Sexual Dysfunction in Acquired Brain Injury (ABI)

Disease/Disorder

Definition

Sexual dysfunction is defined as difficulty with the various aspects of sexual activity such as attraction, arousal, pleasure, and orgasm. Many factors can influence the sexual function of an individual.

Sexual dysfunction can be classified into five categories

• Sexual desire disorders
  • Sexual aversion
  • Hypoactive sexual desire
• Sexual arousal disorders
  • Poor lubrication in women
  • Erectile disorders
• Orgasmic disorders
  • Anorgasmia
• Ejaculatory disorders in men
  • Early ejaculation
  • Delayed ejaculation
  • Anejaculation
• Sexual pain disorders
  • Dyspareunia
  • Vaginismus
  • Noncoital sexual pain disorder

Etiology

Sexual dysfunction in ABI can be related to physical damage to specific brain regions or neural pathways, resultant alterations in the body’s neurochemical milieu, or endocrine disturbances. Behavioral and cognitive impairments, physical limitations, and medication effects may also compromise sexual performance in this population.

Epidemiology including risk factors and primary prevention

Given the broad definitions of sexual dysfunction, large scale epidemiological studies regarding the incidence of sexual dysfunction among ABI patients are difficult to conduct. Previously, sexual dysfunction in traumatic brain injury (TBI) patients was estimated to occur anywhere from 4-71%.^1,2 According to Ek et al,³ a more recent cross sectional study involving 250 patients found that while 78% of patients had resumed some form of sexual activity, among them, 63% experienced no or diminished sexual desire, 54% were dissatisfied with sexual desire, 53% were dissatisfied with the state of their sexual life, and 38% reported no or decreased orgasm. A cohort study by Yang et al^4,5 on erectile dysfunction (ED) covering 72,642 patients found that the incidence of ED in patients with TBI was higher than in patients without TBI (24.66 and 19.07 per 100,000 respectively). A systematic review of 40 studies by Robert et al⁶ analyzing sexual dysfunction in TBI population found that patients experienced a wide range of symptoms, including decreased frequency of intercourse (47-62%), diminished sexual arousal (24-86%), erectile dysfunction (24.2-57%), and difficulty with or achieving orgasm (29-40%).

The risk factors for sexual dysfunction following ABI have yet to be well established using large scale clinical studies. However, current literature reports that factors such as increased age, depression, anxiety and more severe injury were associated with higher rates of sexual dysfunction in patients with TBI.⁷

Patho-anatomy/physiology

The pathophysiology of sexual dysfunction in the ABI population is multifactorial. These factors include biological, physiologic, neuropsychologic, iatrogenic, and social aspects.

• Biological
  • Older age
  • Erectile dysfunction and fewer ejaculations post-ABI
  • Sex
    • There are laboratory studies that support estrogen and progesterone have neuro-protective properties by reducing apoptosis of neural cells after TBI and stroke.⁸
    • Studies show that progesterone and estrogen facilitate neural regeneration in the peripheral nervous system.⁹
    • However, there are also contradicting studies that suggest that females of reproductive age experience greater symptoms due to change in hormones, which negatively affect sexual function in ABI patients.¹⁰
• Physiologic
  • Sexual desire involves cortical, subcortical, brainstem, autonomic, and peripheral nervous system structures. Injury to any of these structures and the subsequent neuroendocrine disruption can cause sexual dysfunction.^11,12,13
    • Injury to hypothalamic-pituitary-gonadal axis decreases levels of sex hormones, resulting in decreased libido.¹⁴
    • In children, lesions in this pathway can lead to hormonal dysregulation, resulting in precocious puberty or hypogonadotropic hypogonadism.
    • Lesions in the medial and preoptic hypothalamic nuclei eliminate sexual behaviors in patients through preventing response to dopamine.
    • Dorsomedial hypothalamic nucleus injury can inhibit ejaculation.
    • Dorsolateral lesions of the frontal lobe may decrease sexual drive.
    • Lesions of the orbitofrontal area may result in socially inappropriate behaviors.
    • Bilateral temporal injury can lead to Kluver-Bucy syndrome, which presents with hypersexuality and hyperorality.
    • Damage to the limbic and prefrontal cortex leads to disinhibition, which results in hypersexuality and excessive masturbation.
    • Damage to the supraoptic nucleus or the septal complex inhibits release of oxytocin, which is involved in lactation, birthing, and orgasm.
    • Damage to motor cortices can cause mobility impairment.
    • Physical impairments such as difficulty with mobility and fatigue from ABI can negatively affect sexual performance.
• Neuropsychological
  • Cognitive and communication impairments such as aphasia, memory deficits, inattention, executive dysfunction, abulia, apathy, decreased emotional regulation, and decreased ability to empathize can hinder ability and opportunity for intimacy.
  • Mental health conditions such as depression and anxiety can play a role in social and physiological factors such as decreased social participation, reduced body image, performance anxiety, reduced libido and pleasure, and fatigue.^15,16
• Iatrogenic/Medication induced
  • Selective Serotonin Reuptake Inhibitors (SSRIs) may increase prolactin levels. This leads to decreased GnRH levels, inhibits FSH and LH production, and in turn limits the production of circulating sex hormones.^17,18,19
  • Serotonin Antagonist and Reuptake Inhibitors (SARIs) such as trazodone, normally block serotonin reuptake inhibitors, therefore are used in improving libido. However, trazodone which blocks alpha-adrenergic receptors, may cause priapism in men and persistent sexual arousal syndrome in women.^17,18,20,21
  • Opioids can suppress the hypothalamic-pituitary-gonadal axis leading to decreased secretion of LH and FSH production.
  • Tricyclic Antidepressants (TCAs) alsoinhibit the reuptake of serotonin and norepinephrine. However, they cause less sexual dysfunction compared to SSRIs.
  • Antipsychotics
    • Sexual dysfunction from antipsychotics can also result from antagonism of histaminergic, dopaminergic (especially D2), cholinergic, and alpha adrenergic receptors, leading to sedation, reduced libido, erectile dysfunction and impaired arousal. First generation antipsychotics such as risperidone, are known to elevate prolactin levels via dopamine receptor antagonism.
    • Atypical antipsychotics are associated with lower incidences of elevated prolactin levels.²²
  • Benzodiazepines enhance GABA receptor activity, which can suppress penile function.
  • Anticonvulsants may lower levels of free gonadal hormones, most notably estrogens.
  • Antihypertensives
    • Beta blockers inhibit the sympathetic nervous system, thereby affecting erection, emission, ejaculation, and the release of luteinizing hormone and testosterone.
    • The mechanism by which diuretics like thiazides cause sexual dysfunction is less clear, though research suggests they may have a direct impact on vascular smooth muscle or reduce responsiveness to catecholamines.²³
    • Clonidine is an alpha-2 adrenergic agonist which reduces sympathetic outflow and decreases norepinephrine. 
• Social
  • Lower self-esteem and negative body image
  • Decreased social participation
  • Altered relationship dynamics compared to prior to the injury
  • Decreased ability of younger population to navigate relationship challenges due to inexperience
  • Reluctance to discuss with healthcare providers
  • Lack of knowledge and resources for sexual dysfunction

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)

According to Zasler et al,²⁴ sexual dysfunction begins immediately after brain injury but may not be recognized until later.

• Initial phase (immediately following the injury)
  • Injury to specific brain areas can result in immediate disruption of sexual behavior through hormone disturbances
  • Motor, sensory, and autonomic dysfunction can affect physical ability for sexual activity, arousal, and genital response.
  • Cognitive deficits can impair relationship skills.
• Sub-acute phase (weeks – months post injury)
  • Hormonal dysregulation becomes more apparent with decreased libido, erectile and lubrication issues, and orgasmic problems.
  • Depression, anxiety, and low self-esteem become more pronounced and relationship strain intensifies.
• Chronic phase (months – years post injury)
  • Some individuals regain function while others report long term issues with sexual dysfunction.
  • Neuroendocrine abnormalities can be persistent at this stage
  • Social or identity challenges emerge.

Individuals with mild brain injuries, strong pre-injury relationships, access to sexual health support, and open communication tend to have a better prognosis for sexual recovery.

Secondary or associated conditions, complications

Sequelae of sexual dysfunction include negative impacts on patients’ emotional, psychological, and social health. Sexual dysfunction can cause or exacerbate depression, anxiety, low self-esteem, poor body image, and cause performance anxiety. Social implications include partner dissatisfaction, loss of intimacy or emotional connection, divorce, and difficulty forming new relationships. Patients experiencing hypersexuality may cause harm to self or others through inappropriate or risky sexual behaviors, exposing themself or others to sexual exploitation or STDs.^24,25

Essentials of Assessment

History

Given the multifaceted nature of sexual dysfunction after brain injury, it is essential to keep the history broad. These topics can often be sensitive for patients so a safe and comfortable environment for patients should be provided, and practitioners should remain non-judgmental. History should include

• General ABI History: Mechanism of injury, timing of injury, severity
• Medical comorbidities such as diabetes, thyroid disorders, cardiovascular disease, hypertension, hyperlipidemia, cancer, and benign prostatic hypertrophy
• Current medications and history of any recent medication changes.^23,26
• Sexual history: Sexual practices, use of protection, timeline of sexual dysfunction symptoms i.e. pre or post brain injury, changes in libido, change in sexual activity frequency, erectile dysfunction, ejaculatory dysfunction, orgasmic dysfunction, nocturnal penile tumescence, dyspareunia, vaginal lubrication, hypersexuality
• Mood and Psych: Depression, anxiety, post-traumatic stress disorder, sleep disorders, emotional lability, substance use, self-esteem, body image
• Endocrine/systemic causes: Testicular atrophy, gynecomastia, breast size changes, fatigue, change in weight, heat or cold intolerance.²⁷
• Infection: History or exposure to STDs from prior partner, fever, chills
• Genitourinary: amenorrhea, dysmenorrhea, testicular swelling or pain, alteration in genital sensation, bowel or bladder incontinence, dysuria, hematuria, change in urinary frequency, vaginal discharge, penile discharge 
• Current functional status and ability to perform ADLs

Physical examination

It is essential to conduct the physical exam following a trauma-informed care approach.

• General
• Cardiopulmonary exam
• Endocrine: Thyroid examination and palpation
• Abdominal exam
• Neuro exam
  • Mental status
  • Motor strength
  • Range of motion
  • Muscle tone
  • Sensory exam: light touch, pinprick, proprioception
    • Assess T11-L2 and S2-S5 given parasympathetic and sympathetic outflow tracts
  • Reflexes, can include anal wink and bulbocavernosus reflexes
• Genitourinary examination
  • Assess for lesions, rashes, ulcerations of genitalia
  • Penile and testicular exam: urethral position, penile discharge, testicle size, and testicular masses
  • Vulva exam: assess for atrophy, inflammation, strictures, and lacerations
  • Vaginal exam
  • Pelvic exam: pelvic floor tenderness, pelvic floor strength
• Rectal exam
  •  Sphincter tone, lesions
• Prostate exam
• Breast exam

Laboratory studies

• Complete Blood Count, Basic Metabolic Panel, fasting glucose, liver function test as cirrhosis can lead to hypogonadism (28), lipid panel
• Endocrine studies: thyroid-stimulating hormone (TSH) and T4, serum free testosterone, prolactin Luteinizing Hormone, (LH) Follicle Stimulating Hormone (FSH), estradiol
• Urine analysis
• Sexually transmitted disease testing including gonorrhea, chlamydia, HIV, vaginosis panel for those at risk

Imaging

• Penile color duplex ultrasound to identify areas of potential venous leak or arterial obstruction in those with erectile dysfunction to determine cause
• Pelvic ultrasound to rule out structural causes such as fibroids, cysts or tumors, as well as infectious causes, such as pelvic inflammatory disease
• Vaginal photoplethysmography and MRI to assess blood flow, an indicator of female sexual arousal
• Somatosensory evoked responses of the dorsal and pudendal nerves to evaluate for neurogenic sexual dysfunction, though this test is more invasive and less utilized.^29,30,31

Supplemental assessment tools

• Brain Injury Questionnaire of Sexuality (BIQS): Evaluate changes in function pre and post TBI.
• DSM-V criteria for hypoactive sexual desire disorder (HSDD): Assess for decreased or lack of sexual desire for patients. These symptoms include
  • Persistent or recurrent lack of sexual fantasies and desires
  • Marked distress or interpersonal difficulty due to sexual activities

Rehabilitation Management and Treatments

Current treatment guidelines

The recently published INTIMASY-TBI by Patsako et al³² provides best practices and guidelines on how to treat adult patients with TBI who suffer from sexual dysfunction.

• Interprofessional training: All team members involved in a patient’s care should be trained to have a fundamental understanding of how an individual’s sexuality, intimacy, and sexual relationships can be affected by TBI. Prior studies support the use of the PLISSIT model (Permission, Limited Information, Specific Suggestions, Intensive Therapy) to initiate conversations regarding sexuality in patients with TBI.
• Culturally Competent Education: Sexuality interventions for individuals with TBI should be culturally sensitive and inclusive of all gender identities, sexual orientations, and expressions. Clinicians should use a person-centered approach, inclusive language, and cultural humility. Providers should be aware of potential cultural nuances that may influence patient views on sex and incorporate them into appropriate interventions.
• Individualized interventions: The symptoms, types of sexual dysfunction, and appropriate interventions, can vary greatly. Patients with TBI can also experience sexual dysfunction for the same reasons as the general population. Non-pharmacological recommendations may include the use of aids like lubricants, dilators, prosthetics, or suggestions for alternative sexual positioning to minimize issues related to balance, physical limitations, or discomfort. Treatment plans may require expertise from multiple rehab professionals. For example, a physiotherapist can be consulted to address a patient’s limited mobility or difficulty with positioning, whereas a speech therapist can assist with communication deficits. If appropriate, rehabilitation physicians can consider medical interventions. Medications like SSRIs are commonly used to treat depression and conditions like premature ejaculation, but they can also cause sexual dysfunction as a side effect. In such cases, consider serotonin receptor antagonists and reuptake inhibitors, such as trazodone, or the norepinephrine-dopamine reuptake inhibitor bupropion. Libido can be enhanced by apomorphine, a dopaminergic agonist, via stimulation of dopamine receptors, or fenfluramine, traditionally used as an appetite stimulant, via releasing serotonin. Phosphodiesterase inhibitors (e.g. sildenafil) or alprostadil injections can be effective treatments for erectile dysfunction. For postmenopausal women, estrogen creams are commonly used to treat vaginal dryness, while androgen therapy can address low libido. In some cases, medications like flibanserin or bremelanotide may be prescribed for hypoactive sexual desire disorder in women.^33,34,35
• Provide written and other supportive educational material: Educational material for patients, partners, and/or caregivers should be written in lay terms, ideally at a 6th grade reading level, and cover the following topics: causes of changes in sexuality, sexual functioning post-ABI, how to improve sexual functioning after TBI, the importance of safe sex, and how to discuss intimacy and sexuality with a healthcare professional.
• Referrals and Peer Support: Provide referrals to appropriate counseling resources, support groups, and specialists.
• Communication and Relationship Training: Communication training should include how to recognize, express, and regulate emotions and needs. Relationship training should include communication, empathy and social understanding. Behavioral challenges such as emotional or behavioral dysregulation, poor hygiene, impaired judgment, disinhibition, or impulsivity should be addressed. Several evidence-based relationship programs have shown positive outcomes, though none currently focus on 2SLGBTQ+ or Indigenous communities, highlighting a gap in inclusive care.

Cutting Edge/Emerging and Unique Concepts and Practice

• Transcranial Magnetic Stimulation: Use of repetitive transcranial magnetic stimulation (rTMS) has demonstrated improvements in sexual activity for patients following spinal and pelvic trauma in a case report by Wang et al⁴ as well as helping with ejaculation latency in an animal model study by Liu et al³⁶ and may be applicable to patient who have had brain injury.
• Regenerative therapy: Ongoing research is being done utilizing low intensity shock wave therapy, platelet-rich plasma, and stem cell therapies with erectile dysfunction and female sexual dysfunction.³¹
• Cognitive behavioral therapy: a small group early research shows it may help with sexual problems after a brain injury, especially with TBI.³⁷

Gaps in the Evidence-Based Knowledge

• More studies inclusive of 2SLGBTQ+ or Indigenous communities
• High quality epidemiological studies with larger and more diverse samples including women, younger stroke patients, mild TBI, patients with aphasia

References

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Original Version of the Topic

Lawrence Horn, M.D. Sexual Dysfunction in Acquired Brain Injury (ABI). 6/7/2013

Previous Version(s) of the Topic

Parisa Zarreii, MD, Maria Humayun, DO, Lawrence Horn, MD. Sexual Dysfunction in Acquired Brain Injury (ABI). 3/13/2018

Author Disclosure

Bryan Le, MD
Merz Therapeutics, Honorarium, Medical Education

Min Ju Kim, DO
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Myrna Hanna, DO
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Rohan Gogoi, MD
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Giorgina Giampaolo, MD
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Aye Mon Win, DO
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