The Impact of Peritoneal Dialysis on the Sexual and Affective Life of Patients
Introduction: Chronic renal failure, peritoneal dialysis and the abdominal catheter have a significant impact on the psychological state, sexual life and behavior of patients and their partners.
Material and Methods: We investigated, using an anonymous questionnaire of 23 questions, the impact of peritoneal dialysis on the sexual and emotional lives of 75 patients treated with this technique of dialysis during the year 2007.
Results: Sixty-five patients participated in this study: 35 Men and 30 Women whose majority belongs to the age group 36-55 years. Thirty-seven are married and 32 have children at the time of the study. Twenty-one reported sexual impotence in PD (32.3%).
The number of sex is decreased in 36 (55.4%), libido in 16 (24.6%) and orgasm in 26 patients (40%).
The PD catheter was embarrassed 13 partners during sexual activity (20%) and 14 constantly avoid looking at the bodies of their spouses during these times (21.5%).
Thirty-four patients (52.3%) are supported and assisted by their partners and the half accepts to discuss with them about their sexual problems.
The partner (44.6%) and the physician (13.8%) are the most requested by patients to talk about sexuality. Fifty-one patients (78.4%) believe that sexual activity is essential for the psychic balance and thirty eight want to have children (58.4%).
Dialysis without problems (43.1%) and family stability (24.6%) are the two main concerns of patients.
Conclusion:The peritoneal dialysis and the PD catheter does not affect the sexual and family life of our patients and the relationship with their spouses. Family support is crucial for the psychic balance of patients whose main concern remains the dialysis uneventfully.
Keywords: Peritoneal dialysis; Sexual problems; Libido; Impotence; Psychology
Like very reached organic, the renal insufficiency can entrained serious disturbances of sexuality. It is often associated with a narcissistic devalorization and a loss of the imaginary feeling of any power [1]. The anguish is so intense that the subject is folded up on itself and cannot invest any more the other as an object of love.
Few teams were interested in the impact of the chronic renal insufficiency and of dialysis on the sexual, emotional and marital life of the patients who are generally treated by hemodialysis.
The goal of our study is to analyze the psychological profile of the patients treated by peritoneal dialysis PD, the impact of the technique on their emotional and sexual life, their relations with spouses and medical staff looking after team.
We prospectively studied a cohort of 75 patients having an end stage renal disease ESRD and treated by PD in our department of Internal medicine of the Charles Nicolle Hospital of Tunis lasting since year 2007.
The material of this study is an anonymous questionnaire, written in clear, easy and comprehensible Arab language associated with the needed explanations under the care of the team. It is filled individually by the patient without the intervention or the looking after of the spouse. Then it is put in an anonymous envelope, put in its turn in one limps sealed.
Patients are following in our center by clinical, biological and radiological exams and semi-annual psychological evaluation.
The statistical study was carried out using the software “Stat view 5.0”. The continuous variables were expressed on average ± standard deviation or in median.
The nominal variables were analyzed with the test «chi2with a p statistically significant when it is ≤ 0.05.
Charles Nicolle’s ethical committee end the ethical committee of the ministry of health approved this clinical study.
Ten patients refused to take part in the study and 65 agreed to answer the questionnaire (86,7%). Our study concerns only theses 65 patients: they are 35 men and 30 women on average of 31,5 ±11 years with extremes of 18 and 75 years. The majority of the patients belonged to the age bracket of 36-55 years (50,7%).
The histogram n°1 shows the distribution of the patients according to the age and the gender.
Thirty seven patients were married (56,9%), 27 single people (41,5%) and one divorced.
Thirty two had children (49%).
Twenty nine (44,61%) patients are diabetic, 15 had hypertension, 12 chronic glomerular nephropathy and 9 unknown nephropathy.
The principal results of the questionnaire are represented by Tables 1, 2, 3 and 4.
The sexual disorders, often present during the chronic renal insufficiency, can deteriorate the quality of life and the body image of the patients. Several factors are at the origin of the sexual dysfunction and the disorders of the fertility: hormonal abnormalities, possible diseases associated with the renal insufficiency and the psychological repercussion with the disease by its effects on the living conditions and the feeling «to be well “. But because of the character which is too often a “taboo «subject, the importance and the exact frequency of this side effect of the CRI are badly known [2].
The serious disturbances of sexuality will be accompanied by a narcissistic devalorization and a loss of the imaginary feeling by any power [3].
During this period any intervention of the sexological type is out of this matter. It is only later on when the somatic treatment can lead to a certain stabilization through the sexual problem will arise [4].
Any disturbance of the urinary function (oliguria or anuria) is lived by certain men like an attack of virility and confirmation of the reality of castration symbolic system. This is particularly obvious for the personalities of phallic structure or exists permanent need to prove virility, the power to reassure themselves as for the anguish of castration [5].
Few studies were interested in the sexual disorders during the CRI and during the treatment by dialysis. They are primarily patients treated by hemodialysis.
Study EPIREL (387 patients) had shown that the sexuality of those is measured by sexual dimensions of the KD-QOL that was bad at the starting of dialysis (HD and PD).
At one year, sexuality improved for the patients treated by PD (score from 53 to 71) while it was degraded at those treated by HD (score from 59 to 49) [6].
We were interested in the study of the emotional and sexual life among 75 patients having ESRD and treated by peritoneal dialysis during year 2007.
The majority of the patients agreed to take part in this study based on an anonymous questionnaire. On the totality of the patients, only the third approximately suffer from a sexual disorder with the type of impotence at the men or frigidity among women.
Fleury brought back more raised frequency of sexual disorders: 65% of the patients are not satisfied with their sexuality and 40% ceased any sexual activity [2].
In our study this disorder is more frequent at the men with a statistically significant difference (51,4 vs 10%, p<0,0001).
The relations inside the couple are strongly disturbed during renal replacement therapy.
The sick man loses his role of authority and referent symbolic system to take the statute of assisted and the object of compassion.
The long disease and unemployment are lived with a strong culpability which will result in a loss of the libido [1]. When the man is sick, the woman ensures the family loads and this inversion of the traditional roles lived in a way very devaluing by the man, results in impotence [1]. The prohibition of pregnancy, is very devaluing for the woman and signs the end of its social role [1,4].
Twenty six of our patients suffer from tiredness during the sexual activity (40%) and 55,4% bring back a reduction in the number of the sexual relations with a reduction in the libido statistically more marked at the men (34,3 vs 13,3 %, p<0,001).
The reduction in orgasm is reported by 40% of the patients with a frequency statistically higher at the men (51,4 vs 26,7%, p<0,001).
Willaume et al. reported that half of their patients did not note any change of their sexuality after the setting for dialysis [6].
The surgical intervention and in particular the insertion of the catheter of PD especially can entrained of the unaesthetic scars which go, among women, to constitute serious attacks of the image of oneself and a narcissistic frustration with a car devalorization source of sexual disorders in particular a frigidity [1,5].
In our study, 56,9% of patients report that their partners are not obstructed by the presence of the catheter of PD and 52,3% in which they do not avoid looking at their bodies during the sexual activity.
Among the partners obstructed by the presence of the catheter, the men occupy the front of the table with a statistically significant difference (28,6 vs 10 %, p<0,001).
The family support in particular of the spouse is capital for the psychological balance of the patient, for his good adhesion with the treatment and for its good being. More half of our patients (52%) found in their partner a support to overcome the handicap represented by the presence of a foreign body in fact the catheter.
During the period of dialysis, much of authors noticed the recrudescence of the masturbations at the two sexes testifying to the regression towards the phallic stage on the one hand and to fold on oneself related to the very strong anguish of the disease [1].
The request for sexual relation thus became a difficult and opposing exercise. Forty percent of our patients require the sexual relation against 29,3% of the partners. Thirty percent refuse to answer this question.
More half of the patients treated by PD frequently discuss their sexuality within the couple what confers a feeling of safety and a good adhesion with the treatment to them. They are especially the men who take the initiative with regard to the request of conversation or even of the sexual relations with a statistically significant difference (62,8 vs 13,3%, p<0,0001).
The relation with the team looking after him or her is very complex. It is sometimes erotized and is accompanied often by regression and infantile attitudes criticized supported by the dependence which exists in reality [1]. This fact the survival of the technique and patients depends permanently on the therapeutic team with whom very productive relations will be established.
Twenty percent of the patients agree to imply the caring team (doctors or male nurses) in their sexual and emotional life.
They are especially the men who agree to speak about it with the doctor or the male nurse with a statistically significant difference (34,3 vs 13,3%, p<0,0001).
The majority of the patients refuse on the other hand to tackle the same subject with the other patients (78,4%) or the friends (66,1%).
In the work of Willaume, almost all the patients refuse to speak about their sexuality with the caring team, but more than the half wish that the subject is tackled with the doctor in consultation [6].
Most of the three quarter of our patients and their partners are members of the progressive idea per many authors and psychologists based on the fact that the re-establishment of the libinal relation and erotic between the partners is capital for psychological balance and the stability of the couple.
The partner and the doctor are the people that the patient can trust with regard to his sexuality with respectively 44,61% and 13,8% of the cases.
The quarter of the patients refuse to speak about their sexuality with another person.
The absence of children in the patient-partner couple worsens the situation and represents another handicap added again to an unstable and badly balanced married life.
The majority of our patients (58,4%) wish to have children and think that their presence will improve their life as a couple.
The sexological treatment of these patients witnessed a large projection lately but the majority of the authors use it only when the vital problems were solved. The purpose of it is amongst other things to decrease the anguish of the patients while avoiding tranquillizing them having like adverse effect the reduction of the libido and thus preferring the psychotherapy of support which will act on the narcissistic devalorization and the attack of the body image [2,7]. Some teams use the anabolisants and the androgens to increase the sexual desire [7]. Few of our patients are followed in a sporadic way by psychologists.
Lastly, in spite of its cardinal importance in the stability of the couple, the sexual activity occupies the fourth place in the daily concerns of the patients after the adequate dialysis, the family stability and the support of the spouse.
However 94,3% of the men think that the sexual activity is of primary importance for psychological balance counters only 60% of the women with a statistically significant difference (p=0,02).
The impact of the chronic renal insufficiency and peritoneal dialysis on the sexual and emotional life of the patients is significant but it is little documented.
The sexual disorders and their psychological repercussions are frequent among our patients who agree to speak about it with their partners and the caring team.
