectedarea ofqualityoflifeinpatientswithrheumaticdiseases.1
Theapparentlackofinterestofthedoctorinrelationto sex-ualfunctionofhis/herpatientscouldbeexplainedbyfactors suchasconstraints inconsultationtime,uneasinesswhen discussingsexuality(bothbythephysicianandthepatient), uncertaintiesaboutphysicianroleandrelativecompetenceon issuesofsexualityofhis/herpatients.1,4,7,8
Thesexualresponsecycleconsistsofthefollowingphases: (1)Desire:characterizedbyfantasiesaboutsexualactivityand desireforsexualactivity.(2)Excitation:subjectivefeelingof sexualpleasureandaccompanyingphysiologicalchanges;in man,characterizedbypeniletumescenceanderection,while inthewomanpelvicvascularcongestion,lubrication,vaginal expansion,andswellingoftheexternalgenitaliaareobserved. (3)Orgasm: climaxofsexualpleasure, withrelease of sex-ualtensionandrhythmiccontractionofperinealmusclesand reproductiveorgans.Inman,itischaracterizedbythe sensa-tionofejaculatoryinevitability,followedbyejaculation,while inthewomancontractionsofthelowerthirdofvaginalwall occur.(4)Resolution:feelingofrelaxationandgeneral well-being.9–11
Sexualdysfunctionisdirectlylinkedtotheimproper func-tioningofoneofthephasesthatcomposethesexualcycle. AccordingtothediagnosticcriteriaofDSM-IV(Diagnosticand StatisticalManualofMentalDisorders,fourthedition), sex-ualdysfunctionsarecharacterizedbydisturbancesinsexual desireandbypsychophysiologicalchangesthatcharacterize thesexualresponsecycle,causingmarkeddistressand inter-personaldifficulties.12
RAcaninfluencesexualfunctioninseveralaspects.13The
reasonsfordisturbancesinsexualfunctioningare multifacto-rialandincludeaspectsrelatedtothediseaseitselfandalso tothetreatment.
Inastudyconductedbyourgroup(unpublisheddata),in which68womendiagnosedwithearlyRA(lessthanayearof symptomsatdiagnosistime)wereevaluated,wefoundahigh frequencyofsexualdysfunction(79.6%ofpatientswithactive sexuallife),afigurehigherthaninmostpreviousstudiesof patientswithestablishedRA.1,4,13–15
Inasecondstudy5evaluating163patientswithdiagnoses
of various rheumatic diseases, including 24 patients with establishedRA,wefoundsexualdysfunctionin18.4%ofall evaluatedpatientsandin8.3%ofRApatients.Itisimportant tomentionthat24.2%ofallpatientsand17%ofRApatients hadnosexualactivityduringthestudyperiod.
Abdel-Nasseretal.showedintheirstudythatover60%of femalepatientswithRAhaddifficultyinsexualperformance (i.e.,sexualdisability)andadecreaseinsexdrive.Thisinability wasrelated,amongotherfactors,todiseaseactivity,painand disability,asassessedbyHAQ.7
Pain,morningstiffness,jointswellingandfatiguecanlead toadecreasedsexualinterest,aswellashinderingthesexual act.Inaddition,lowself-esteemandanegativebodyimage, whichcommonlyaffectpatientswithRA,arerelevant psycho-logicalfactors.1,4,7,9
Theperceptionofanegativebodyimage,decreasedjoint mobilityandmusclestrength,morningstiffnessandpoor per-formance indaily physicalactivitiesalso contributeto the deteriorationofsexualhealthinpatientswithRA.Drugsused in their treatment may also lead to sexual dysfunction.16
Fig.1–Ontheleft,thispositionpreventsthewomanperforminghipabductionandkneeandspineflexion,andallow restingherupperlimbs,sincethepartnerperformshipabductionandholdshisweightduringsexualactivity.Ontheright, avariationofthisposition,thatcanbeadoptedifthemanpresentsRA.
ArthritisInformation:SexandArthritis;reproducedwithpermissionfromArthritisResearchUK.
administration.Afterafewweeksofdiscontinuationorofdose reductionofthis medication,thepatientimproves.17
Impo-tencehasbeenreportedwiththeuseofhydroxychloroquine andsulfasalazine.16
Corticosteroidscanhavesideeffectswithgreatimpacton sexualfunction,withchangeinbodyimage,aswellasleading todepressionandpsychosis.Medicationsusedtotreat comor-bidconditionssuchasfibromyalgiacanalsoinfluencesexual functioninRApatients.Tricyclic antidepressantsand sero-toninreuptakeinhibitorsmayleadtoadecreaseoflibidoand hamperinreachingorgasm.18
Role
of
the
rheumatologist
in
the
orientation
of
the
patient
with
rheumatoid
arthritis
on
sexual
function
Panush et al. describe a strategy to approach and offer guidanceonsexualfunction,calledbytheseauthorsas PLIS-SIT(permission,limitedinformation,specificstrategiesand intensivetherapy).19Permissionconsistsinquestioningthe
patientabouthis/hersexual dysfunction,takingthe liberty and showingopennessto dialogue.Thedoctor mustshow the patientthat his/hersexual problemscanbe mitigated. Furthermore,it isessential thatthe doctorencouragesthe dialoguewiththepatient’spartner,duetohis/herneedtobe awareofthedifficultiesofthecouple.19,20
Thesecondstepistosearchandprovideinformationabout sexualdysfunction. Atthis stage,one shouldestablish the causeofthe problem–lackoflibido,pain, fatigue,vaginal dryness,anxiety,fear ofnothavingagood performanceor notsatisfyingthepartnerarepossiblecauses.19
Thethirdphaseistodevelopspecificstrategiesforeach problem.Lowsexualdesirecanbecircumventedbyreplacing medications,psychotherapy andstressreduction. Transder-maltestosteronemaybeusedinwomenwithlowlevelsof thishormoneorinthoseundergoingsurgicalmenopause.21
Astovaginaldryness,lubricatingoilsorintravaginal estro-gencreamsmaybeused.19 Withregardtopainandfatigue,
thepracticeofdifferentsexualpositions,restingbefore inter-course and the use of muscle relaxants or painkillers are recommended.19,20Theuseofsupportsinthejointshelpsin
maintainingthesexualpositions;ontheotherhand,heatin theformofcompressestakeseffectreducingjointstiffness. Itisrecommended,though,totakeawarmbathbefore inter-course,toachievemuscularrelaxation.
Hip arthroplasty can help in cases of joint immobility. Theindicationsforthissurgeryareincreasing.Lafosseetal. appliedaquestionnaireto135post-hiparthroplastypatients, andthevastmajorityreportedimprovedsexuallife,especially women,becausethissurgeryallowedagreatervarietyof sex-ualpositions.22
Menwitharthritismaydevelopimpotence,usuallyof psy-chogenicorigin.Insuchcases,phosphodiesteraseinhibitors maybeused,withalevelofevidenceAincasesoforganic, psychogenicandpharmacologicalerectiledysfunction.18
Asafourthstep,thepatientwouldbereferredtothesex therapist,incaseoffailureofotherstrategies.Insome situa-tions,thecouple’ssexualdysfunctionisnotonlyafunctionof arthritis.19
Table1summarizesrecommendationsonsexual dysfunc-tiondiscussedabove.
Guidanceastochangesinthepositionstakenduring sex-ual activity is based on principles of joint protection and energyconservation.Theconceptinvolvespatienteducation onproperjointalignmentandmovement,basedon biome-chanicsprinciples,besidesadoptingstrategiesofdivisionand organization ofthe dailyroutinetopreventfatigue,reduce painandmaintainanoptimalleveloffunctionality through-outtheday.23
As with most activities of daily living, sexual activities aredevelopedthroughpersonalexperiencesthatdefineand change the way these relations occur between partners.20
Thus,theguidanceshouldbeindividualized,providedtimely andusinganappropriateandaccessiblelanguage,toenable therelationshipoftheconceptsillustratedbythehealthcare professionalwithexamplesfromeverydaylifeofthepatient, facilitating the understandingand the incorporationofthe guidelinesintohis/herroutine.24
Thepositionsthatcanbeadoptedbypatientsandpartners involvereducinghipandkneeamplitudeofmotion,changes inposition(decubitus),anduseoffurniture,pillowsandother supportinordertominimizetheeffortrequiredforpostural maintenance.25Changesinthepositionsalreadytakenbythe
patientcanfacilitatetheprocessofadaptationand incorpo-rationofthephysician’sinstructions(Fig.1).
Amongtheproposedchanges,thecombinationofchanges inpositionandreducedjointrangeofmotionarealternatives formostpatientssufferingjointpaininbothupperandlower limbs(Fig.2).
Table1–Recommendationsonsexualfunction/dysfunctiontothepatientwithadiagnosisofrheumatoidarthritis.
Generalguidelines Discussionofproblemswiththepartner,explorenewsexualpositions,useofpainkillersandmusclerelaxants beforeintercourse.Useofheattorelievepainandjointstiffness(compresses,warmbath)
Vaginaldryness Useoflubricants,vaginalestrogencreams
Erectiledysfunction Useofsildenafil,sextherapy
Lackoflibido Evaluatepossibleexchangeofmedications,techniquesforstressreduction,testosteronereplacementin specificcases
Fig.2–Lateraldecubitusposition;reductioninhipand kneerangeofmotion,aswellaslowbackspinealignment. ArthritisInformation:SexandArthritis;reproducedwith permissionfromArthritisResearchUK.
Inaddition,thealignmentofthespine,hipandkneejoints can be maintained with the aid of pillows and cushions, decreasingthepain.
Although in some cases the patient may need to use his/herupperlimbs,somepositions(Fig.3)allowrestingthese structures,preventingthemfrombeingusedtosupportbody weight. Thesepositions may besuggestedto patientsthat presentconstraintsandjointdeformitiesintheirlowerlimbs. Inadditiontochangesinpositions,environmental modifi-cationsallowcarryingouttheactivityinamoresimilarwayto theusualforthepatient,favoringtheperformanceofsexual activitywithoutmajorchanges.Thegoalofthesechangesis topromotethetransferofweightbearingforothersurfaces; thus,thepatientsavesenergy,enjoyingmomentsofrest dur-ingsexualactivitywiththeuseofbracketsandsupportsthat canbeobtainedwiththefurnitureitself,andwithpillowsand cushions.Fig.4showsexamplesofsimplechangesthatcan beadoptedbypatientsinvariousstagesofthedisease.
Itisimportantthatthemedicalstaffalsoadvisethepatient aboutotherwaysofexpressingtheirsexuality, astouching,
Fig.3–Thepatienthasconstraintstohipandknee mobility.Inadditiontothecomfortprovidedbythereduced amplitudeofmovement,thispositionallowsreducingthe effortrequiredforposturalmaintenance.
ArthritisInformation:SexandArthritis;reproducedwith permissionfromArthritisResearchUK.
caressing,kissingandwiththeuseofanotpenetrativesex, that mayalso bepartofthe sexualactivity ofthe patient. Furthermore,interventionsthataimtoimprovethese activ-itiescontributetoabetterrelationshipbetweenpatientsand theirpartners,favoringtheempowermentwithrespecttothe diseaseprocessand,consequently,qualityoflife.26
Multidisciplinary
approach
to
sexual
dysfunction
Duetothemultiplicityandcomplexityofformsofsexuality expression,theapproachofpatientswithsexualdysfunction involvesbroadaspectsandhard-to-approachthemes,whose handlingrequirestheformationofbondsandanenvironment enablingtheunderstandingofaspectsbeyondphysical com-plaints,forinstance,emotionalandsocialfactors.2,14,27
Fig.4–Inbothsituations,thepatientleansonthebedorfurniture,avoidingweightbearingontheupperlimbsandthe completionofsexualactivitywithreducedmobilityofhipandknees.
Thus,patientcaredeliveredbyamultidisciplinaryteam allowsthedevelopmentofactionsatdifferentlevelsof com-plexity in health care. These actions should address the different contexts of the activities performed by patients in their daily lives, including the expression of their sexuality.25,26,28
Inthisperspective,thepsychologistactsfavoringthe man-agementofemotionalproblemsrelatedtotheillnessprocess andtheimplicationsoftheseissuesontheaffectiveand sex-ualrelationshipwiththepatient.27,29Interventionstocontrol
pain andincrease mobility and musclestrength, providing improvedphysicalcapacityforthepatient, areheldbythe physicaltherapist,29andthisprocessismonitoredbya
phys-icaleducationprofessional,30inordertopromoteareduction
ofobjective symptomsrelated toRA,such asfatigue,pain andjointmovementrestrictions.Guidelinesonthe organiza-tionoftheroutineandprotectionofjointsduringactivities ofdailyliving,aswellastheindicationofassisted technol-ogytomodifyobjectsandenvironments,aredemandsmetby occupationaltherapists.27,31
Conclusions
TheknowledgeoftheimpactthatRApromotesinsexualityby therheumatologistandotherhealthprofessionalsisofgreat importance,sinceitfacilitatesthephysician–patient discus-sionabouttheinfluenceofthediseaseinseveraldomainsof patient’squalityoflife,besidesallowingtheoptimizationof thetreatmentofRA,hereencompassingtheattentiontothe patient’ssexualdifficulties.
Conflict
of
interest
Theauthorsdeclarenoconflictofinterest.
Acknowledgment
Theauthorswould liketo thankthe ArthritisResearchUK Foundation, that have kindly allowed the reproduction of imagesillustratingthisarticle.
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