Re : Erectile Dysfunction in Patients with Chronic Renal Failure

4. Fung MM, Bettencourt R, Barrett-Connor E: Heart disease risk factors predict erectile dysfunction 25 years later: the Rancho Bernardo Study. J Am Coll Cardiol. 2004; 43: 1405-11. 5. Lai CF, Wang YT, Hung KY, Peng YS, Lien YR, Wu MS, et al.: Sexual dysfunction in peritoneal dialysis patients, Am J Nephrol. 2007, 27: 615-21. 6. Bellinghieri G, Santoro G, Santoro D, Lo Forte B, Savica V, Favazzi P, et al.: Ultrastructural changes of corpora cavernosa in men with erectile dysfunction and chronic renal failure , Semin Nephrol. 2004; 24: 488491.


Re: Erectile Dysfunction in Patients with Chronic Renal Failure
To the Editor: Although it is a major factor affecting quality of life in end stage renal disease (ESRD), sexual dysfunction receives very limited attention in follow up of dialysis patients (1). Successful dialysis improves most symptoms of ESRD, yet many patients continue to experience many forms of sexual dysfunction during the dialysis treatment (2). Sexuality was the fifth most important life stressor cited by 135 dialysis patients in a study of quality-of-life issues (3). More than half of patients suffering from ESRD and receiving dialysis treatment describe sexual dysfunction, most commonly a loss of interest in sexual activity (1,4). Despite the importance of these issues, only 25 % of patients discuss sexual function with their physicians (3). Moreover, it has been noted that lack of knowledge about sexuality, conservative attitudes toward sexuality, and anxiety when discussing sexual concerns are widespread among health care providers (5).
Sexual dysfunction addresses alterations related to drive, arousal, penile erection/vaginal lubrication, ability to reach orgasm and satisfaction with orgasm (6); all are affected by ESRD. A questionnaire given to dialysis patients revealed that 65 % were dissatisfied with sex since starting dialysis, 40% have stopped having sex, 27 % have no desire for sex, and 23 % reported they could not achieve orgasm (2). There is no known single cause for these changes, but there are several physical and psychological factors that are thought to contribute to them.
Stress, depression and anxiety due to kidney disease and treatment may affect patients' sexual desire and ability to enjoy sex (4). Other factors that may influence a patient's interest in sex include medications, diet, anemia, lack of sleep, inadequate dialysis, uremia and changes in hormone balance (1,3,7).
Complaints of reduction in libido, impotence and marked reduction in the frequency of sexual relations have been reported in more than 50% of male ESRD patients (7). Proposed factors that may cause sexual dysfunction in male dialysis patients are uremia, decreased penile blood supply, hormonal disturbances, low hematocrit level, drugs such as betablockers, fatigue, psychological problems such as depression and anxiety, and difficulties with partner (1,2,8).
In comparison to males, sexual dysfunction is more common in healthy females as well as females on dialysis (1). A study comparing sexual function before and after renal insufficiency found that the percentage of females who completely abstained from sexual intercourse increased from 9 to 40%. Among the females on dialysis who continued to have sexual activities, the anorgasmic percentage increased from 9 to 31% (8,9). In another study, 100% of the women on hemodialysis, 67% of those on peritoneal dialysis, and 31% of those with kidney transplants reported a lack of desire for sexual activity and lack of sexual fantasy (10). Numerous hypotheses have been put forward as to the origin of the sexual dysfunction in female dialysis patients including: uremia, hyperprolactinemia, gonadal dysfunction, depression, changes in appearance, hyperparathyroidism and zinc-deficiency (7-10). Moreover, the capacity of hemodialysis in reversing sexual dysfunctions do not appear to be significant at 6-months (11) and 18 month follow ups (12).
The study conducted by Messina et al. adds further understanding of erectile dysfunction that reaches up to 60 % in their patients undergoing hemodialysis.
Since improving the quality of life is a major goal in medicine, we should pay more attention to the sexual functioning of our patients that might help increasing our patient's enjoyment and satisfaction with life with minimal or no additional costs.