Received: 2 March 2017 | Accepted: 5 May 2017

DOI: 10.1111/ijcp.12969

S Y S T E M AT I C R E V I E W

Determinants of sexual function and dysfunction in men and

women with stroke: A systematic review

Wendy Dusenbury1 | Pernille Palm Johansen2 | Victoria Mosack1 | Elaine E. Steinke1

1
School of Nursing, Wichita State University,
Wichita, KS, USA
2
Department of Cardiology, The Heart
Centre, Copenhagen University Hospital
Rigshospitalet, Copenhagen, Denmark
Correspondence
Wendy Dusenbury, DNP, APRN, FNP-BC,
CNRN, ANVP-BC, School of Nursing, Wichita
State University, Wichita, KS, USA.
Email: Wendy.Dusenbury@wichita.edu
Summary
Aim: The aim of this systematic review was to examine determinants of sexual func-
tion and dysfunction in men and women poststroke, and to evaluate effectiveness of
interventions.
Methods: A systematic review was conducted using the databases of PubMed,
Medline, CINAHL, Cochrane, and Psychinfo, for studies published between January,
2000 and October, 2016. Included were original research, adult ≥18 years, English
language, and experimental and non-­experimental designs. Excluded were studies of
stroke caused by sexual activity, stroke triggered unusual behaviours, and changes in
sexual orientation. Studies were evaluated for quality using The Effective Public
Health Practice Project Quality Assessment Tool for Quantitative Studies. Of 19 stud-
ies reviewed, 13 were descriptive, three case-­controlled and three intervention/ran-
domised controlled trials (RCTs) designs.
Results: Participants across studies were predominantly men (90%), with moderate
erectile dysfunction (ED), and mild depression. Changes in sexual activity, sexual dis-
satisfaction and sexual dysfunction were common, including decreased libido, orgas-
mic problems and ED, significantly worse from pre to poststroke. Results for side of
hemiparesis and sexual dysfunction were inconclusive. Sexual rehabilitation interven-
tions differed, but resulted in improved sexual satisfaction, sexual activity frequency
and erectile function in two studies.
Conclusions: Sexual dysfunction commonly occurred poststroke, continuing for
months or as long as 2 years. Intervention studies were limited, with only two RCTs,
thus, firm conclusions cannot be made. Few studies included women or younger
stroke patients, indicating the need for further RCTs with larger and more diverse
samples.

1 | INTRODUCTION time of stroke and regularly in follow-­up care.1 Return to intimacy is

Sexuality is an important aspect of quality of life for many survivors
of stroke. Both the physical and psychological impact of having a
stroke can affect return to sexual intimacy and the partner relation-
ship. A consensus document from the American Heart Association
and European Society of Cardiology recommends that stroke survi-
vors and their partners be assessed regarding sexual function at the
often a gradual process that is somewhat dependent on stroke seque-
lae such as hemiparesis or paralysis, dysphasia, cognitive changes and
emotional reactions. Both the desire to be sexually active and the abil-
ity to engage in sexual activity may be impacted. Reasons for change
in sexual frequency include decline in functional abilities, medications,
depression or difficulty communicating about sex (eg, aphasia).2,3 As
a result, decreased libido; problems with arousal, orgasm and vaginal

Int J Clin Pract. 2017;71:e12969. wileyonlinelibrary.com/journal/ijcp © 2017 John Wiley & Sons Ltd | 1 of 13
https://doi.org/10.1111/ijcp.12969
2 of 13 | DUSENBURY et al.
lubrication in women; and erectile dysfunction (ED) and ejaculatory
problems in men have been reported.2,4 Other factors influencing sex-
ual function include fear about a recurrent stroke, depression, fatigue,
spasticity and neurogenic bladder, any of which can affect sexual de-
sire and frequency of sexual activity.3-5 In a systematic review of the
social consequences of stroke, deterioration of sexual relationships in
eight studies ranged from 5% to 76%.6 For those returning to sexual
activity, sexual satisfaction tends to improve, and those who ceased
all sexual activity report dissatisfaction. Modifications may be needed
in the type and frequency of sexual activity.7 Position changes may
be helpful for those adapting to hemiparesis or other deficits, and ex-
amples are provided in an online supplement to the previously cited
consensus statement.1
The prevalence of sexual dysfunction ranges from 20% to 75%,
occurring more frequently in men, but present in either gender.4 The
anatomic location of the stroke can affect sexual function, for example
sexual dysfunction occurs more frequently in those with a right hemi-
spheric stroke, and those with thalmic lesions may have ED, while cer-
ebellar lesions may produce ejaculatory problems.3 Hyposexuality is
common poststroke, although some patients exhibit hypersexuality.8
Sexual issues poststroke have been poorly addressed by healthcare
professionals,7,9 with a lack of understanding of the complex issues
surrounding sexual function and dysfunction in stroke. While many
review articles have been published, the authors sought to examine
quantitative studies to better understand the state of the science re-
lated to sexual function and stroke. Therefore, the aim of this system-
atic review was to examine: among men and women poststroke, what
characteristics are determinants of sexual function and dysfunction,
and what interventions have been shown to be effective?
2 | METHOD
2.1 | Design
We performed a systematic review with the purpose of describing
determinants of sexual function and dysfunction, and the effective-
ness of interventions in those with stroke. The PRISMA framework
and checklist was used to guide accurate and complete conduct and
reporting of this systematic review.10
2.2 | Definitions
For the purpose of this review, the following definitions were used:
Stroke is a broad term that commonly refers to acute neurologic dys-
function, and includes the subtypes of: ischaemic stroke, CNS infarc-
tion, silent CNS infarction, intracerebral haemorrhage, stroke caused
by intracerebral haemorrhage, silent cerebral haemorrhage, suba-
rachnoid haemorrhage, stroke caused by subarachnoid haemorrhage,
stroke caused by cerebral venous thrombosis, and not otherwise spec-
11
ified. For purposes of this systematic review, all subtypes of stroke
were considered. Sexual functioning is defined as a person’s ability to
experience sexual pleasure and satisfaction when desired.12 Sexual
dysfunction is broadly defined as the inability to fully enjoy sexual
Review criteria
This systematic review was conducted using five established
databases (PubMed, Medline, CINAHL, Cochane, PsychInfo).
Study design those that were experimental, quasi-­
experimental, non-­experimental and mixed methods. Eligible
studies focused specifically on stroke and sexual function,
sexual dysfunction or sexual problems. Studies were inde-
pendently reviewed by two reviewers for quality assess-
ment on six components (selection bias, study design,
confounders, blinding, data collection method, withdrawals/
dropouts) and an overall global rating.
Message for the clinic
Sexual dysfunction commonly occurs after stoke, resulting
in decline or absence of sexual activity, sexual dissatisfac-
tion and depression, persisting for months or years. Thus, it
is important for healthcare professionals to routinely assess
sexual functioning over time, using this information to guide
intervention. Both men and women, and younger and older
individuals, experience sexual dysfunction after stroke; thus,
assessment, management and patient education are impor-
tant for all stroke patients.
intercourse, and is classified as either organic or non-­organic. Organic
dysfunction includes ED, vaginismus and dyspareunia, whereas, non-­
organic dysfunction consists of lack of sexual desire, sexual aversion
or lack of sexual enjoyment, failure of genital response, orgasmic
dysfunction, premature ejaculation non-­organic vaginismus and non-­
organic dyspareunia.13 Sexual dysfunction is often measured by self-­
reported validated questionnaires and interviews.
2.3 | Eligibility criteria
2.3.1 | Inclusion criteria
Studies were included in the systematic review if they met these cri-
teria: original research, adult ≥18 years or “all adults” with stroke and
sexual function, dysfunction or sexual problems; studies published
in the English language and between the dates of January, 2000 and
October, 2016; and used experimental, quasi-­experimental, non-­
experimental, and/or mixed methods designs.
2.3.2 | Exclusion criteria
Studies were excluded if they involved paediatric patients, participants
<18 years, animal studies, and studies older than 16 years. Further, we
excluded studies of stroke caused by sexual activity, stroke triggered
unusual sexual behaviours, eg, hypersexuality and changes in sexual
orientation; studies of family/spouses; studies of healthcare profes-
sionals; and review articles, case report and qualitative studies.
DUSENBURY et al.
FIGURE 1 Inclusion process10
2.4 | Search strategy
A systematic literature search was conducted in the following databases:
PubMed, CINAHL, Medline, Cochrane and Psychinfo. To ensure a com-
prehensive overview of studies, we used both controlled vocabulary (eg,
Medical Subject Headings [MeSH]) and free-­text words to search titles
and abstracts of potential articles. An initial search was undertaken to
ensure that all relevant key words were included to obtain the maximum
possible articles for inclusion. The search terms were sexual dysfunc-
tion and stroke, sexual desire and stroke, sexual problems and stroke,
ED and stroke, sexual concerns and stroke, sexuality and stroke, sexual
function and stroke; the operands of ‘AND’ and ‘OR’ were used for
follow-­up searches. Key words were used to search in all databases. A
total of 127 references were found through database searching with the
majority in either PubMed (n=42) or CINAHL (n=42). After removing du-
plicates, 79 articles remained for screening, and further, 58 articles were
excluded because of being qualitative studies, case studies, case reports,
or focusing on either spouses or health professionals, literature reviews
(see Figure 1). This resulted in 22 full-­text articles that were assessed
for eligibility, and subsequently three articles were excluded because of
outcomes being not related to sexual function/dysfunction. Finally, 19
studies were included and evaluated in the systematic review.
2.5 | Quality assessment
Each study was evaluated using eligibility criteria by all authors, expe-
rienced in sexual counselling and stroke rehabilitation. An established
| 3 of 13
instrument, the Effective Public Health Practice Project (EPHPP)
Quality Assessment Tool for Quantitative Studies, was the tool used
for this evaluation. It is an established instrument for which sexual
health is one area of focus.14,15 Quality assessment included com-
ponent ratings for selection bias, design, confounders, blinding, data
collection methods, withdrawals and drop outs, intervention integrity,
analyses related to the research question, and a global rating for the
study. Based on six component areas, studies were scored as strong,
moderate or weak, resulting in a global rating for the paper.15 A strong
paper had no weak ratings; a moderate rating resulted from one weak
rating; and a weak rating resulted from two or more weak component
ratings.
2.6 | Data analysis
Two main reviewers (WD, ES) analysed the extracted data inde-
pendently, and held group discussions in evaluating the quality of
papers using the EPHPP instrument. Individual component ratings
on each paper were discussed and consensus reached for any dis-
crepancies in ratings. The reviewers agreed upon the final ratings of
the paper and the global quality rating. A third reviewer (PPJ) was
available if consensus was not to be reached, although there were
no unresolved disagreements in ratings. Quantitative data extracted
included details about the population, study aim, methods and study
outcomes of interest for this systematic review. Incomplete report-
ing was noted in some studies, making quality assessment more
difficult.
4 of 13 | DUSENBURY et al.
3 | RESULTS
3.1 | Methodological quality
Of the 19 studies reviewed, the global rating of quality resulted in
five studies rated as moderate16-20 and 14 studies that were weak.21-
34
There were no studies meeting the criteria for a strong rating. In
regards to gender, there were no studies exclusively focusing on
sexual function or dysfunction in women. There were seven studies
16-18,20,22,23,27
that focused on men exclusively, twelve studies that
19,21,24-26,28-34
included both men and women, and two studies that
19,28
included patients and spouses. In regards to design, there were
13 descriptive studies,21-33 all with a weak global quality rating. There
16-18
were three case-­control studies, all rated as moderate; one cohort
analytic intervention study rated as moderate19; and two randomised
34
controlled trials (RCT), with one rated as weak and one as moderate
20
in quality. The most common reasons for weak ratings were in the
individual component ratings for study design (13 studies), blinding
(18 studies), confounders (six studies), data collection method (three
studies) and selection bias (four studies).
3.2 | Characteristics across studies
There were a total of 1701 men (90%) and 182 women (10%) across
studies, with women represented only in descriptive studies. The
mean age of participants across studies that included both men and
women was 58.46 years (10 studies). By gender, the mean age for
men was 60.86 years (eight studies) and 56.69 years for women
(three studies). Mean age was calculated from 16 of 21 studies that re-
ported this data. The mean National Institutes of Stroke Scale (NIHSS)
reported in five studies was 3.84. The IIEF-­5 (International Index of
Erectile Function, five items) score was reported in four studies16-18,22;
the mean score across studies was 7.91, reflecting overall moderate
ED, although individual study mean scores ranged from 2.74 to 10.40.
Depression was measured in several studies, although instruments
21,32,33
used differed. In three studies, mean Beck Depression Inventory
scores were 11.58, reflecting mild mood disturbance. The PHQ-­9 was
used in one study with a mean score of 4.92, indicating minimal to mild
depression.31 The depression subscale of the Hospital Anxiety and
Depression Scale used in one study did not indicate depression in the
sample (mean score 5.9).24 The mean Hamilton Depression scores in
those with sexual dysfunction was 7.50 for men and 12.9 for women,
indicating mild depression.29 Despite the variety of instruments used,
mild depression was commonly reported across studies. Depression
24,29
was linked with sexual dysfunction in some studies. Emotional
incontinence with excessive or inappropriate laughing or crying was
described in one study, and was associated with decreased coital fre-
quency and erectile function.26
3.3 | Descriptive studies
The results from descriptive studies are presented in Table 1. Most
21,32
stroke patients viewed sexual activity as important, although
sexual dissatisfaction was common for men and women post-
stroke,25,29,33 and sexual activity frequently declined or was absent
after stroke.25,28,33 Return to sexual activity generally occurred be-
tween the third and sixth month poststroke.28 Some patients worried
that sexual activity would cause another stroke,32,33 while others were
concerned about the effects of stroke and sexual dysfunction.33
The prevalence of sexual dysfunction across descriptive studies
were variable, ranging from 29% to 94.8%,21,24,29-32 and when av-
eraged, the prevalence rate was 64.45%. Of note, Bugnicourt et al.
reported more sexual dysfunction in men,24 while another study re-
ported greater dysfunction in women.31 Common across studies was
the negative impact of the stroke on sexual function.
The specific type of sexual dysfunction experienced poststroke
was described in some studies. Changes in libido occurred in 44%-­
70% of patients.21,26,32 This decline in libido was reported as long as
2 years poststroke.26 Kimura et al. noted significant decline in libido
for men and in the total sample, and the loss of libido was predicted
by the depression score.29 Changes in coital frequency also occurred,
ranging from 49% to 70% of patients,21,25,26,28 with continued change
in coital frequency at one and two years poststroke.22,26,28 Reports
of ED in men was variable, ranging from 26% to 60%.21,22,26 Other
studies did not provide a comparable score for ED, although it was
a significant factor in analyses33 or was qualified by factors such as
age over 50 years and by a Modified Rankin Score (mRS) of 2 or 3.25
Ejaculatory changes occurred in 60% of men in one study,21 and was
significant in other studies,25,33 including those over age 50 years and
with a mRS of 2 or 3.25
Changes in orgasm occurred from before to after stroke,33 and in
60% of patients in one study.21 Women were significantly affected by
changes in vaginal lubrication poststroke.33 Duits et al. note that sexual
inhibition affected both sexual desire and orgasmic function in stroke
patients, and was amplified by fear of performance failure.27 Other
factors contributing to sexual dysfunction were memory difficulties,
emotional changes, communication difficulties, mobility and func-
tional problems and social participation.31 Regarding functional prob-
lems, site of hemiparesis was studied with varying results. Akinpelu
et al. found no difference by side of hemiparesis,21 while Kimura et al.
noted sexual dysfunction in men with both left-­ and right-­sided le-
sions, but greater sexual dysfunction in those with left-­sided lesions.29
In contrast, and although non-­significant, another study found greater
ED in men in right-­sided lesions.33 In another study, 94% of stroke
patients reported that physical limitations affected sexual activity, and
fatigue was a factor affecting sexual activity for 50% of women and
39% of men.32
Multiple factors and comorbidities can affect sexual activity.
Bugnicourt et al. reported that impaired sexual function was more
likely to be associated with initial motor impairment, visual impair-
ment, aphasia, left brain lesions and the use of angiotensin converter
enzyme inhibitors and diuretics.24 Common among other studies was
a history of diabetes and hypertension.22,23 Other contributing fac-
tors to ED were hypercholesterolaemia, smoking, obesity, and medi-
cations,22 as well as age greater than 65 years, prior stroke and lower
urinary tract symptoms.23
TABLE 1 Stroke and sexual dysfunction—descriptive studies
Study Aim
Akinpelu et al. In Nigerian stroke survivors
(2013) to determine the influence
of sociodemographic,
clinical, and psychological
factors on sexual
dysfunction
Bener et al. To investigate the
(2008) prevalence of ED and its
severity in male stroke
patients in Qatar, and
assess comorbidities and
risk factors associated
with ED
Bӧhm et al. To determine the effect of
(2007) telmisatran, ramipril, or a
combination in ACEI
intolerant patients on
erectile function in high
risk CVD patients, with
frequency of sexual
activity, sexual desire,
satisfaction with sex life,
and concomitant drug
therapy and ED.
Bugnicourt To determine the
et al. (2014) prevalence of impaired
sexual function in young
ischaemic stroke patients
Design/Sample/Outcomes
Descriptive, cross-­sectional
Stroke for at least 3 months, living with spouse
Sexual function poststroke compared with prestroke
N=77 men (n=60; mean age 57.0±10.0) and women (n=17; mean age
48.4±10.2)
Median stroke duration: 13.5 months (range=3-­84 months)
Modified Motor Assessment Scale; Stroke-­Specific Quality of Life Scale;
BDI; Questionnaire on sexual dysfunction, including seven areas of sexual
function
Descriptive, cross-­sectional, survey
Face-­to-­face interviews
N=605 male stroke patients
Majority over age 60 years (38%), followed by ages 50-­59 years (33.7%),
ages 40-­49 years (22.5%), and ages less than 40 years (5.8%)
IIEF-­5
Sub-­study of the ONTARGET/TRANSCEND trial
Descriptive survey
Baseline, 2 years, study completion
For ED sub-­study: N=1537, Mean age 64.9±6.4 years; 21% (n=323) had a
prior stroke, and 3.2% (n=49) a TIA
Modified Kolner [Cologne] Evaluation of Erectile Function; IIEF-­5;
International Prostate Symptom Score from the Cologne Male Survey
Descriptive, survey, telephone follow up
Consecutively admitted patients to neurology department over a 2-­year
period, age <60 years
N=104 (62 men, 42 women), mean age 48.0±9.4 years
NIHSS 3.6±5.7
Sexual function at 1 year poststroke
mRS; Stroke risk factors; NIHSS; HADS; Single item sexual function question
Summary of Findings
DUSENBURY et al.
81.9% viewed sex as important; 67.5% could express willingness for sex to spouse; 62%
unwilling to have sex; 50.6% had fear of repeat stroke; 60% of men have fear of
impotence;
94.8% reported sexual dysfunction in one or more of seven sexual activities, with more than
70% related to libido and coital frequency, and 60% dysfunction related to erection,
ejaculation and orgasm
Psychological factors of willingness to have sex, general attitude about sex, and ability to
express sexual feelings negatively affected sexual function; there were no gender
differences
Side of hemiparesis did not significantly affect sexual function
Mean BDI score 13.1±8.3
Mean QOL score of 181.0±30.5 (out of 245 possible)
ED was reported by 48.3% of the total sample, with 17.4% severe, 15.9% moderate, and
15% mild ED; In a subsample with ED, 59.6% were ages 60-­75 years. Diabetes, HTN,
hypercholesterolemia, smoking, and obesity were significantly higher incidence in those
with ED
Medications taken for diabetes, HTN, and heart disease were significantly associated with
ED
The mean IIEF-­5 score was significantly lower in those with ED (2.74±0.93), compared with
those without ED (4.64±0.20).
Results only related to stroke:
Factors significantly associated with the prevalence of ED were age over 65 years
(P<.00001), diabetes mellitus (P<.00001), prior stroke (P<.00002), hypertension (P<.0072),
and lower urinary tract symptoms (p<0.0007).
Those with stroke had increased risk of ED (OR 1.70).
29% had impaired sexual function
Those with impaired sexual function more likely to have initial motor impairment (P=.038),
visual impairment (P=.044), aphasia (P=.043), and left brain lesions (P<.001), and were
taking an ACEI (P<.001) and diuretics (P=.003)
Independent risk factors for impaired sexual function were depression (OR 9.1, P=.001) and
ACEI use (OR 6.0, P=.001).
Mean HADS depression subscore 5.9±4.6
|
(Continues)
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TABLE 1 (Continued)
6 of 13
|

Study Aim Design/Sample/Outcomes Summary of Findings

Cheung (2002) Assess the impact of stroke Descriptive, survey 73.6% had one stroke, mostly ischaemic (86.8%), with right-­sided deficits (52.8%)
on sexual functioning in N=106 (63 men, 43 women) The frequency of coitus declined or was absent poststroke, with 69.5% sexually active
Chinese patients with mild Mean age 56.2±11.8 years before to 48.6% poststroke, although men had somewhat greater coital frequency
or no disability Consecutive patients attending stroke clinic, >6 months since stroke, poststroke than women (52.4% vs 42.9%).
non-­depressed, and mild (mRS 2 or 3) or no disability (mRS 0 or 1) Overall, 53.3% reported sexual satisfaction before stroke compared with 24.8% poststroke
Measures of sexual function: libido, coital frequency, sexual arousal, Factors significantly contributing to poststroke decline in sexual function were: change in
ejaculation, orgasm; Sexual satisfaction libido for age >50 years and unwillingness for sexual activity; the effect of stroke on coital
BDI; Barthel Score; mRS frequency in those married and stroke effects on sexual activity; erection in men, including
a mRS of 2 or 3 and a history of HTN; ejaculation in men, including age >50 years and a
mRS of 2 or 3; and sexual satisfaction impacted by the stroke effects on sexual function
and unwillingness for sexual activity.
Choi-­Kwon & To explore emotional Descriptive, survey, telephone interview 3 months poststroke reductions in libido (49%), coital frequency (65%), and erectile function
Kim (2002) incontinence (excessive N=70 (56 men, 14 women) (26%) were noted; and at 2 years (n=55), libido (44%), coital frequency (49%), and erectile
and/or inappropriate Mean age 56 years function (20%).
laughing or crying) and Consecutive clinic patients assessed 2-­4 months poststroke, and Low coital frequency before stroke was associated with decreased libido, coital frequency,
sexual activity changes at approximately 2 years poststroke by interview and erectile function at 3 months, and emotional incontinence was associated with
3 months and 2 years Barthel Index; Motor impairment; Emotional incontinence by patient/family decreased coital frequency and erectile function. Those with severe motor impairment and
poststroke report low Barthel Index score also had decreased libido at 3 months.
Sexual activity questions for libido, coital frequency, erectile function (or Low coital frequency before stroke and emotional incontinence were independently
vaginal lubrication in women) associated with ED at 3 months
Coital frequency before and after stroke
Duits et al. To explore relationships Descriptive, survey Inhibition caused by threat of performance failure was significantly and negatively related
(2009) between psychological N=19 men with first stroke to sexual desire and orgasmic function (P<.01)
and sexual variables, and Acute focal deficit ≥24 hours, verified by brain scan, and at least 3 months Sexual excitation was significantly, positively associated with sexual desire
the relative contribution poststroke (mean=23.6±12.5; range=6-­47 months) Anxiety and depression for sexual variables was non-­significant
of psychological variables Mean age 58.5±6.1 years Sexual inhibition because of threat of performance failure was the only significant predictor,
to sexual function NIHSS 5.6±3.9 explaining 30% of total variance (p=0.02)
mRS; NIHSS; IIEF; Sexual Inhibition/Sexual Excitation Scale; Anxiety and
depression subscales of the Symptom Checklist-­90
Giaquinito et al. To evaluate sexual changes Descriptive, survey, interview of patients and partners, at admission to Mean weekly sexual performance significantly declined from baseline (1.59) to 1-­year (0.38)
(2003) at 1 year poststroke rehabilitation centre and after 1-­year as reported by patients, with lower ratings by the partner, 1.25 and 0.18, respectively.
N=62 (46 men, 16 women) Approximately 50% had no sexual activity at 1-­year, more so for women, but not
Consecutively admitted patients to rehabilitation unit with first stroke statistically significant.
2 weeks prior Predictive factors for sexual activity were age and Functional Independence Measure score
Mean age 64±9.2 years (P=.009, and p=0.0059, respectively)
59.7% had left hemisphere lesions, 37.1% right hemisphere lesions, and Two patients had enhanced sexual activity, described as deviant; both had lesions in the
3.2% with pons lesions right temporal lobe
20.9% had language impairment Return to sexual life was reported to occur between the 3rd to 6th month poststroke;
Cumulative Illness Rating Scale changes in sexual desire were reported
Structured interview regarding sexual activity and drugs
CES-­D; Structured Clinical Interview; Functional Independence Measure

(Continues)
DUSENBURY et al.
TABLE 1 (Continued)

Study Aim Design/Sample/Outcomes Summary of Findings

Kimura et al. To examine the association Descriptive, survey Impaired sexual function before stroke in men was 21.4% and poststroke was 58.6%, while
DUSENBURY et al.

(2001) between sexual problems
and neuropsychiatric
findings, including
poststroke depression
Oyewole et al. To investigate disability and
(2016) sexual dysfunction on
health-­related quality of
life in Nigerian stroke
survivors
Seymour & To investigate changes in
Wolf (2014) sexual activity after stroke
Stein et al. To explore patient
(2013) preferences for
information and
counselling poststroke
Thromboembolic stroke or intracerebral haemorrhagic infarction
N=100 (75 men, 25 women
Recruited from two centres
Interviewed at baseline and at 3 or 6 months (n=91) or 12 months (n=9)
Assessed sexual functioning prior to stroke at baseline or in month prior to
follow-­up assessment
Neurological and psychological exam; Social Functioning Examination;
Present State Examination;
Hamilton Rating Scale for Depression;
MMSE
Descriptive, cross-­sectional, survey
Consecutively admitted to outpatient clinic, ≥3 months poststroke
N=121 men and women
Mean age 62.64±11.23 years; men 62.98±11.34, women 62.26±11.19;
Stroke-­Specific Quality of Life—short version; Changes in Sexual
Functioning Questionnaire—short form; World Health Organization
Disability Assessment Schedules—short form
Descriptive, cross-­sectional
Recruited from a rehabilitation research group
N=13 mild stroke patients (9 men, 4 women), 6-­18 months poststroke,
sexually active in the past month
Mean age 62.08±15.10, 9 men and 4 women
NIHSS 2.38±1.71
Quality of Sexual Function Scale; Stroke Impact Scale; PHQ-­9
Descriptive, survey, cross-­sectional
Recruited from a stroke registry
N=38 (14% response rate); 23 men, 14 women
Mean age 55.1±14.2 years
Changes in Sexual Functioning Short Form; Fatigue Assessment Scale; BDI;
Barthel Index; Questions on sexual counseling information
in women rates were 20% before to 44% after stroke.
Dissatisfaction with sex life poststroke was significant for men (P<.0001), women (P=.029),
and the total sample (P<.0001).
Libido significantly declined in men (P=.0046) and total sample (P=.0023).
Both men (P=.0007) and women (P=.0005) with sexual dysfunction had significantly higher
depression, and men with sexual dysfunction had greater impairment of ADLs (P=.0009)
Greater sexual dysfunction occurred in men with left hemispheric lesions (61.4%; p=0.013),
right hemispheric lesions (29.5%; P=.028) and in those with poststroke depression (P=.0094),
compared with those without sexual dysfunction
Mean depression score in those with sexual dysfunction, 7.5 in men and 12.9 in women
Significant predictors of sexual dysfunction were depression score, left hemispheric lesions
and poststroke depression diagnosis, while loss of libido was predicted by depression
score.
95% reported moderate to severe disability, and 86.8% had sexual dysfunction, more so in
women (P=.0001).
Sexual dysfunction in those with mild disability resulted in more favourable QOL when
compared with those with moderate to severe disability and sexual dysfunction (P=.001)
Regression analysis showed that global disability negatively affected QOL, but sexual
function was not significant
The Quality of Sexual Function score indicated mild problems overall (55±17.92), and was
negatively correlated with all Stroke Impact Scale domains, although depression was
correlated with more psychosomatic QOL, sexual activity level, and sexual dysfunction
Results for sexual dysfunction and Stroke Impact Scale domains suggest greater difficulty
with memory, emotion, communications, ADLs, mobility, hand function, social participa-
tion, and perception of stroke recovery.
38.5% reported negative effects on sexual function because of stroke
Mean PHQ-­9 score 4.92±7.24
All men and 58% of women met criteria for sexual dysfunction
71% rated sexual issues as moderately to very important,
42% rated sexual functioning as worse poststroke, 42% as no change, 5% noted improve-
ment; there were no significant gender differences for change in sexual functioning
In 94%, physical limitations affected sexual activity; 58.8% reported feeling less sexually
desirable; sexual concerns included worry of sex causing another stroke and harming their
partner
Mean BDI score 11.74±10.55
Depression scores were: 3% minimal depression, 54.4% mild depression, 36.4% moderate
depression, 6% severe depression
|

50% of women and 39% of men met criteria for significant fatigue

(Continues)
7 of 13
 8 of 13 | DUSENBURY et al.

HTN, hypertension; IIEF, International Index of Erectile Function; MMSE, mini mental status examination; mRS, Modified Rankin Score; NIHSS, National Institutes of Health Stroke Scale; ONTARGET/
ADL, activities of daily living; BDI, Beck depression inventory; CES-­D, Centre for Epidemiologic Studies—Depression Scale; ED, erectile dysfunction; HADS, Hospital Anxiety & Depression Scale;

TRANSCEND, ONgoing Telmisartan Alone and in combination with Ramipril Global End-­point Trial/Telmisartan Randomised AssessmeNT Study in ACE-­INtolerant Subjects with Cardiovascular
3.4 | Case-­controlled studies

No differences in sexual variables by right-­ and left-­sided hemispheric lesions, and although
non-­significant, men reported more erectile problems in those with right compared with

sample, 65%, the stroke affected sexual function, 57.3% (69.8% in men), and willingness
for sexual activity, 61.2% (85.7% in men); findings were significantly different between
Stroke significantly affected erection and ejaculation in men, and vaginal lubrication and

men and women for importance of sexual activity, fear of impotence, stroke effect on
Fear of impotence was reported by 29.1% of men, fear of recurrent stroke in the total
There were statistically significant changes in baseline to poststroke scores for sexual Studies comparing stroke patients to control subjects are illustrated
activity frequency (P<.001), and vaginal lubrication, orgasm, satisfaction (all P<.001).

sexual function, discussion of sex with partner, and willingness for sexual activity.
in Table 2. Similar to descriptive studies, ED was common, although
some participants reported being sexually satisfied, 76% in one
study.16 Erectile dysfunction was present in 45.6% prior to stroke
and 78.9% after stroke, compared with 27.3% in controls.16 Mean
IIEF-­5 scores were significantly lower in the stroke group compared
with controls, 5.89 vs 10.67, respectively. Prestroke levels of ED did
not differ from controls, while pre to poststroke values were signifi-
cantly different (P<.001).16 Findings from Koehn et al. were similar
with mean IIEF-­5 scores of 19.8 prestroke, 13.1 poststroke and 21.8
for controls.17 Contributors to absence of sexual intercourse include
lack of desire, physical discomfort, incomplete erections, although du-
ration of stroke, sexual desire and decreased erectile function were
left-­sided lesions (72% vs 48%)

non-­significant.16
Physical factors such as side of hemiplegia and location of brain
Mean BDI score 9.9±4.1

lesions were examined in all three studies. Regarding ED, Sikiru et al.
Summary of Findings

orgasm in women

found that mean IIEF-­5 scores significantly differed (P<.001) be-

tween groups and was greater for left hemiplegia (10.40) compared
with right hemiplegia (7.55) and controls (21.50), although post hoc
comparisons revealed greater effects on erectile function overall in
those with right hemiplegia (P=.013).18 Koehn et al. reported that ED
occurred commonly in those with right (87.5%) and left hemispheric
with paresis; 59.5% with right lateralisation, more so for women, and left
lateralisation more common in men (47.6%); 35.9% right and 45.6% left
62.1% ischaemic, 27.2% haemorrhagic, and 10.7% lacunar stroke; 47.6%

satisfaction, importance of sexuality, fear of impotence, fear of another

subcortical stroke, 44.7% affecting anterior cerebral circulation; 91.3%

lesions (70.6%), and with varying results by artery and brain region.17
First time stroke recruited from neurology department, with mild or no

Disease; PHQ-­9, Patient Health Questionnaire 9-­Item; QOL, quality of life; TIA, transient ischaemic attack.
frequency, erection, ejaculation, vaginal lubrication, orgasm, sexual

Right cerebellar lesions were shown to contribute to ejaculatory dis-

Depression and Anxiety Scales; Questions assessing libido, coital
NIHSS, Glasgow Coma Scale; Barthel Index; mRS; BDI; Hamilton

order, while basal ganglia lesions negatively affected sexual desire.16

Patients with two or more brain lesions had significantly reduced
disability, not depressed, between ages of 40-­80 years

erectile function.16
hemispheric lesion, and 19.4% both hemispheres

3.5 | Intervention studies

stroke, unwillingness for sexual activity

The three intervention studies are described in Table 3, with one

cohort analytic study19 and two RCTs.20,34 Of note, sample sizes
Descriptive, survey, interviews

were small in all studies, ranging from 10 to 30 stroke patients. The

N=103 (63 men, 40 women)
Design/Sample/Outcomes

Mean age 57.9±10.0 years

interventions in all studies included an information component, ver-

bal, written or both. Sansom et al. used a sexual rehabilitation in-
tervention tailored to the individual based on the PLISSIT model,34
while Song et al. provided education individually the day prior to
hospital discharge.19 Tibaek et al. study was unique in the evalua-
tion of pelvic floor muscle training over a 12-­week period, includ-
ing home exercise.20 The timeframe for measurement of outcomes
stroke patients with mild

differed across studies as 1 month,19 6 weeks,34 and 12 weeks and

To evaluate the impact of

functioning in Turkish

6 months.20
stroke on sexual

Significant results postintervention compared with controls oc-

or no disability

curred for sexual satisfaction (P=.02) and frequency of sexual ac-

tivity per month (P=.000)19; and erectile function (P=.04) and ED
(Continued)

induced bother (P=.05) at 12 weeks, but not significantly different

Aim

at 6 months.20 Of note, variables in studies that were non-­significant

were sexual knowledge,19 and in Sansom et al. study, there were
Tamam et al.
TABLE 1

no differences for sexual functioning, psychological functioning,

(2008)
Study

and quality of life, although some trend towards improvement was

noted.34
DUSENBURY et al.
4 | DISCUSSION
The results of this systematic review clearly illustrate that the major-
ity of men and women with stroke experienced sexual dysfunction, as
high as 95%,21 with a significant impact on sexual quality of life. Sexual
dysfunction was largely defined for men as ED, but sexual dysfunction,
35
including the criteria of sexual distress, was not clearly articulated
in results for women. Changes in sexual function can occur for both
younger and older stroke patients, and only one study in this review
examined younger stroke patients, with a mean age of 48 years.24 The
mean age in most studies was between 60 and 65 years of age, so
clearly more study is needed related to sexual function and dysfunc-
tion in younger stroke patients. A strength across all studies was the
use of well validated instruments, although a variety of instruments
were used, making comparisons between some studies difficult.
Sexual dysfunction occurs with changes in sexual function, such
as reduced or absent sexual desire, arousal, or orgasm, and sex-
ual dysfunction can occur with or without biological problems.35
Proportionally, only 10% of studies overall included women; thus,
more research to understand sexual concerns, sexual activity and sex-
ual dysfunction in women is clearly needed. Erectile dysfunction was
commonly reported in men across studies, and IIEF-­5 scores reflected
moderate to severe ED. This is consistent with prior reports of erec-
tile and ejaculatory problems as a common occurrence poststroke.36
Not clear in most studies was underlying sexual dysfunction prior to
stroke for both men and women. This is a limitation in that comorbid-
ities and risk factors associated with stroke can contribute to sexual
dysfunction, such as hypertension, dyslipidaemia, diabetes, metabolic
syndrome and smoking.3,37 There were no studies that examined hor-
monal factors in men and women, although these are well-­known pre-
dictors of sexual dysfunction and are associated with cardiovascular
disease.38 Additionally, cardiovascular medications are well known to
contribute to sexual dysfunction; however, most studies reported only
frequency data related to medications. In one study however, it was
noted that 70% of stroke patients were taking at least one medication
32
known to cause sexual dysfunction. Bener et al. found significant dif-
ferences in stroke men with ED compared with those without ED for
22
ACEI, diuretics, clopidogrel, heparin, warfarin and amaryl. A clearer
understanding of medication effects on sexual function in stroke and
more precise statistical comparisons are needed. Moreover, the use of
PDE5 inhibitors in stroke merits further investigation.
While most studies focused on sexual dysfunction, it was clear
that sexual function in general suffered after stroke. Coital frequency
declined, ranging from more than 50%-­70% in two reports,21,25
with coital frequency changing from weekly to monthly or even less
often.25,33 This often resulted in changes in sexual satisfaction with
about 50%-­75% reporting sexual dissatisfaction poststroke.21,25,29,33
Sexual dysfunction also contributed to negative changes in libido, or-
gasm, vaginal lubrication, erection and ejaculation,21 consistent with
common sexual problems in stroke previously reported.1,3
Results specific to the stroke, stroke aetiology and standard
measures such as NIHSS and mRS were inconsistently reported.
Only three studies reported modified mRS,24,25,33 and data were not
| 9 of 13
reported in the same way, for example mean scores vs a score range,
making comparisons difficult. The mRS provides a measure of over-
all disability and could be an additional predictor of return to sexual
function. It would be important for studies to report baseline func-
tion prestroke compared with poststroke function. NIHSS scores were
only reported in five studies,17,24,27,31,33 and this information would be
more meaningful if interpreted with the location of the lesion. For ex-
ample, NIHSS is less discriminatory for posterior circulation strokes.39
Similarly, data on the impact of lesion location and sexual dysfunction
were inconclusive, with variability in how study results were reported
and specific variables evaluated. In some reports, those with left side
lesions had greater impairment in sexual activity,24 and more sexual
dysfunction in men, but not women,29 while those with right-­sided
lesions had more emotional incontinence.26 Stroke patients with right
hemiplegia had decreased erectile function scores.33 Thus, conclu-
sions cannot be drawn from these limited findings. Additionally, two
studies that reported ED by specific brain region had such low num-
bers when distributed among categories, that interpretation of find-
ings was difficult.16,17
Considering the psychological impact of stroke on sexual function,
some studies showed that patients fear a repeat stroke with sexual
activity and men often fear impotence. Depression was measured in
six studies, and stroke patients overall had minimal to mild depression.
There was inconsistency in the instruments used, limiting interpre-
tation. Given the association of depression with stroke and depres-
sion and sexual dysfunction,1,3,40 we recommend that future studies
include measures of depression, with comparisons before and after
stroke when possible. Use of a consistent measure of depression
across studies (eg, BDI or PHQ-­9) would advance knowledge of de-
pression related to sexual dysfunction in stroke, and allow more accu-
rate comparisons among studies.
In evaluating the three intervention studies, neither of the two
RCTs showed an effect between groups, with only effects within
groups or trends from the findings reported. Two studies were similar
with a focus on individualised education and counselling,19,34 while
the third study was distinctly different in focus related to pelvic floor
muscle training.20 Some sexual function variables reached statistical
significance, while others did not. Thus, findings are inconclusive and
must be interpreted with caution. Sample sizes were small, limiting
generalisability. Further study of sexual function and dysfunction
with stroke is clearly needed, and RCTs with larger samples are rec-
ommended to further understanding of which interventional compo-
nents are more effective. This would be essential in then translating
research to practise.
A systematic review often leads to further questions for research.
The following are questions that merit further investigation. Does sex-
ual counselling alleviate fears and improve sexual interest and sexual
activity? To what extent does controlling cardiovascular and stroke
risk factors contribute to improved sexual function? What is the role
of medications and sexual dysfunction in stroke, and can adjustment
of medication classes or dosages improve sexual function? How fre-
quently are PDE5 inhibitors used in stroke and what is the effective-
ness in treating sexual dysfunction? Do sexual function, dysfunction
 10 of 13

Table 2 Stroke and sexual dysfunction—case-­controlled studies

|

Study Aim Design/sample/outcomes Summary of findings

Jung et al. To identify sexual function Case-­control IIEF-­5 scores were significantly lower in the stroke group compared with controls (5.89±7.08
(2007) of stroke patients and the Recruited from neurology or urology clinic with vs 10.67±7.10, P<0.01)
effect of location of the confirmed stroke Duration of stroke, sexual desire, and decreased erectile function were non-­significant
brain lesion on sexual At least 6 months poststroke Patients with 2 or more brain lesions had significantly reduced erectile function compared on
function N=109 male stroke patients and N=109 age-­matched 1 lesion (P<.01)
controls Contributors to absence of sexual intercourse was lack of desire (59.4%), physical discomfort
Patient mean age 64.93±8.81 years, with (14.4%), incomplete erections (12.6%)
24.44±16.65 months since stroke; Controls mean age 91.2% had not used methods to improve sexual function, with only 7.2% trying oral drugs
64.69±8.85 years 76% reported satisfaction with their sex life
IIEF-­5; 9 items measuring frequency of sexual inter- A significant ejaculatory disorder was noted in patients with right cerebellar lesions (P<.05),
course, ejaculation, change in sexual desire, conditions and decreased sexual desire in left basal ganglia lesions (p<0.05)
preventing intercourse, methods to improve sexual
function, sexual information, fear of sexual intercourse,
sexual satisfaction, need for treatment by specialists
Koehn et al. To assess the prevalence Case-­control 45.6% of patients had ED in 3 months prior to stroke compared with 78.9% poststroke;
(2015) of poststroke ED in N=57 men with ischaemic stroke in past 24 months, 27.3% of controls had ED
relation to ischaemic mean age 62.6±10.5 years IIEF scores decreased significantly before to after stroke (median 23 vs 16; P<.001), and
lesion location and stroke N=22 age-­matched controls, age 61.7±11.2 years significantly lower than controls (median 24; P<0.001)
severity Self-­reported ED prevalence after stroke compared with Poststroke ED severity was significantly worse compared with controls, while prestroke ED
3 months prior to stroke severity did not differ from controls
Controls completed one set of questionnaires In 26 patients with ED prior to stroke, IIEF scores declined from a median of 19 before to 8.5
IIEF-­5; BDI; NIHSS; after stroke (P=.001), and ED severity worsened (P=.003) poststroke
CT tomography or MRI IIEF scores (Mean 13.1±8.9 vs 21.8±4.5 controls) were inversely correlated with age of
patients and controls, and BDI scores
Depression occurred in 5.4% patients before to 17.9% after stroke
ED poststroke occurred in 87.5% of those with right hemispheric (21/24) and 70.6% of left
hemispheric lesions (24/34)
ED by infarction location: MCA (n=27/34, 78.8%), PCA (n=4/5, 80%), ACA (n=1/1, 100%),
basal ganglia (3/3, 100%), brain stem (8/10, 80%), cerebellar (2/5, 40%), and >1 location
(2/2, 100%)
Sikiru et al. To evaluate the effect and Case-­control Mean IIEF-­5 values for right hemiplegia were 7.55±4.07, 10.40±5.70 for left hemiplegia, and
(2009) correlation between Recruited from hospital physiotherapy department 21.50±4.27 for controls, with significant differences between the groups (P<.001) on
erectile dysfunction and N=105 hemiplegic men erectile function. Compared with controls in post hoc analyses, the effect of stroke on
side of hemiplegia in Left hemiplegia (n=50) with mean age 61.78±7.79 years, erectile function was significantly different for both left and right hemiplegia, and comparing
older Nigerian stroke right hemiplegia (n=55) with mean age 62.11±9.32 left to right (P=000). Right hemiplegia had greater effects on erectile function compared
patients Age over 50, >1 year duration of single stroke with left hemiplegia (P=.013).
N=40 age-­matched controls, mean age 64.00±8.53 years
IIEF-­5
ACA, anterior cerebral artery; BDI, Beck depression inventory; ED, erectile dysfunction; IIEF, International Index of Erectile Function; MCA, middle cerebral artery; NIHSS, National Institutes of
Health Stroke Scale; PCA, posterior cerebral artery.
DUSENBURY et al.
Table 3 Stroke and sexual dysfunction—intervention studies
Study Aim
Sansom et al. Assess the effectiveness of a
(2015) structured sexual rehabilitation
programme with written
materials, compared with
written material alone, and to
evaluate the impact of the
intervention on sexual and
psychological in an Australia
stroke cohort
Song et al. To examine the effectiveness of
(2011) a sexual rehabilitation
intervention programme for
stroke patients and spouses in
improving knowledge,
satisfaction, and sexual activity
at 1 month after intervention
Tibaek et al. To evaluate the effect of pelvic
(2015) muscle floor training on erectile
function in men with lower
urinary tract symptoms after
stroke
ED, erectile dysfunction; IIEF, International Index of Erectile Function; MMSE, mini mental status exam; PLISSIT, permission, limited information, specific suggestions, intensive therapy; RCT,
randomised controlled trial.
Design/sample/outcomes
RCT
Consecutively admitted patients, randomly assigned to treatment or control groups
Assessed at baseline and 6 weeks
Sexual rehabilitation intervention, 30 minute session tailored to individual needs using
PLISSIT model
Content included common changes poststroke, counselling regarding fears, challeng-
ing stereotypical views of sexuality and sexual satisfaction, and strategies to
minimise poststroke sexual dysfunction
Written education (fact sheet) was provided to intervention and control groups
N=10 stroke patients (five men, five women), ages ≥18 years
n=4 intervention group, Mean age 64.8±20.6 years (two men, two women)
n=6 control group, Mean age 64.8±20.6 years (three men, three women)
Depression, Anxiety, and Stress Scale; Changes in Sexual Functioning Questionnaire—
short form; Functional Independence Measure; Stroke and Aphasia Quality of Life
Scale
Cohort analytic; Non-­equivalent control group pre–post test design
Recruited from neurology department in South Korea, and ages 40-­46 years
Intervention included information on common sexual problems, changes in sex life
after stroke, health sexual life, addressing sexual fears, strategies to minimise sexual
dysfunction and addressing questions
Followed up at 1 month
N=46 (19 men, four women); 23 stroke patients (12 couples intervention, 11 couples
control); patients were 82.6% male
Mean patient age 57.89±6.59 years
All patients had hemiplegia, 69.6% right-­sided and 30.4% left-­sided; 60.9% had
sensory disturbance; 39.1% had language deficits
Sexual Beliefs and Information Questionnaire; Derogatis Sexual Functioning
Inventory; Sexual Frequency Scale; MMSE; Barthel Index
Prospective, randomised, single-­blinded, parallel group RCT
Randomised to treatment or control groups
4-­week run-­in period, randomisation, 12-­week posttest, follow up at 6 months
Intervention—pelvic floor muscle training over 12 weeks, including informational
sessions, home exercises, group treatment, and digital anal palpation to give
feedback to participants
Controls received standard rehabilitation
N=30 male stroke patients
n=15 treatment group, Median age 68 years
n=15 control group, Median age 70 years
IIEF-­5
two additional questions to assess satisfaction/bother of ED, and use of medicines or
appliances to treat ED
Summary of findings
92% had sexual dysfunction
58% viewed sexual rehabilitation as important
DUSENBURY et al.
There were no significant differences at 6 weeks between
intervention and controls for sexual functioning,
psychological functioning, and quality of life, although
there was a trend towards improvement in both groups for
sexual and psychological functioning, functional independ-
ence, and quality of life was noted
The intervention when compared with controls resulted in:
Non-­significant gains in sexual knowledge
Sexual satisfaction significantly improved (P=.02)
Frequency of sexual activity per month significantly
increased in experimental subjects compared with controls
(4.29 vs 1.86; P=.000)
Frequency of sexual intercourse per month was significantly
greater in experimental subjects compared with controls
(3.31 vs 1.18; P=.001)
No significant differences between groups on baseline
characteristics
Median IIEF-­5 score at baseline was 17
Treatment group IIEF-­5 scores significantly improved from
pre to posttest at 6 weeks (P=.04), but non-­significant at
6 months; the control group did not improve at either time
period
ED induced bother showed significant improvement from
pre to posttest at 6 weeks (P=.05), but not significant at
6 months; control group findings were non-­significant
Between group findings were all non-­significant at pretest,
posttest, and 6 months
|
11 of 13
12 of 13 | DUSENBURY et al.
and return to sexual activity differ between younger and older stroke
patients, and between men and women? What is the impact of sexual
dysfunction on the patient/partner dyad? In addition, education alone
is often insufficient in promoting successful return to sexual activity.
Thus, what are important elements of a sexual counselling and reha-
bilitation programme that would support stroke patients and partners
in sexual activity?
4.1 | Limitations
A strength of this review was quality assessments for study design and
meeting specific criteria using an established instrument. Firm gener-
alisations cannot be made because of variability in study design, gen-
erally small sample sizes, differing variables measured with a variety
of sexual function/dysfunction instruments, inconsistent use of estab-
lished measures, eg, NIHSS or Barthel Index, and variation in how data
were reported. There were no studies that focused only on women,
and when women were included in studies, the proportion was quite
low compared with men. Younger stroke patients were also not well
represented in studies. Of the 19 studies, only three studies were inter-
ventional in nature, with two as RCTs, but with a different focus to the
intervention; thus, conclusions regarding the most effective interven-
tions cannot be drawn. Additionally, results of this systematic review
should be interpreted with caution given the large number of studies
rated as weak. This systematic review focused on sexual dysfunction
from the patient perspective; as studies become available, sexual dys-
function from the partner perspective should be evaluated.
5 | CONCLUSION
Sexual dysfunction commonly occurred in the majority of patients
poststroke. This frequently resulted in decline or absence of sexual
activity and sexual dissatisfaction. Specifically, sexual function was
negatively impacted by changes in libido and coital frequency, ED and
ejaculatory problems in men, decreased vaginal lubrication in women
and orgasmic problems in both men and women. Of note, these
changes in sexual function continued for months and up to 2 years
poststroke. Additional contributors to sexual dysfunction were func-
tional problems poststroke, communication difficulties and memory
or emotional issues. In case-­controlled studies, increased ED from pre
to poststroke was particularly striking. While interventions differed
in focus in intervention studies, there was postintervention improve-
ment in sexual satisfaction, frequency of sexual activity and erectile
function. The study provides important insights regarding sexual
function and dysfunction among stroke patients, and emphasises the
importance of sexual counselling by healthcare providers across set-
tings, as sexual dysfunction may persist over time, with the need for
ongoing support and intervention. Firm conclusions cannot be drawn
based on the large number of descriptive studies and few intervention
studies available. Further research and RCTs are needed to increase
knowledge and to design effective interventions for men and women,
as well as for younger and older individuals after stroke.
AC KNOW L ED G EM ENTS
None.
FU ND I NG
None.
AU T HO R CO NT R I B U T I O NS
WD: concept/design, data analysis/interpretation, drafting article,
critical revisions of article, approval of article; PPJ: data analysis/in-
terpretation, drafting article, critical revisions of article, approval of
article; VM: data analysis/interpretation, drafting article, critical revi-
sions of article, approval of article; EES: concept/design, data analysis/
interpretation, drafting article, critical revision of article, approval of
article, statistics.
D I S C LO S U R E
None.
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How to cite this article: Dusenbury W, Palm Johansen P,
Mosack V, Steinke EE. Determinants of sexual function
and dysfunction in men and women with stroke:
A systematic review. Int J Clin Pract. 2017;71:e12969.
https://doi.org/10.1111/ijcp.12969