Female sexual dysfunction in ESRD: an underappreciated epidemic?


While life-sustaining, chronic dialysis is associated with substantial impairments in health-related quality of life (HRQoL) (1,2). The well-recognized decrements in HRQoL in patients with ESRD are likely related to multiple factors, including functional limitations, impaired social well being, vocational disruptions associated with a thrice-weekly or quotidian treatment, and a large burden of physical and emotional symptoms. Specific symptoms that occur with regularity in patients on chronic dialysis are fatigue, cramping, pain, and dyspnea (3,4). Another symptom that appears to occur frequently in patients with ESRD is sexual dysfunction, etiologies forwhich include hormonal dysregulation, vascular disease, autonomic dysfunction, medication side effects, and psychologic illness such as depression (5,6). To date, the preponderance of research on sexual dysfunction in patientswithESRDhas focused onmen. Although there are several domains of male sexual function that may be impaired, the most frequently studied has been erectile dysfunction (ED), in part because of the availability of efficacious pharmacological therapy (7,8). Multiple studies have documented ED to be highly prevalent and strongly correlated with HRQoL in men on chronic dialysis and have identified the clinical predictors of this symptom (9,10). In a comprehensive cross-sectional study of 302 communitybased male hemodialysis patients, Rosas et al. (9,11) found that ED was present in 82%, was severe in 45%, and was associated with impairments in multiple domains of HRQoL.A subsequent study by Türk et al. (10) demonstrated that ED was present in 104 (70%) of 148 patients on chronic hemodialysis and was closely correlated with decrements in physical and mental well being. Older age and diabetes were associated with ED in both of these studies. Data from these and other studies, which collectively enrolled thousands of patients, confirm the high prevalence and clinical importance of ED in men on dialysis and inform our understanding of factors that help predict the presence of this symptom. Although women comprise approximately one-half of all patients with ESRD, considerably less attention has been paid to female sexual dysfunction in this population. A series of small past studies suggest that sexual dysfunction is common among women receiving chronic dialysis. Yazici et al. (12) studied 117women with ESRD and found that sexual dysfunction was present in 94% of patients on peritoneal dialysis and 100% of those on hemodialysis. More recently, Seethala et al. (13) found impairments in multiple domains of sexual function in 66 female patients on chronic dialysis and high rates of sexual dysfunction among women with partners and those who reported to be sexually active. Notwithstanding these findings, studies investigating this issuewere limited by the enrollment of small numbers of patients and the lack of statistical power to elucidate which clinical factors are associated with and predict the presence of sexual dysfunction. In an effort to broaden our understanding of the prevalence and correlates of female sexual dysfunction in ESRD, in this issue ofCJASN, Strippoli (14) report the results of a large study of women receiving chronic hemodialysis. In this cross-sectional analysis, 1472 women were recruited from 27 randomly selected dialysis units in Europe and South America and asked to complete the Female Sexual Function Index (FSFI), a commonly used 19-item instrument that assesses six discrete domains of sexual function over the previous 4 weeks: desire, arousal, lubrication, orgasm, satisfaction, and pain. The maximum score for each domain is 6, and a composite summary score is generated by summing individual domain scores. Summary scores range from 2.0 to 36, with lower scores indicatingmore severe sexual dysfunction and a score,26.55 denoting the presence of sexual dysfunction (15). In addition to administering the FSFI, the investigators collected comprehensive demographic and clinical data and asked patients to complete the Center for Epidemiologic Studies-Depression instrument to assess for depression. Recursive partitioning and amalgamation was used to delineate groups of clinical variables that correlatedwith the presence of sexual dysfunction. Overall, 659 of 1472 women (45%) completed the study questionnaires. Among these 659 participants, 555 (84%)were identified as having sexual dysfunction based on FSFI scores,26.55. Individual domains with the greatest level of dysfunction were arousal (median, 1.8), orgasm (median, 2.0), and desire (median, 2.4), whereas satisfaction (median, 3.6) appeared to be the least impaired domain. In adjusted analyses, factors associated with a lower risk for sexual dysfunction included having a partner or being listed for a kidney transplant, whereas symptoms of depression, lower Renal Section, Medical Specialty Service Line, and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania; and Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania

DOI: 10.2215/CJN.03870412

Cite this paper

@article{Weisbord2012FemaleSD, title={Female sexual dysfunction in ESRD: an underappreciated epidemic?}, author={Steven D . Weisbord}, journal={Clinical journal of the American Society of Nephrology : CJASN}, year={2012}, volume={7 6}, pages={881-3} }