Sex problems in Chronic Kidney Disease Patients

Chronic Kidney Disease is characterised by progressive deterioration of the kidney’s ability to perform its function properly. As a chronic disease, it does not exist in isolation. It affects the individual and other organs of the body drastically, which eventually leads to physical, social, physiological, economic and psychological disturbances. Losing the ability to carry out certain activities and failing to fulfil their roles effectively makes the patient’s life spin around completely. However, one aspect that is often not addressed and researched enough in association with patients with CKD, is how the sexual ability of the individual gets disbalanced. Sexual function disorders among CKD patients are more common than they are talked about and understanding this common consequence of kidney disease is imperative to understand how the individual’s comprehensive physical and psychological well-being operates.

Both men and women who are diagnosed with CKD experience sexual dysfunction. What does it look like for both of them?

Sexual dysfunction in patients with CKD (Manish Rathi and Raja Ramachandran (2012):

Men:

• Decreased libido
• Erectile dysfunction
• Premature or delayed ejaculation
• Difficulty in achieving orgasm

Women:

• Decreased libido
• Difficulty in achieving orgasm
• Lack of vaginal lubrication
• Infertility
• Pain during intercourse
• Menstrual irregularities that may include premature menopause

Both men and women experience different disorders in relation to sexual disorder, which have been categorised by Watson et al. in 4 categories:

• Desire
• Arousal
• Orgasm
• Pain

Along with this, they also make in-depth sense of what sexual dysfunction might look like for CKD patients in terms of their gender. For males,

• Abnormal changes to pituitary and testicles
• Abnormal chemistries that affect testosterone levels

For females,

• Abnormal changes to pituitary and ovaries
• Abnormal chemistries that affect estrogen levels
• Ovarian failure

Engaging in sexual activity is a body’s natural calling, it is imperative for the smooth function of the body, both physically and mentally. Any disturbance or hitch in carrying out this activity, may add onto the already existing problems. It reinforces the psychological and physical trauma that the individual is already going through. Feeling pain while having intercourse, failure to achieve orgasm, less desire to engage in sexual activity and inability to get aroused are serious dysfunction and disorders that need to be investigated and examined thoroughly.

What is the cause of this sexual dysfunction? Many factors contribute to this condition and according to Strippoli et al. (2010), they are:

• Hormonal disturbances such as hyperprolactinemia and hypogonadism in males and change in hypothalamic-pituitary function in women.
• Anemia
• CKD mineral and bone disorder
• Psychosocial factors such as depression, anxiety, body image issues, poor self-esteem, loss of employment, marital discord, social withdrawal, fear of disability and death, financial difficulties
• Autonomic neuropathy
• Medications such as antidepressants and antihypertensives
• Comorbid illness such as diabetes or high blood pressure

One’s ability to engage in sexual activity is driven by physical and emotional factors and with CKD along with its treatment, both of these factors are misplaced, misbalanced and affected to such an extent that the individual finds it difficult to seek pleasure from or even engage in sexual activity. Other contributing, physical and emotional, factors may include physical discomfort, uremia, body pain, lack of energy, leg cramps, fatigue, sleep disorders, guilt, change in family roles, grief etc.

These contributing factors are common in both the sexes. Certain factors and features of sexual dysfunction among CKD patients are pertaining uniquely to males and females.

Male sexual dysfunction:

• Erectile dysfunction: penile erection is characterised by adequate penile blood flow and intracavernosal arterial blood pressure. An erectile dysfunction may be characterised by decreased arterial blood flow, venous leakage due to shunts, altered penile smooth muscle function, hormonal disturbances, side effects of medicines and neurogenic dysfunction (Rathi and R. Ramachandran (2012). Smooth muscle dysfunction and impaired venous-occlusion results in efflux of blood from cavernous space that results in erectile dysfunction. Along with this, when the pentosidine concentration is high, it leads to erectile dysfunction and research shows that the pentosidine concentrations are 22 times higher in CKD and 3-4 times in transplant patients than the general population. (Rathi and R. Ramachandran, 2012). Factors such as abnormalities in gonadal pituitary system, disturbance in autonomic nervous system, endothelial dysfunction, anemia, zinc deficiency may also contribute to the occurrence of erectile dysfunction. (Homma et al., )
• Testosterone deficiency: also known as hypogonadism, low levels of testosterone are common among patients with CKD and as the individual’s age increases, this imbalance increases. With pituitary and hypothalamic alterations in conjunction with low testosterone levels, the individual experiences low sex drive along with irritability and fatigue.
• Changes in prolactin secretion: hyperprolactinemia is a condition whereby the body has high levels of prolactin in the blood. When prolactin clearance is disturbed owing to CKD, especially in stage 5, it leads to hypogonadotropic hypogonadism, which eventually leads to erectile dysfunction,decreased libido,infertility etc. (Edey, 2017)

It is therefore fundamental to understand that a number of factors contribute to the weak sex life of a male who has CKD. Poor blood supply to the penis, leaky blood vessels, hormonal imbalance, damage of the nerve that disrupts the nerves from working efficiently,psychological issues and tiredness are some contributors to the low sex drive and inability to engage in sexual activities for males.

Female sexual dysfunction:

• Menstrual abnormalities: As compared with the general population, women with CKD experience irregular periods along with vaginal infections. Amenorrhea is seen in 50-100% of female patients who are in the fifth stage of CKD. Abnormal menstrual bleeding is also experienced owing to polymenorrhea, menorrhagia etc. Ovarian cyst formation in uremic patients is also a common phenomenon. (Rathi, R. Ramachandran, 2012). Irregular periods or a complete stop of menstruation might be the case for many CKD or dialysis patients.
• Low sex drive: women receiving dialysis are found to experience decreased libido and reduced ability to reach orgasm. Uremic women face these difficulties and when amenorrheic dialysis patients experience low estradiol levels, it leads to vaginal atrophy, dryness etc. (Pezeshki and S. Ghazizadeh, 2011).
• Fertility issues: conception is rare for women suffering from ESRD. Issues of menstrual irregularities, late diagnosis of pregnancy etc adds to the fertility issues for women suffering from CKD. Often, problems such as spontaneous abortion, stillbirth, neonatal death etc. are found in women with chronic renal dialysis.
• Dyspareunia or pain during intercourse: this is a common issue faced by women with kidney disease. It may be due to lack of lubrication or any other infection. Vaginismus also causes painful intercourse. It makes the muscles around the vagina tight and difficult or sometimes even impossible to engage in sex.

Along with these medical complications, mental complications also deteriorate the sex life of CKD patients. What are some of the treatment options?

For men,

1. Therapy
2. Adequate nutritional intake
3. Phosphodiesterase type 5 inhibitors(PDE5Is) for erectile dysfunction
4. Testosterone replacement therapy
5. Renal transplantation
6. Control of anemia and secondary hyperparathyroidism
7. Hormone injections
8. Vacuum tumescence therapy
9. Penile injection therapy
10. Penile insertion therapy

For women,

1. Hormone replacement therapy
2. Treating illness such as anaemia that might be causing low sex drive
3. Therapy to treat depression, anxiety, body image issues etc
4. Certain drugs given to increase genital and clitoral blood flow
5. Treatment with erythropoietin (EPO) to improve hormonal imbalance etc.
6. Therapy to treat psychological disturbances such as anxiety, depression, lack of self-esteem.

For many, sex life comes back to normal after successful kidney transplant. One should consult their doctor, therapist and nutritionist in order to bring back pleasure and happiness in their lives.

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