Prospective follow-up of sexual function after elective repair of abdominal aortic aneurysms using open and endovascular techniques

Article Outline

• Abstract
• Methods
  • Statistical analysis
  • Ethical considerations
• Results
• Discussion
• Conclusion
• Author contributions
• Acknowledgment
• References
• Copyright

Objectives

Surgical intervention in the treatment of abdominal aortic aneurysms (AAA) can affect sexual functions, resulting in a negative impact on the quality of life. The aim of this study was to investigate the preoperative information given about sexual functions and to compare the functional changes after open (OR) and endovascular repair (EVAR) for patients with AAA during one year after treatment.

Methods

Seventy-six patients participated in the study (40 OR and 36 EVAR). A questionnaire was used to measure the sexual function preoperatively, and then after one month and one year following surgical interventions. Four aspects related to sexual function were studied: interest in sex, quality of erection, ability to achieve orgasm, and ejaculation. Two questions about the preoperative information covering the sexual function and another two questions about the patients concern for their sexual activities were also added. Fisher's exact test was used to test for significant relative changes within each group of treatment for the variables studied.

Results

Ninety-one percent reported that they did not receive any preoperative information about the risk for any possible negative impact on the sexual function. None of the EVAR patients were given such information. Forty-two percent of all patients felt some anxiety about having sex before the operation, which decreased to 7% after one year. About 22% reported having strong/moderate ability of their erection and 54% reported this as being weak/very weak preoperatively. Patients who preoperatively had reported some form of sexual interest had experienced a significant impairment in sex (P < .039) one year after the interventions. Patients treated with EVAR reported a significant impairment in the quality of erection (P < .033) and their ability to achieve ejaculation (P < .047) one year after the operation. A similar tendency was seen in the OR group, but did not achieve statistical significance.

Conclusion

Few patients were given or understood any preoperative information concerning the risk and possibility of a negative impact on their sexual function following surgical interventions. This was especially reported by patients in the EVAR group. Following the operation, the reported sexual interest and ability was decreased among patients in both groups. When only those patients who had reported some form of interest in sexual activity before the intervention were analyzed, a small significant impairment in quality of erection and achieving ejaculation could be found during the one year follow-up in the EVAR group.

Erectile dysfunction has a negative impact on the quality of life.¹ It can be a consequence of abdominal aortic aneurysms (AAA).² Erectile dysfunction can also be a complication after open repair of AAA.³ The impairment of sexual function following AAA surgery has usually been attributed to autonomic nerve injury. Little is known of whether EVAR has an influence on the sexual function. The sexual organs are mainly supplied by the hypogastric arteries. It is not known how much impact interference with these conduits has on sexual function. It is, however, a theoretical possibility present with both open and endovascular procedures. Jimenez et al⁴ found in a review of articles from MEDLINE that the incidence of sexual dysfunction is lower overall in patients operated upon with EVAR. These findings were based on retrospective studies and can therefore only provide knowledge, which may be subject to question.², ³, ⁴, ⁵, ⁶ The results of these studies may be challenged since they had a follow-up percentage of less than 50% of the included and participant patients.

A prospective study from Netherlands showed that both EVAR and open elective AAA repair have an impact on sexual function in the early postoperative period but the recovery to the preoperative level was faster with EVAR than after OR.⁷ Assessment of health related quality of life (HQOL) following AAA surgery has been examined for patients with AAA in several studies with different instruments such as SF-36 and Nottingham Health Profile (NHP).⁸, ⁹, ¹⁰, ¹¹, ¹², ¹³ These instruments, however, do not enlighten the sexual life. SF-36 does not contain any questions at all and NHP contains only one regarding sexual function. For those patients facing an operation against AAA, little is documented or known about the importance and frequency of any preoperatively given information, concerning the risk of sexual dysfunction after surgery. Sexual function may be affected by many factors apart from the actual surgery and it is very important to take these factors into consideration.

The aim of this study was to investigate the importance and frequency of preoperative information given concerning possible sexual dysfunction and to compare the functional changes after open and endovascular repair of patients with AAA during the first postoperative year.

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Methods 

This study includes patients planned for elective surgery (OR and EVAR) between February 2003 and December 2004 from two University units of vascular surgery. Patients were consecutively invited to participate in the study. The inclusion criteria were: being able to express themselves and understand the Swedish language; being mentally clear; and diagnosed having AAA. Measurements were conducted before surgery, and one month and one year following surgery.

A validity and reliability tested questionnaire for measuring sexual function developed by Marquis¹⁴ was used. The instrument consists of the following questions: Your interest in sex? Quality of your erection? Achieving orgasm? Achieving ejaculation? Each question could be answered with the alternatives: very strong (0); strong (1); moderate (2); weak (3); very weak (4); or none (5). In this study, two specific questions directed to female patient's sexual function following surgery were added. These questions have previously been used in research after colorectal surgery.¹⁵ Women had to answer the questions: Your interest in sex? Achieving orgasm? The gender specific questions were: Have you experienced any problems with insufficient vaginal moisture in connection with sexual activity? Has the sensitivity and senses from the vagina changed after surgery? The possible answer were: yes; no; or no interest). Two questions focussing on the preoperative information given were added in the questionnaire to all patients. These questions were: Have you received any information about any potential influence or change on the sexual function in connection with the surgical procedure? Are you satisfied with the information you have been given regarding this aspect? Two questions, one close ended and one open ended, concerning patients anxiety and their sexual activity were also added: Are you worried about having sex after the diagnosis and surgery (yes, no, no interest). If you are worried, what are your major concerns?

All invited patients at both hospitals were given information about the study and after acceptance they answered the questionnaire and the supplemental questions. The questionnaire was then sent to each patient's home address after one month and then again after one year following surgery.

Statistical analysis 

The material is described with values expressed as percentages using mean, median, and standard deviation (SD) to show the variations. A non parametric test has been used. The analysis has been performed in two steps. In the first step, all the patients were included in the analysis and in the second step only those patients who had reported some form of interest in sexual activity. Pitmans test was used for testing potential relationships between variables. P value was used to prove significance. Differences have been compared by using Fisher's exact test for paired comparison. Differences were considered significant when P < .05.

Fisher's exact test was used in order to calculate significant changes of variables over time within each group. This is equal to each group being its own control. The relative changes from each group have been used for comparison between EVAR and OR. There was a difference in age between patients intervened with EVAR to patients with OR. This made it less suitable to use the absolute values from each group in a comparison between the two interventions. All comparisons regarding the impact over time by the two interventions are based on this specified analysis. Fisher's permutation test was used in order to investigate if age affects the answers.

Marquis¹⁴ uses a scale from 0 to 5 (the lower the score, the higher the function). In the second step of analysis, when measuring patients having some interest and some sexual function, only values between 0 and 4 were used. The score 5 was excluded in this part of the calculation since that corresponds to no interest or no function.

Ethical considerations 

All the patients were thoroughly informed about the aim of the study and their right to decline participation whenever they wanted. Ethical considerations used in the study were based on the Ethical Code of Nursing.¹⁶ The Ethical Research Committee of the Faculty of Medicine, Sahlgrenska Academy (S 712-02), has approved all the studies in the research program.

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Results 

A total of 90 patients were invited to participate and 14 of these declined this invitation. The average age of these 14 patients was 73 years in the EVAR group (n = 6) and 70 years for patients in the OR group (n = 8). Thus 76 patients (40 OR/36 EVAR) agreed to participate and completed the questionnaire preoperatively. The postoperative response rates for EVAR and OR were 88% versus 91% at one month and 84% versus 93% at 52 weeks. Characteristics, risk factors before surgery, and some demographic data are described in Table I. A majority of the patients suffered from hypertension and cardiovascular disease. There were no significant differences in characteristics between patients in the EVAR and OR group except age. Patients in the OR group were significantly younger than patients in the EVAR group (P < .001). There was no significant difference in the patients' answers to the questions between the two hospitals.

Table I. Patients' (n = 76) age, gender, diseases, and risk factors in the two groups and P value between the two groups: endovascular aneurysm repair and open repair

EVAR, Endovascular aneurysm repair; OR, open repair.

There were 26 tubular grafts and 14 biilical grafts implanted in the OR group and nineteen aorto-aortic tube grafts and seventeen aortobiilical stents in the EVAR group. Two patients had their hypogastric arteries occluded in connection with the EVAR procedure. One of these patients reported having the same sexual function before and after one year. The other patient reported very weak sexual function preoperatively and after one year reported having no interest in sex. Therefore this patient is not included in the calculation one year after operation (ie, the second analysis where only patients with sexual interest were included).

A majority (91%) of all patients (n = 75) reported that they did not receive any information preoperatively about any possible influence on their sexual function as a consequence of the intervention. In the EVAR group, all patients reported that they did not receive any information concerning the sexual aspect and consequences of the treatment. Older patients received less information than younger (P < .0042). In spite of this lack of information, 37% of the patients were satisfied with the information they had received preoperatively.

Overall, 23% of the patients (n = 75) stated that before operation they had no interest in sexual activity. Significantly more men than women reported interest in sexual activities (P < .001) and their ability to achieve orgasm (P < .001). Three of four women treated with EVAR had no interest in sex before the operation and one reported having normal function both before operation and after one year. Seven of nine women treated with OR had no interest in sex before operation and one had normal function before operation and after one year. The other patient reported normal function before surgery but that the sensitivity in the vagina was diminished after one year. Older patients reported a lower interest in sex than younger (P < .04). These differences in variables have been considered when comparing interest in sex and sexual function between the two treatment groups since the relative changes over time within each group were compared. Table II illustrates whether age or treatment method has any bearing on the change in the response. About 42% of all patients felt some anxiety about having sex before operation, while after one year, only 7% reported the same concern. There was a correlation between anxiety for sexual activity and age (P < .0091), with younger patients reporting more anxiety than older patients.

Table II. The changes in answers in relation to method of treatment and age

When comparing the interest in sex between the different time periods, 30% of the patients (n = 40) in the OR group reported no interest in sex preoperatively compared with 25% (n = 37) after one year. In the EVAR group, the corresponding figures were 20% (n = 35) before operation and 17% after one year (n = 30). These differences were not statistically significant. Before surgery, about half of all patients (48 %) reported a strong/moderate interest in sex. About 22% reported having a strong/moderate ability of their erection while 54% reported a weak/very weak quality of erection. About 37% of all patients reported moderate ability to achieve ejaculation. Detailed results concerning erection and ability to achieve ejaculation are presented in Table III. There was a positive significant correlation between interest in sex and achieving orgasm (P < .001), quality of erection (P < .001), and achieving ejaculation (P < .001).

Table III. Patients' reported sexual function in percent before surgery, after one month, and one year following surgery in both groups, endovascular aneurysm repair and open repair

EVAR, Endovascular aneurysm repair; OR, open repair.

In the first analysis, all patients were included in the calculations independent of their interest in sex. There were no significant differences between the two treatment groups before surgery in “interest in sex, the quality of erection, achieving orgasm, and achieving ejaculation.” There was no significant difference between the two treatments groups in the change over time (Table IV).

Table IV. Patients reported interest in sex, quality of erection, and achievement of orgasm and ejaculation before surgery, one month, and one year following surgery

Fishers′ exact test	EVAR			OR
	n	Mean ± SD	Two-tailed P value	n	Mean ± SD	Two-tailed P value
Interest in sex (baseline - 1M)	33	0.12±0.96	>.30	35	0.11±0.76	>.30
Interest in sex (baseline - 1Y)	30	0.20±0.71	.22	37	0.08±1.19	>.30
Interest in sex (1M - 1Y)	30	0.07±0.91	>.30	34	−0.06±1.07	>.30
Quality of erection (baseline - 1M)	33	0.15±0.87	>.30	35	0.20±1.05	>.30
Quality of erection (baseline - 1Y)	30	0.27±0.83	.14	37	−0.08±0.95	>.30
Quality of erection (1M - 1Y)	30	0.13±0.90	>.30	34	−0.26±0.79	.094
Achieving orgasm (baseline - 1M)	32	0.09±0.86	>.30	35	0.09±0.70	>.30
Achieving orgasm (baseline - 1Y)	30	0.33±0.96	.10	37	−0.11±1.02	>.30
Achieving orgasm (1M - 1Y)	29	0.21±0.68	.18	34	−0.20±0.91	.28
Achieving ejaculation (baseline - 1M)	32	0.25±1.05	.25	35	0.34±1.00	.072
Achieving ejaculation (baseline - 1Y)	30	0.37±1.03	.090	37	0.19±1.00	>.30
Achieving ejaculation (1M - 1Y)	29	0.07±0.92	>.30	34	−0.15±1.13	>.30

*Significant P < .05.

Mean, standard deviation (SD), and P value over time (analysis 1), score 0-5.

EVAR, Endovascular aneurysm repair; OR, Open repair.

In the second analysis, only patients who had preoperatively reported some form of interest in sex and sexual functions were included in the calculations. Baseline observations did not demonstrate any significant differences between the treatment groups. Changes over time for quality of erection and achieving ejaculation in the two groups are presented in Fig 1, Fig 2. Changes in steps for quality of erection and achieving ejaculation are presented in Fig 3.

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• Fig 1. 

  A, Changes in quality of erection for patients treated with OR (Patients with no reported interest in sex were excluded before calculation). B, Changes in achieving ejaculation for patients treated with OR (Patients with no reported interest in sex were excluded before calculation).

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• Fig 2. 

  A, Changes in quality of erection over time for patients treated with EVAR (Patients with no reported interest in sex were excluded before calculation). B, Changes in achieving ejaculation over time for patients treated with EVAR (Patients with no reported interest in sex were excluded before calculation).

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• Fig 3. 

  A, Change in quality of erection from before operation to 1 year after. (1 steps improvement = from normal->strong, 2 steps improvement = from normal to very strong. Patients with no reported interest in sex were excluded before calculation). B, Change in achieving ejaculation from before operation to 1 year after. (1 steps improvement = from normal->strong, 2 steps improvement = from normal to very strong. Patients with no reported interest in sex were excluded before calculation).

A significant impairment of the patient's interest in sex (P < .039) from the situation preoperatively until one year after operation were found in the whole group. Patients treated with EVAR had a significant impairment in the quality of erection (P < .033) and achieving ejaculation (P < .047) from preoperatively until one year after operation. No significant differences were found within the OR group. Even if the same tendency was present within the OR group, no significant differences could be found (Table V). About 38% of the OR patients (n = 37) reported after one year a weak or very weak ability to achieve ejaculation in relation to 25% (n = 40) before operation, but this difference was not statistically significant. In the EVAR group, the comparing figures were 40% before operation and 54% after one year, and in this case the difference became significant.

Table V. Patients reported interest in sex, quality of erection, and achievement of orgasm and ejaculation before surgery, one month, and one year following surgery

Fisher's exact test	EVAR			OR
	n	Mean ± SD	Two-tailed P value	n	Mean ± SD	Two-tailed P value
Interest in sex (before operation - 1 Month)	25	0.16±0.80	>.30	23	0.09±0.67	>.30
Interest in sex (before operation - 1 Year)	23	0.30±0.70	.093	25	0.24±0.93	.30
Interest in sex (1 Month - 1 Year)	23	0.09±0.79	>.30	24	0.04±1.08	>.30
Quality of erection (before operation - 1 Month)	26	0.15±0.73	>.30	20	0.25±0.64	.18
Quality of erection (before operation - 1 Year)	23	0.39±0.72	0.033 ⁎	23	0.04±0.64	>0.30
Quality of erection (1 Month - 1 Year)	23	0.09±0.67	>.30	21	0.19±0.60	.29
Achieving orgasm (before operation - 1 Month)	23	0.00±0.67	>0.30	22	0.05±0.49	>0.30
Achieving orgasm (before operation - 1 Year)	22	0.32±0.84	.15	24	0.00±0.59	>.30
Achieving orgasm (1 Month - 1 Year)	22	0.27±0.70	.15	22	−0.09±0.68	>.30
Achieving ejaculation (before operation - 1 Month)	20	0.15±0.67	>.30	20	0.30±0.98	.28
Achieving ejaculation (before operation - 1 Year)	20	0.45±0.83	.047 ⁎	24	0.38±0.92	.094
Achieving ejakulation (1 Month - 1 Year)	19	0.26±0.73	.24	20	0.15±0.99	>.30

Mean, standard deviation (SD) and P value over time (analysis 2), score 0-4.

EVAR, Endovascular aneurysm repair; OR, open repair.

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Discussion 

Sexual ability, performance, and interest are dependent on physical as well as mental variables. Facing the reality of an operation for AAA and thoughts about the risk for rupture may influence the patients' interest in having sex. About 40% of all patients in this study felt some anxiety about having sex before operation. This figure decreased to 7% after one year. It is possible that repeated answering of the questionnaires contributed to a more open attitude to sexual interest and therefore maybe decreased the patients reported anxiety about sexual activity. The percentage of patients answering “no interest” also had a tendency to decrease one year after treatment in both treatment groups. However, most of the patients did not report any change in sexual function before and one year after operation. On the contrary, only the EVAR group showed a significant impairment in the quality of erection and achieving of ejaculation after one year. The same tendency was seen with OR patients but did not reach any statistical significance. These findings cannot be explained by the differences in age since only the relative changes within each treatment group were tested. However, the patients in the EVAR group was older but there were no significant differences in characteristics or “interest in sex, the quality of erection, achieving orgasm, and achieving ejaculation” between patients in the EVAR and OR group.

Our results do not confirm earlier published studies. One should, however, be aware that previous studies have mainly been retrospective², ³, ⁴, ⁶ and have a response rate of 40% or lower. The response rate of the present study was about 90%, which should be regarded as satisfactory. We feel that it is very difficult to evaluate such complex activities as sexual interest and ability using a retrospective approach. This study is based on patients' self-reported experiences of their sexual functioning and not on any physiological measurements and thus does not indicate whether their experiences are influenced by injuries to the iliac vessels, crucial nerves, or change in their mental status. The explanation of the findings needs further research.

Analysis of changes in sexual function might be more relevant for those who are interested in sex and have some kind of sex life before the surgical intervention. We analyzed the material in two steps since patients with no expressed interest or ability might develop that after the operation. Theoretically, any intervention and/or the disease itself could trigger and induce an increased level of anxiety, which preoperatively might block any thoughts concerning sex. There is a close relationship between ability and interest. Dysfunction may lead to a decrease in interest. On the other hand, it is difficult to know whether the patients who lacked interest had a change in the physical ability to achieve erection and orgasm.

The international index of erectile function (IIEF) did not fully fit in our study because it contains many questions that are of minor relevance. The instrument in our study uses only four questions, in a scale from very strong to very weak and none. The low number of questions in the questionnaire might be an explanation to the few drop outs. The instrument used is tested for reliability and validity.¹⁴

This study shows that the information given to the patients in the participating hospitals regarding the potential effect of the operation on their sexual function was clearly insufficient. The vast majority of patients reported that they did not receive any such information. This is in line with Akdolun et al,¹⁷ who found that most patients do not receive any information regarding the changes in sexual function in connection with myocardial infarction. In our study, no patient planned for EVAR was given any information about possible sexual consequences, which might mirror the current belief about the potential risk for sexual impact with the endovascular procedure. According to our present study, this conclusion may be questioned. Some patients stated that it was the operation itself that was most worrying and in comparison, sexual function was regarded as unimportant. It is therefore difficult to judge whether the patients anyhow received information but it might not have been understood or in cooperated. It cannot be taken for granted that the patients would elect an operation if they had been given and understood vital and crucial information. The result of this study shows that those patients who received information were generally satisfied but some of those who stated that they had not received any information about the possible effects on their sexual function were also satisfied.

Our study shows a higher sexual dysfunction preoperatively than Lee et al³ reported but agree with Prinssen et al.⁷ Preoperatively, about 25% of the patients had no function/interest in one of the variables: interest in sex; the quality of erection; achieving orgasm; and achieving ejaculations, which agrees with Xenos.⁶ About 19% to 20% of all patient reported moderate, strong, or very strong quality of erection before, after one month, and after one year, which agrees with earlier studies², ³ reporting a sexual dysfunction in about 80% of the patients.

Prinssen et al⁷ showed that both OR and EVAR can have an impact on sexual function in the early postoperative period but patients treated with EVAR recovered to preoperative levels faster than after OR. There were no differences seen between OR and EVAR regarding the sexual function after three months. Although the study of Prinssen et al⁷ was randomized and the questionnaire was validated, the questionnaire did not measure sexual dysfunction on a scale. The answers to this questionnaire were completely agree, partly agree, completely disagree, or don't know. The instrument is part of a Swedish Health-Related Quality of life survey and is therefore not specially constructed to focus on problems regarding sexual functions. Thus, this instrument could not measure the ability to achieve ejaculation and therefore could only give a limited knowledge basis. Some retrospective studies indicate less impairment of sexual function with EVAR compared with OR.⁴, ⁶ This is not in agreement with our findings, but as previously stated, we do not think that a retrospective approach is the best way to elucidate sexual function over time in connection with different interventions.

In the second analysis in which only patients who had preoperatively reported some form of interest in sex and sexual functions were included in the calculations, a significant impairment developed in the quality of erection and the ability to achieve ejaculation in the EVAR group during the first year after the operation. One explanatory factor for this result is that EVAR-treated patients have to return to the hospital for regular check-ups in the form of X-rays. These postoperative controls may cause worries and anxiety, which can influence erectile ability and the ability to achieve ejaculation. In this study, coiling of the hypogastric arteries was performed preoperatively in only two cases in the EVAR group. These two patients do not explain the result. A tendency to having a lower sexual function over time was also seen in the OR group, which would agree with earlier studies,³, ⁴, ⁶, ⁷ but this tendency was not significant in our study.

It is important to study the effects of the OR and EVAR methods on women's sexual functions, as the prevalence of AAA in women may increase when their lifestyle becomes increasingly similar to that of men. In previous studies, women's perceived sexual functioning is focused upon¹⁸, ¹⁹ but no comparison had been made between EVAR and OR. In this study, comparison between women in the OR and the EVAR groups were not performed since the number of women was insufficient. The small number of women who participated in this study reported significantly lower interest in sex compared with the men, for which several explanations are possible. One of the two women operated with OR reported normal function before surgery but the sensitively in the vagina became diminished after one year, which perhaps indicates that women's sexual functions can also changes after an operation for AAA. One should be aware that sexual ability is always difficult to measure, as some people may experience their sexual dysfunction as embarrassing, which may lead to less truthful responses.

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Conclusion 

A majority of the patients with AAA reported not to have received preoperative information about potential impact on sexual function from interventions against abdominal aortic aneurysms. Preoperatively, only about half of the patients expressed a moderate, strong, or very strong interest in sex. Only about 22% reported having a strong/moderate ability of their erection. Patients who preoperatively had reported some form of sexual interest had experienced a significant impairment in sex one year after the interventions. The analysis of all patients independent of their preoperative ability or interest in sex showed no significant differences between EVAR and OR treated patients in their sexual function preoperatively compared with one month and one year after the operation. Following the operation, the reported sexual interest and ability was decreased among patients in both groups. When only those patients who had reported some form of interest in sexual activity before the intervention were analyzed, a small significant impairment in quality of erection and achieving ejaculation could be found during the one year follow-up in the EVAR group.

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Author contributions 

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The authors are grateful to the patients for their participation in the study.

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