Sexual Functioning in Chronic Kidney Disease

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Paraskevi A. THEOFILOU

Abstract

Sexual functioning is composed of both physiological and psychological factors among patients with chronic kidney disease (CKD). However, the role of depression and anxiety has not yet been studied extensively. This study aimed to investigate the relation of depressive and anxiety symptoms to sexual functioning among hemodialysis (HD) and peritoneal dialysis patients. A sample of 144 patients was recruited from three general hospitals in the broader area of Athens, consisting of 84 patients undergoing in-center HD and 60 patients in continuous ambulatory peritoneal dialysis. Measurements were conducted with the following instruments: the World Health Organization Quality of Life instrument, the General Health Questionnaire (GHQ-28), the State-Trait Anxiety Inventory (STAI 1/STAI 2), and the Center for Epidemiologic Studies Depression Scale. The results indicated that satisfaction with sexual life had a negative association with all the subscales of the GHQ-28 questionnaire (somatic symptoms, anxiety/insomnia, social dysfunction, severe depression). Sexual functioning was also related negatively to depression as well as state and trait anxieties. Findings provide evidence that the presence of depressive and anxiety symptoms relates signifificantly to the negative evaluation of sexual functioning in patients with CKD.

Keywords: Anxiety, chronic kidney disease, depression, sexual functioning

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INTRODUCTION

Patients who have chronic kidney disease (CKD) and are treated by hemodialysis (HD) or peritoneal dialysis (PD) face a stressful and disruptive chronic illness with a complex and demanding treatment regimen.1–3 This has an impact on the quality of life (QoL) of both patients and their families, changing the distribution of responsibility with regard to decision making, employment, and housework, as well as affecting diet, recreation, and social activity.4–8

Sexual dysfunction is a set of disorders characterized by physical and psychological changes that result in the inability to perform satisfactory sexual activities. This condition has been found to be signifificantly more common in men and women with CKD than in the general population.9

Multiple factors contribute to the frequent occurrence of sexual dysfunction in CKD patients, including hormonal disturbances (such as hyperprolactinemia, hypogonadism in males, and changes in hypothalamic-pituitary function in women),10 anemia,11 CKD mineral and bone disorder,12 psychosocial factors (such as depression, anxiety, poor self-esteem, social withdrawal, marital discord, body image issues, fear of disability and death, loss of employment, and financial difficulties),13–15 autonomic neuropathy,16 medications (including antihypertensives, antidepressant, and histamine receptor blockers),13 and comorbid illness (such as diabetes mellitus, cardiovascular disease, and malnutrition).13,17

The purpose of this study is to examine the association of depression as well as anxiety with sexual functioning in CKD patients. We mainly hypothesize that compromised mental health is related to a lower level of satisfaction regarding sexual life.

MATERIALS AND METHODS

A sample of 144 patients was recruited from three general hospitals in the broader area of Athens, consisting of 84 patients (58.3%) undergoing in-center HD and 60 patients (41.7%) in continuous ambulatory PD. Selection criteria included:

1. >18 years of age

2. Ability to communicate in Greek

3. Diagnosed with CKD

4. Dialysis treatment of at least a year

5. Satisfying level of cooperation and perceived ability

The rate of response was very high, reaching 99%. Thus, the total sample includes almost all patients of these three units, consisting of 86 males (59.7%) and 58 females (40.3%), with a mean age of 60.6 years  14.9. Participants were Greek adults having signed a consent form for participation. All subjects had been informed of their rights to refuse or discontinue participation in the study according to the ethical standards of the Helsinki Declaration. Ethical permission for the study was obtained from the scientific committees of the participating hospitals. Full descriptive data of the sample are presented in Table 1.

Measurements were conducted with the following instruments:

1. The World Health Organization Quality of Life instrument (WHOQOL-BREF).22 It is a self-report generic QoL inventory of 26 items, validated within Greek populations.23 From the WHOQOL-BREF, the study presented here used one key question to evaluate sexual functioning that was rated on a Likert scale. This question concerns the patient’s satisfaction with his/her sexual life (“satisfied with sexual life”). Higher scores indicate a better QoL.

2. The General Health Questionnaire (GHQ-28) is a widely used self-report measure of general health, developed by Goldberg,24 and validated with Greek populations.25 It may identify short-term changes in mental health and is often used as a screening instrument for psychiatric cases in a medical setting and general practice. The 28-item version used in this study consists of four subscales: (i) somatic symptoms, (ii) anxiety/insomnia, (iii) social dysfunction, and (iv) severe depression. Higher scores indicate a worse general health status.

3. The State-Trait Anxiety Inventory (STAI 1/STAI 2). It consists of 20 items referring to self-reported state anxiety and 20 items to trait anxiety.26,27 State anxiety reflects a "transitory emotional state or condition of the human organism that is characterized by subjective, consciously perceived feelings of tension and apprehension, and heightened autonomic nervous system activity”; it may fluctuate over time and can vary in intensity. In contrast, trait anxiety denotes “relatively stable individual differences in anxiety proneness” and refers to a general tendency to respond with anxiety to perceived threats in the environment.26 Higher scores mean that patients are more anxious.

4. The Center for Epidemiologic Studies Depression Scale (CES-D)28–30 is a 20-item self-report measure of depression. A higher score means that the patient is more depressed. A value above 9.03 is required for a subject to be classified as depressed.30

Kolmogorov–Smirnov test was performed in order to check whether the values of the sample would fall within a normal distribution. Next, the analyses used aimed to investigate the relationship between sexual functioning and depression as well as anxiety. Thus, correlation analysis was performed using Pearson’s rho. Hierarchical regression analyses were also used to assess the above association not only in the total sample but also in the groups of HD and PD patients separately. A P value of 0.05 or less was considered to indicate statistical significance.

All analyses were performed with the Statistical Package for the Social Sciences (SPSS 13.0 for Windows, Chicago, IL, USA).

RESULTS

The values of the total cohort were found to pass the normality distribution test. Investigating the relation between sexual functioning and mental health in the total sample, satisfaction with sexual life was associated negatively with all the subscales of the GHQ-28 questionnaire (somatic symptoms, anxiety/insomnia, social dysfunction, severe depression) as well as depression, measured by CES-D scale, state and trait anxiety (Table 2).

Further investigation was performed on the two groups of patients separately. In HD patients, satisfaction with sexual life was associated negatively with all the sub-scales of the GHQ-28 questionnaire (somatic symptoms, anxiety/ insomnia, social dysfunction, severe depression). This variable was also related negatively to depression, measured by the CES-D scale (Table 3).

With regard to PD patients, the results showed that satisfaction with sexual life had also a negative association with all the sub-scales of the GHQ-28 questionnaire (somatic symptoms, anxiety/insomnia, social dysfunction, severe depression). Sexual functioning was related negatively to depression as well as state and trait anxiety (Table 4).

A hierarchical regression analysis was performed in order to investigate the aforementioned association in the total sample. Specifically, depression was found to have a negative effect on satisfaction with sexual life (Table 5). The negative effect of depression was also observed in HD patients (Table 6). However, there were no statistically significant relations between sexual functioning and mental health in PD patients.

DISCUSSION

The present study shows strong associations between sexual functioning with mental health in CKD patients.

Concerning the relation between depression as well as anxiety and the variable of satisfaction with sexual life in the total sample, it seems that a satisfactory sexual life makes the patient feel less anxious and depressive and evaluate his/her status of general health more favorably. In the relevant literature, it has been suggested that increased sexual function in individuals with CKD has the potential to positively affect outcomes through a number of mechanisms, including decreased levels of depressive affect and increased patient perception of QoL.13–15, 18–20

In a further investigation that was performed on the two groups of patients separately, the above conclusions are also confirmed. Specifically, in HD patients, it seems that feeling sexually restricted may induce stress, anxiety, and depressive mood.

With regard to PD patients, satisfaction with sexual life seems to play a substantive role in their status of health and more specifically in the favorable way they evaluate the level of their mental and general health.

Several limitations in this study warrant mention. First, sexual functioning was measured with a limited item from the WHOQOL-BREF questionnaire. Although future studies addressing similar questions should ideally use well-established instruments that have proven reliable and valid, the reliability and validity of sexual functioning instruments that capture factors specific to dialysis and the lives of dialysis patients have not been established. Second, this research focused on the dimension of sexual functioning that relates to patients' satisfaction with their sexual life. Other dimensions of this variable (e.g., erectile function, sexual desire, orgasmic function, etc.) merit additional study. Third, it was not possible to assess whether the levels of sexual dysfunction preceded or followed the initiation of dialysis, which should be viewed as a limitation, especially for associations with adherence indicators and other outcomes assessed cross-sectionally at the initiation of the study. Sexual dysfunction may vary over time and may be important to consider at the initiation of dialysis therapy.

There is also a need for future research to use prospective and longitudinal study designs to examine the interaction between sexual functioning and mental health in patients with CKD.

Another methodological issue relates to sample representativeness. Studies on the broader CKD population and recruiting even larger samples to enable effective multigroup analysis should be pursued in future research.

Despite its limitations, the present study demonstrates the importance and the contribution of mental health to the patients’ evaluation of sexual functioning and specific satisfaction with their sexual life.

ACKNOWLEDGMENTS

The author would like to thank the patients for their participation in the study and acknowledge the support given by the health professionals and the administrative personnel of the dialysis participating units.

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