NeuroRehabilitation 41 (2017) 293–315 293

DOI:10.3233/NRE-001481
IOS Press

Stroke and sexual functioning:

A literature review
Anabelle Grenier-Genesta , Marina Gérarda and Frédérique Courtoisb,∗
a Department of Psychology, Université du Québec à Montréal, Montreal, QC, Canada
b Department of Sexology, Université du Québec à Montréal, Montreal, QC, Canada

Abstract.
BACKGROUND: Stroke has multiple impacts on patients’ sexual functioning, be it directly caused by the neurological
lesion (s) or indirectly triggered via other psychophysiological processes. Despite a growing number of publications, sexuality
is still rarely addressed in the stroke literature - yet, patients have indicated their need for sexual rehabilitation services.
OBJECTIVE: To provide a literature review on post-stroke sexual functioning as well as available rehabilitation programs
targeting patients’ sexuality.
METHODS: A systematic literature review was conducted on PubMed using the following key words and their combination:
“stroke”, “sexuality”, “stroke characteristics”, “hemisphere”, “sexual”, and “sexual dysfunction”.
RESULTS: Existing data suggests the existence of significant associations between stroke and male and female sexual
dysfunction (SD) as well as desire/libido and sexual satisfaction. The exact contribution of patients’ neurological profile (stroke
laterality, location, and severity) on their SD remains inconclusive with research providing mixed findings. Psychological
factors are shown to play a significant part in the development of patients’ SDs. A few intervention programs have been
developed to specifically guide health professionals when addressing patients’ needs regarding their sexual recovery.
CONCLUSION: Sexual rehabilitation needs to be an integrative part of stroke patients’ rehabilitation process, preferably
at the interdisciplinary level.

Keywords: Stroke, sexuality, sexual rehabilitation, neurological disorders, urinary incontinence, sexual dysfunction,
neurosexuality

1. Introduction to reach 7.8 million in 2030 (Strong et al., 2007). Once

Strokes are one of the leading causes of long-term
disability (Caplan, 2009; Wityk & Llinas, 2006) and
the second leading cause of mortality in Western soci-
eties for individuals aged 15 years and over (Strong
et al., 2007). Over the past decades, epidemiological
data indicate that the prevalence of strokes has been
on the rise, claiming 5.7 million lives in 2005, up to
6.5 million lives in 2015; a number which is expected
∗ Address for correspondence: Frédérique Courtois, PhD,
Director, Department of Sexology, Université du Québec à
Montréal, CP 8888 Succursale Centre-ville, Montreal, QC H3C
3P8, Canada. Tel.: +1 514 835 6784; Fax: +1 514 987 6787;
E-mail: courtois.frederique@uqam.ca.
considered a disease targeting the elderly, strokes are
now more and more prevalent among younger genera-
tions. Individuals aged 55 and under have seen stroke
rates rise from almost 13% in the 1990s to 18.6% in
2005 (Kissela et al., 2012). This age group shift is
particularly concerning as more and more individu-
als who are still otherwise healthy and sexually active
are likely to suffer from the various consequences
of strokes. Typically, the extent of the damage pro-
voked by strokes differs based on the type of strokes
(ischemic, hemorrhagic, lacunar stroke, and transient
ischemic attacks). Neurological lesions and/or sec-
ondary physical and psychological factors can lead
to very diverse profiles of recovery (Wityk & Llinas,
2006; Geyer & Gomez, 2008).

1053-8135/17/$35.00 © 2017 – IOS Press and the authors. All rights reserved
294 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
Although the psychological and physical seque-
lae of strokes have been largely documented, little
research has been devoted to the investigation of the
impact of strokes on sexual functioning (McLaughlin
& Cregan, 2005). In fact, the rehabilitation process
and medical professionals involved in this process
leave little room to the discussion of sexual func-
tioning (Schmitz & Finkelstein, 2010; Rosenbaum,
Vadas, & Kalichman, 2013). Yet, the available liter-
ature shows high rates of sexual dysfunction in both
men and women who suffered a stroke, along with a
reduction in sexual frequency and sexual satisfaction
(Korpelainen, 1999; Taman et al., 2008; Rosenbaum,
Vadas, & Kalichman, 2013). More importantly,
patients recovering from a stroke have voiced the
need to address the issue of post-stroke sexual func-
tioning during rehabilitation (Rosenbaum, Vadas, &
Kalichman, 2013; Ng et al., 2017). In fact, recent data
indicate that more than half of the patients surveyed
consider sexual rehabilitation an important compo-
nent of the rehabilitation process (Ng et al., 2017).
The major aim of this article is to provide a
general review of the available empirical data on
sexual dysfunction amongst post-stroke individu-
als. Firstly, the few existing studies addressing
the relationship between stroke characteristics (lat-
erality and location) and sexual dysfunction will
be presented. Secondly, empirical research investi-
gating links between sexual dysfunction (erectile,
ejaculatory, lubrication and orgasmic function) and
stroke will be reviewed, along with empirical studies
addressing issues of sexual desire, sexual frequency,
and sexual satisfaction. In addition, indirect factors
underlining post-stroke sexual dysfunction, such as
physical and psychological sequelae, will be dis-
cussed. Finally, a review of available rehabilitation
programs will be presented.
2. Methods
2.1. Search strategy
Relevant articles were initially identified using
PubMed databases (from inception to 2017). Firstly,
the following key words were used: “stroke”, “sexu-
ality”, and “sexual dysfunction” (SD) as well as their
combination (see Fig. 1). Additional published arti-
cles were hand-search via the reference lists of the
articles identified through the previously mentioned
databases. Secondly, in order to optimize the num-
ber and quality of the articles selected on the topic
stroke characteristics and sexual function, an addi-
tional literature search was conducted on PubMed
with the following two key words combinations:
“stroke characteristics AND sexual”, and “stroke
AND hemisphere AND sexual”.
2.2. Eligibility criteria
Articles had to meet a number of criteria to be
included in the present review. Only published human
studies of the following research designs were con-
sidered for inclusion in our PubMed search: “clinical
trials”, “journal articles”, “RCT”, and “clinical stud-
ies”. Single or multiple case reports, qualitative case
studies as well as opinion articles were excluded.
Studies were also considered eligible if the language
of publication was English or French.
2.3. Study selection
Articles meeting the aforementioned eligibility
criteria were then assessed by two team members
for relevance screening. Results were pooled and
duplicates were deleted. Pertinent studies were first
assessed based on their study titles and abstracts to
ensure that 1) they primarily addressed the issue of
sexual dysfunctions in individuals with stroke, and
that 2) stroke individuals were the primary popula-
tion of interest. Following this initial selection, each
article was read carefully by members of the research
team to ensure that the content addressed adequately
the topic of interest. Article were selected if they pri-
marily addressed the assessment and prevalence of
post-stroke sexual dysfunction. Among the eligible
and pertinent articles selected, articles were included
if the online version of/access to the article, albeit
seemingly relevant, was available in order to ade-
quately appraise the content of the paper.
2.4. Search results
Twenty-one empirical articles addressing the direct
effects of stroke on the various domains of sexual
functioning (erection, ejaculation, orgasm, lubrica-
tion, desire/libido, sexual satisfaction, and sexual
frequency) as well as the association (s) of stroke
characteristics and sexual dysfunction were obtained
through the PubMed searches listed below. The
additional hand-searches of available reference lists
yielded another 4 articles, bringing the number of
articles addressing the first two goals of this review
to 25. The section of this review dedicated to the
 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
Fig. 1. Flow chart for literature search on stroke and sexual function.
presentation of the indirect factors – urinary inconti-
nence, physical sequelae, depression and well-being,
anxiety – affecting sexual function was drawn from
these 25 articles and was also supplemented by a
hand-search. The final section on sexual rehabilita-
tion programs was computed through a combination
of PubMed literature searches, hand-searches, and
consultations with other field experts.
3. Post-stroke sexual functioning
3.1. Stroke characteristics and sexual
dysfunction
The direct consequences of strokes on sexual func-
tion are partly dependent upon patients’ neurological
profile, such as stroke laterality (see Table 1) and
stroke location (see Table 2) (Sjögren et Fugl-Meyer,
295
1982; Hawton, 1984; Coslett & Heilman,1986;
Monga et al., 1986; Brandstater, 1988; Boldrini et al.,
1991; Korpelainen et al., 1999; Kimura et al., 2001;
Cheasty et al., 2002; Choi-Kwon & Kim, 2002; Braun
et al., 2003; Giaquinto et al., 2003; Spinella, 2004;
Hyun et al., 2006; Mutarelli et al., 2006; Jung et al.,
2008; Tamam et al., 2008; Jawad et al., 2009; Suf-
fren et al., 2011; Bugnicourt et al., 2014). Currently,
this line of research is marked by a lack of consensus
on the matter, since some studies report an absence
of correlation between stroke laterality and sexual
dysfunction (Boldrini et al., 1991; Cheung, 2002;
Choi-Kwon et Kim, 2002; Giaquinto et al., 2003;
Tamam et al., 2008), while others provide data sug-
gesting the existence of an association between the
left hemisphere (Kimura et al., 2001; Braun et al.,
2004; Bugnicourt et al., 2014) or the right hemi-
sphere (Coslett & Heilman, 1986; Jung et al., 2008)
and the presence of sexual dysfunction. Although
 296
Table 1
Stroke laterality and sexual functioning post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Sjögren & Fugl-Meyer, 1982 N = 110 M = 53 Neuro eval., motor eval., standar. Cross tabulation, χ2 , discriminant Right-hemispheric stroke associated
N = 102 SD = 8 sensi eval., AVQ assess analysis w/hemi-neglect
sex. active
Coslett & Heilman, 1986 N = 21 M R = 39–68 Neuro assess., EEG, tructured χ2 Drop in libido, in EF, and in sex
interview on sexual functioning frequency for right-emispheric
stroke
Monga et al., 1986 N = 113 M = 68.6 Non-validated questi. package Descriptive stats, ANOVAs, Women w/right-sided lesions report
N = 78 M R = 30–80 assessing sex funct., libido, sex. factor analysis PCA, t-tests lesser decline in sexual function
N = 35 W frequ., sex satisfaction
Boldrini et al., 1991 N = 86 M = 52.7 Clinical examination CT scan, Descriptive stats, Cross No SIG association b/w laterality and
N = 39 M SD = 5.45 structured interview about sex tabulation, χ2 sexuality
N = 23 W
Kimura et al., 2001 N = 100 M = 58.8 Neuro assess, PSE, JHFI Wilcoxon, t-test, χ2 , logistic More frequent SD in men w/left
N = 75 M SD = 13.5 regression hemispheric stroke; more cases of
N = 25 W R = 25–89 hemi-neglect w/right hemispheric
stroke
Cheung, 2002 N = 139 M = 56.2 Non-validated questi. on sex χ2 , Student t-test, logistic No SIG association b/w laterality and
N = 63 M SD = 11.8 function, clinical data regression sexuality
N = 53 W
Choi-Kwon & Kim, 2002 N = 70 R = 40–80 Neuro eval. structured interview, Descriptive stats, Student t-test, No relation b/w stroke laterality and
N = 56 M Barthel Index MRC Scale, χ2 Fisher, McNemar, Logistic libido, inter-course frequency, EF,
N = 14 W qualitative assess of emotional regression VL; stronger emotional lability
lability, SA & CFBS w/right hemispheric stroke
Giaquinto et al., 2003 N = 62 M = 64 CT scan, clinical examination, Descriptive, t-test, correlations, No relation b/w laterality and sexual
N = 46 M SD = 9.2 structured interview and multiple regressions activity
N = 16 W non-validated questi. on sex
Braun et al., 2004 NA NA Literature review Fisher exact test (FET) Hypo-sexuality w/left hemispheric
stroke; hyper-sexuality w/right
hemispheric stroke
Tanam et al., 2008 N = 103 M = 57.9 Interviews, RS, Barthel Index, CNS, χ2 , Mann-Whitney U, Student No relation b/w laterality and libido,
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

N = 40 W R = 40–80 GCS, NIHSS, non-standard questi. t-test, one-way ANOVA, orgasm, inter-course frequency,
N = 63 M on sex function McNemar and VL
Bugnicourt et al., 2014 N = 104 M = 48 Neuro eval., MRS, non-standard Student t-test, χ2 , Mann-Whitney, 20% reported drop in sex activity
N = 62 M SD = 9.4 questi. on sex function stepwise regression w/right hemispheric stroke; 70%
N = 42 F w/left hemispheric stroke
b/w: between; CFBF: Coital Frequency Before Stroke (non-standardized questionnaire about intercourse frequency); CNS: Canada Neurology Scale; EEG: electroencephalogram; EF: Erectile
Function; Eval.: evaluation; Funct.: functioning; GCS: Glasgow Coma Scale; IIEF-5: International Index of Erectile Function; JHFI: Johns Hopkins Functioning Inventory; M: men; MRC: Medical
Research Council; MRS: Modified Rankin Scale; NIHSS: National Institutes of Health Stroke Scale; Questi: questionnaire; R: age range; RS: Rankin Scale; SA: Sexual Activity (non-standardized
questionnaire about sexual activity); SD: Sexual Dysfunction; SIG: Significant; Standard: standardized; VL: vaginal lubrication; w/: with; W: women.
 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
several studies of functional neuroanatomy highlight
the role played by the limbic system, particularly
the thalamus with regards to sexuality (Pfaus, 1999;
Baird et al., 2007), the existing stroke literature fails
to provide a consistent account of particular areas
associated with sexual dysfunction. This situation is
in part due to the existence of methodological chal-
lenges, such as the use of non-validated instruments
for the assessment of sexual function (Coslett & Heil-
man, 1986; Korpelainen et al., 1998, 1999; Giaquinto
et al., 2003; Tanam et al., 2008; Burgnicourt et al.,
2014) or case reports (Cheasty et al., 2002; Spinella,
2004; Mutarelli et al., 2006; Jawad et al., 2009; Suf-
fren et al., 2011). Finally, stroke severity, defined
as the number of brain lesions, also constitute an
important stroke characteristics affecting sexuality.
Very little research has focused on this particular
aspect of patients’ neurological profiles and its links
to sexual dysfunction in the stroke population. Avail-
able research does suggest that multiple brain lesions
are associated with a higher prevalence of sexual
dysfunction, more specifically with erectile function
(Jung et al., 2008).
3.2. Sexual dysfunction profile post-stroke
Research indicates that both male and female sex-
ual function can be severely compromised following
strokes. In fact, recent research suggests that stroke
increases by 15 the risk of sexual dysfunction and by 5
the risk of sexual inactivity (Azanmasso et al., 2016).
Overall, men who suffered a stroke tend to exhibit
high rates of sexual dysfunction, particularly erec-
tile and ejaculatory difficulties (see Tables 3 and 4).
Rates of erectile dysfunction range from 28% to 75%
depending on the samples (Hawton, 1984; Monga
et al., 1986; Korpelainen et al., 1998, 1999; Cheung,
2002; Jung et al., 2008; Tanam et al., 2008; Akinpelu
et al., 2013) and rates of ejaculatory dysfunction are
reported to vary between 64.5% and 70% in some
studies (Monga et al., 1986; Boldrini et al., 1991;
Korpelainen et al., 1998; Cheung, 2002; Taman et al.,
2008; Akinpelu et al., 2013).
Women on the other hand report a compromised
orgasmic function (see Table 5) with rates of dys-
function reaching 77.5% in some samples (Monga
et al., 1986; Boldrini et al., 1991; Korpelainen et al.,
1998, 1999; Cheung, 2002; Bener et al., 2008; Taman
et al., 2008; Akinpelu et al., 2013; Yilmaz et al.,
2017), as well lubrication difficulties (see Table 6)
fluctuating from 50% to 77% (Monga et al., 1986;
Korpelainen et al., 1998, 1999; Cheung, 2002; Taman
297
et al., 2008; Akinpelu et al., 2013; Yilmaz et al.,
2017).
Significant desire or libido difficulties have also
been reported by both sexes recovering from strokes
(Hawton, 1984; Monga et al., 1986; Korpelainen
et al., 1998, 1999; Cheung, 2002; Choi-Kwon &
Kim, 2002; Jung et al., 2008; Taman et al., 2008;
Thompson & Ryan, 2009; Yilmaz et al., 2017) (see
Table 7), along with a decreased frequency of sexual
activity (Allsup, 1981; Sjögren & Fugl-Meyer, 1982;
Hawton, 1984; Monga et al., 1986; Boldrini et al.,
1991; Korpelainen et al., 1998, 1999; Cheung, 2002;
Choi-Kwon & Kim, 2002; Tanam et al., 2008) (see
Table 8), the latter being more significant for indi-
viduals who are hemiplegic than for those who are
hemiparetic (Sjögren & Fugl-Meyer, 1982). Finally,
save a few exceptions (Boldrini et al., 1991), research
generally points to an overall drop in sexual satisfac-
tion post-stroke for both men and women (Monga
et al., 1986; Korpelainen et al., 1998, 1999; Bener
et al., 2008; Tanam et al., 2008; Akinpelu et al., 2013;
Yilmaz et al., 2017) (see Table 9).
3.3. Indirect stroke factors underlining sexual
dysfunction
Given the multifactorial nature of sexual dysfunc-
tion following stroke, a biopsychosocial approach
allows for a global view of the problematic. In fact,
as discussed previously, not only can the neurologi-
cal damage caused directly by the stroke affect the
neurophysiology of the sexual response, but sec-
ondary factors associated with strokes can indirectly
impact sexual activity as well. Indirect consequences
of strokes onto sexual function include physical limi-
tations resulting from the neurological lesion (s) (see
Table 10) (Hawton, 1984; Choi-Kwon & Kim, 2002;
Jung et al., 2008; Bugnicourt et al., 2014; Seymour &
Wolf, 2014; Yilmaz et al., 2015) as well as physiologi-
cal factors such as urinary incontinence (see Table 11)
(Gelberet al., 1993; Nakayama et al., 1997; Brittain
et al., 1998, 1999; Barrett, 2002; Kolominsky-Rabas
et al., 2003; Edwards et al., 2006; Lecroy, 2006;
Bekker et al., 2010; Nilsson et al., 2011; Williams
et al., 2012).
Post-stroke physical changes, particularly those
affecting body image, are also potent underlying
factors of psychogenic sexual dysfunction. Quali-
tative data indicate that facial appearance may be
altered following stroke and may result in an excess
of salivation, which in turn affects overall physical
appearance. Women who feel they may look older
 298

Authors
Hawton, 1984
Brandstater, 1988
Korpelainen et al., 1999
Kimura et al., 2001
Choi-Kwon & Kim, 2002
Jung et al., 2008
Tanam et al., 2008
Bugnicourt et al., 2014
BDAE: Boston Diagnostic Aphasia Examination; b/w: between; CFBF: Coital Frequency Before Stroke (non-standardized questionnaire about intercourse frequency); CNS: Canada Neurology
Table 2
Stroke location and sexual functioning post-stroke
Participants Age Methods Analyses SD rates/Results
N = 50 M >65 Semi-structured interview Physical NA No relation b/w stroke location and 1) SD
Dependency, non-standard eval. severity 2) SD prevalence
assessing 16 routines
NA NA NA NA No SIG impact of stroke location on SDs;
case of hyper-sexuality w/temporal lobe
stroke
N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression No relation b/w stroke location and 1) SD
N = 117 M SD = 10.2 funct., RS, GDS marginal homog., Kruskal-Wallis severity 2) SD prevalence
N = 100 M = 58.8 Neuro assess, PSE, JHFI Wilcoxon, t-test, χ2 , logistic More frequent SD in men w/left hemispheric
N = 75 M SD = 13.5 regression stroke; more cases of hemi-neglect w/right
N = 25 W R = 25–89 hemispheric stroke
N = 70 R = 40–80 Neuro eval. structured interview, Descriptive stats, Student t-test, χ2 No relation b/w stroke location and 1) SD
N = 56 M Barthel Index MRC Scale, Fisher, McNemar, logistic severity 2) SD prevalence
N = 14 W qualitative assess of emotional regression
lability, SA & CFBS
N = 109 M M = 64.93 Neuro eval., MRI/CT IIEF-5 + 9 χ2 , Mann-Whitney U, Spearman Increased EJD w/right cerebellum stroke;
SD = 8.81 ads-on questions partial r drop in desire w/left basal ganglia stroke
N = 103 M = 57.9 Interviews, RS, Barthel Index, χ2 , Mann-Whitney U, Student t-test, No relation b/w stroke location and 1) SD
N = 63 M R = 40–80 HAM-D, BDI HAM-A, CNS, one-way ANOVA, McNemar severity 2) SD prevalence
NIHSS, GCS, Non- standardized
questionnaire on sex funct
(Korpelainen et al., 1999)
N = 104 M = 48 Neuro eval., MRS, non-standard Student t-test, χ2 , Mann-Whitney, Stroke location unrelated to drop in sexual
N = 62 M SD = 9.4 questi. on sex function stepwise regression activity
N = 42 F
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

Scale; CT: Computerized Tomography; EEG: electroencephalogram; EF: Erectile Function; EJD: ejaculation; Eval.: evaluation; Funct.: functioning; GCS: Glasgow Coma Scale; IIEF-5: International
Index of Erectile Function; JHFI: Johns Hopkins Functioning Inventory; M: men; MRC: Medical Research Council; MRI: Magnetic Resonance Imaging; MRS: Modified Rankin Scale; NIHSS:
National Institutes of Health Stroke Scale; Questi: questionnaire; R: age range; RS: Rankin Scale; SA: Sexual Activity (non-standardized questionnaire about sexual activity); SD: Sexual
Dysfunction; SFE: Social Functioning Examination; Standard: standardized; w/: with; W: women.
 Table 3
Erectile function post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Hawton, 1984 N = 50 M >65 Non-standard eval. assessing 16 NA 91% regained EF after 7 weeks; 28%
routines indicated loss of rigidity
Monga et al., 1986 N = 113 M = 68.6 Non-validated questi. package Descriptive stats, ANOVAs, factor 64% reported abnormal EF
N = 78 M R = 30–80 assessing sex funct., libido, sex. analysis PCA, t-tests
frequ., sex satisfaction
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standard questi. assessing sex Mann-Whitney U, crosstab χ2 , Loss EF at 2 m in 8%, at 6 m in 6%; overall
N = 38 M SD = 8.2 funct., penile gauge Kruskal-Wallis drop in EF in > 50%
N = 43 R = 32–65
at 6 months
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression Loss or drop in EF in 75%
N = 117 M SD = 10.2 funct. marginal homog., Kruskal-Wallis
Cheung, 2002 N = 139 M = 56.2 Self-administered non validated χ2 , Student t-test, logistic regression Diminished EF in 38.7%; loss of EF in 21%
N = 63 M SD = 11.8 questi. on sex function
N = 53 W
Bener et al., 2008 N = 605 M M = 56.1 IIEF-5 Mann-Whitney, Student t-test, χ2 , 48.3% reported some form of ED; 36% had
SD = 9.8 Fisher’s exact test, Pearson’s r severe ED, 32.9% moderate ED, 31.2%
had mild ED
Jung et al., 2008 N = 109 M M = 64.93 IIEF-5 + 9 ads-on questions. χ2 , Mann-Whitney U, Spearman Lower IIEF scores; 3rd cause of absence of
SD = 8.81 partial r inter-course = incomplete EF
Tanam et al., 2008 N = 103 M = 57.9 Non- standardized questionnaire on χ2 , Mann-Whitney U, Student t-test, Loss of EF in 15.9%; diminished EF in
N = 63 M R = 40–80 sex function one-way ANOVA, McNemar 47.6%
Akinpelu et al., 2013 N = 77 M = 55.2 Non-standard questi assessing sex χ2 , Mann-Whitney U ED reported by 61.7% of the sample
N = 60 M SD = 10.8 funct.
N = 17 W
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

ED: erectile dysfunction; EF: erectile function; homog.: homogeneity; IIEF-5: International Index of Erectile Function; m: months; M: men; questi.: questionnaire; R: age range; SD: sexual
dysfunction; W: women.
299
 300

Table 4
Ejaculatory function post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Monga et al., 1986 N = 113 M = 68.6 Non-validated questi. Package Descriptive stats, ANOVAs, factor 70% reported EJ diffi-culties; 43% reported
N = 78 M R = 30–80 assessing sex funct., libido, sex analysis PCA, t-tests premature EJ
frequ., sex satisfaction
Boldrini et al., 1991 N = 86 M = 52.7 Clinical examination, structured Descriptive stats, Cross tabulation, χ2 Decline in EJ reported by 41%
N = 39 M SD = 5.45 interview about sexual function
N = 23 W
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standard questi. assessing sex Mann-Whitney χ2 , crosstab χ2 Loss EJ at 2 m in 18%, at 6 m in 12%; drop
N = 38 M SD = 8.2 funct., penile gauge Kruskal-Wallis in EJ at 2 m in 37%, at 6 m in 52%
N = 43 R = 32–65
at 6 months
Cheung, 2002 N = 139 M = 56.2 Self-administered non validated χ2 , Student t-test, logistic regression Loss of EJ in 27.9%; diminished EJ in
N = 63 M SD = 11.8 questi. on sex function 24.6.9%
N = 53 W
Tanam et al., 2008 N = 103 M = 57.9 Non- standardized questionnaire on χ2 , Mann-Whitney U, Student t-test, Loss of EJ in 16.1%; diminished EJ in 48.4%
N = 63 M R = 40–80 sex function one-way ANOVA, McNemar
Akinpelu et al., 2013 N = 77 M = 55.2 Non-standard questi assessing sex χ2 , Mann-Whitney U EJ dysfunction reported by 63.3% of the
N = 60 M SD = 10.8 funct sample
N = 17 W
EJ: Ejaculation; m: months; M: men; questi.: questionnaire; R: age range; SD: sexual dysfunction; W: women.
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
 Table 5
Female orgasm post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Monga et al., 1986 N = 113 M = 68 Non-validated questi. package Descriptive stats, ANOVAs, factor Loss of orgasm reported in 77%
N = 35 W R = 36–86 assessing sex funct., libido, sex analysis PCA, t-tests
frequ., sex satisfaction
Boldrini et al., 1991 N = 86 M = 52.7 Clinical examination, structured Descriptive stats, Cross tabulation, χ2 No change in orgasm reported by 67% of
N = 39 M SD = 5.45 interview about sexual function women
N = 23 W
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standard questi. assessing sex Mann-Whitney U, χ2 , crosstab χ2 Absent orgasm in 20% at 6 m; overall drop
N = 12 W SD = 8.2 funct., penile gauge Kruskal-Wallis in orgasm in 30% at 6 m
N = 43 R = 32–65
at 6 months
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression Absent orgasm in 17%; overall drop in
N = 75 W SD = 10.2 funct., marginal homog., Kruskal-Wallis orgasm in 38%
Cheung, 2002 N = 139 M = 56.2 Self-administered non validated χ2 , Student t-test, logistic regression Absent orgasm in 67.5%; drop in orgasm in
N = 63 M SD = 11.8 questi. on sex function 15%
N = 53 W
Tanam et al., 2008 N = 103 M = 57.9 Non-standardized questionnaire on χ2 , Mann-Whitney U, Student t-test, Absent orgasm in 60%; overall drop in
N = 40 W R = 40–80 sex function one-way ANOVA, McNemar orgasm in 27.5%
Akinpelu et al., 2013 N = 77 M = 55.2 Non-standard questi assessing sex χ2 , Mann-Whitney U Orgasm dysfunction reported by 63.6%
N = 60 M SD = 10.8 funct.
N = 17 W
Yilmaz et al., 2017 N = 51 W M = 43.33 FSFI Kolmogorov-Smir. χ2 , FSFI Orgasm scores SIG < than for controls
SD = 8.82 Mann-Whitney U, Student t-test,
Spearman’s r
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

homog.: homogeneity; m: months; M: men; questi.: questionnaire; R: age range; SIG: Significant; W: women.
301
 302

Table 6
Vaginal lubrication post-stroke
Athors Participants Age Methods Analyses SD rates/Results
Monga et al., 1986 N = 113 M = 68 Non-validated questi. package assessing Descriptive stats, ANOVAs, factor 29% reported normal or slow normal VL
N = 35 W R = 36–86 sex funct., libido, sex frequ., sex analysis PCA, t-tests
satisfaction
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standard questi. assessing sex Mann-Whitney U, χ2 , crosstab χ2 Absent VL in 10% at 6 m; overall drop in VL
N = 12 W SD = 8.2 funct., penile gauge Kruskal-Wallis in 50% at 6 m
N = 43 R = 32–65
at 6 months
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression, Absent VL in 12%; overall drop in VL in
N = 75 W SD = 10.2 funct., marginal homog., Kruskal-Wallis 34%
Cheung, 2002 N = 139 M = 56.2 Self-administered non validated questi. χ2 , Student t-test, logistic regression Absent VL in 37.5%, drop in VL in 32.5%
N = 63 M SD = 11.8 on sex function
N = 53 W
Tanam et al., 2008 N = 103 M = 57.9 Non-standardized questionnaire on sex χ2 , Mann-Whitney U, Student t-test, Absent VL in 56.4%; overall drop in VL in
N = 40 W R = 40–80 function One-way ANOVA, McNemar 30.8%
Akinpelu et al., 2013 N = 77 M = 55.2 Non-standard questi assessing sex funct. χ2 , Mann-Whitney U VL dysfunction reported by 47.1% of the
N = 60 M SD = 10.8 sample
N = 17 W
Yilmaz et al., 2017 N = 51 W M = 43.33 FSFI Kolmogorov-Smir. χ2 , FSFI VL scores SIG < than for controls
SD = 8.82 Mann-Whitney U, Student t-test,
Spearman’s r
homog.: homogeneity; m: months; M: men; questi.: questionnaire; R: age range; SD: sexual dysfunction; SIG: Significant; VL: Vaginal Lubrication; W: women.
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
 Table 7
Desire/libido in men and women post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Hawton, 1984 N = 50 M >65 Non-standard eval. assess 16 routines NA 91% of men reporting desire pre-stroke note
return of desire 6.5 weeks post-stroke
Monga et al., 1986 N = 113 M = 68.3 Non-validated questi. package Descriptive stats ANOVAs, factor 21% of men & 34% of women report normal
N = 78 M R = 30–86 assessing sex funct., libido, sex analysis PCA, t-tests libido post-stroke
N = 35 W frequ. sex satisfaction
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standardized questi., assessing Mann-Whitney U, χ2 , crosstab χ2 Loss of libido reported by 6% at 2 m and 7%
N = 38 M SD = 8.2 sex function, penile gauge Kruskal-Wallis at 6 m; Drop in libido reported by 32% at
N = 12 F R = 32–65 2 m and by 44% at 6 m; no change in
libido in 60% at 2 m, in 49% at 6 m
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression Drop in libido reported by 57% of patients
N = 117 M SD = 10.2 function marginal homog., Kruskal-Wallis and by 65% of partners
N = 75 W
Cheung, 2002 N = 139 M = 56.2 Self-administered non Validated χ2 , Student t-test, logistic regression Drop or absent libido in 54.3%; 44.8%
N = 63 M SD = 11.8 questi. on sex function report unchanged libido
N = 53 W
Choi-Kwon & Kim, 2002 N = 70 R = 40–80 SA & CFBS Descriptive stats, Student t-test, χ2 Drop in libido in 49%, in 44% of the sample
N = 56 M Fisher, McNemar, logistic at 2 year follow-up
N = 14 W regression
Jung et al., 2008 N = 109 M M = 64.93 IIEF-5 + & 9 ads-on questions χ2 , Mann-Whitney U, Spearman Drop in libido is #1 factor of absence of
SD = 8.81 partial r sexual activity
Tanam et al., 2008 N = 103 M = 57.9 Non-standardized questionnaire on χ2 , Mann-Whitney U, Student t-test, No changes in libido in 40.8%; absent/drop
N = 40 W R = 40–80 sex function one-way ANOVA, McNemar in libido in 58.3% of the sample
N = 63 M
Thompson & Ryan, 2009 N = 16 M = 56 Qualitative interviews Morse & Field’s methods (1996) Loss/drop in desire associated with edication
N=7W R = 33–78 & fear of causing another stroke
N=9M
Akinpelu et al., 2013 N = 77 M = 55.2 Non-standard questi assessing sex χ2 , Mann-Whitney U Libido difficulties reported by 70.1%
N = 60 M SD = 10.8 funct.
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

N = 17 W
Yilmaz et al., 2017 N = 51 W M = 43.33 FSFI Spearman’s r, χ2 , Mann-Whitney U, FSFI Desire scores SIG < than for controls
SD = 8.82 Student t-test
Asses.: Assessment; CFBF: Coital Frequency Before Stroke (non standardized questionnaire about intercourse frequency); Eval.: Evaluation; Funct.: Function; homog.: homogeneity; IIEF-5:
International Index of Erectile Function; FSFI: Female Sexual Function Index; m: months; M: men; questi.: questionnaire; R: age range; SA: Sexual Activity (non standardized questionnaire about
sexual activity); SD: sexual dysfunction; SIG: Significant; Standard: Standardized; W: women.
303
 304

Table 8
Sexual frequency in men and women post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Allsup-Jackson, 1981 N = 50 R = 40–65 Phone interviews about sexual NA 60% report drop in sex activity; 30% report
N = 26 M function sex activity <1 per month; 20% report no
N = 24 W sex activity
Sjögren & Fugl-Meyer, 1982 N = 110 <66 Neuro eval., motor eval., standar. Cross tabulation, χ2 , discriminant 72% report drop in sex frequency; 36%
N = 102 M = 53 sensi eval., AVQ assess analysis report absence of sex activity
sex active SD = 8
Hawton, 1984 N = 50 M >65 Non-standard eval. assessing 16 NA Decline in sex frequency correlated with
routines disability level
Monga et al., 1986 N = 113 M = 68.3 Non-validated questi. package Descriptive stats ANOVAs, factor 64% of men & 54% of women report no
N = 78 M R = 30–86 assessing sex funct., libido, sex Analysis PCA, t-tests sexual activity post-stroke
N = 35 W frequ. sex satisfaction
Boldrini et al., 1991 N = 86 M = 52.7 Clinical examination, structured Descriptive stats, Cross tabulation, χ2 Most participants report decline in sex
N = 39 M SD = 5.45 interview about sexual function frequency
N = 23 W
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standard questi. assessing sex Mann-Whitney U, χ2 , crosstab χ2 Absence of sex activity for 28% at 2 m and
N = 38 M SD = 8.2 funct., penile gauge Kruskal-Wallis for 14% at 6 m; 18% report sex activity <1
N = 12 F R = 32–65 per month at 2 m and 21% at 6 m
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression Absence of sex activity for 33%; drop in sex
N = 117 M SD = 10.2 funct. marginal homog., Kruskal-Wallis frequency reported by 45%
N = 75 W
Cheung, 2002 N = 139 M = 56.2 Self-administered non validated χ2 , Student t-test, logistic regression Absence of intercourse for 51.4%
N = 63 M SD = 11.8 questi. on sex function post-stroke; 22.9% report intercourse <1
N = 53 W per
Choi-Kwon & Kim, 2002 N = 70 R = 40–80 SA & CFBS Descriptive stats, Student t-test, χ2 Drop in sex frequency in 65%, in 49% of the
N = 56 M Fisher, McNemar, logistic sample at 2 year follow-up
N = 14 W regression
Jung et al., 2008 N = 109 M M = 64.93 IIEF-5 + 9 ads-on Questions χ2 , Mann-Whitney U, Spearman Majority of men had sex activity <1 per
SD = 8.81 partial r month
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

Tanam et al., 2008 N = 103 M = 57.9 Non-standard questi. on sex function χ2 , Mann-Whitney U, Student t-test, Absence of sex activity for 14.6%; 24.3%
N = 40 W R = 40–80 one-way ANOVA, McNemar report sex. activity <1 per month
N = 63 M
Asses.: Assessment; CFBS: Coital Frequency Before Stroke (non standardized questionnaire about intercourse frequency); Eval.: Evaluation; Funct.: Function; homog.: homogeneity; IIEF-5:
International Index of Erectile Function; m: months; M: men; questi.: questionnaire; R: age range; SA: Sexual Activity (non standardized questionnaire about sexual activity); sexual dysfunction;
Standard: Standardized; W: women.
 Table 9
Sexual satisfaction in men and women post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Monga et al., 1986 N = 113 M = 68.3 Non-validated questi. package Descriptive stats, ANOVAs, factor 26% of men & 37% of women reported to be
N = 78 M R = 30–86 assessing sex funct., libido, sex analysis PCA, t-tests satisfied with sex activity
N = 35 W frequ. sex satisfaction
Boldrini et al., 1991 N = 86 M = 52.7 Clinical examination, structured Descriptive stats, Cross tabulation, χ2 92% report no change in sexual satisfaction
N = 39 M SD = 5.45 interview about sexual function
N = 23 W
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standard questi. assessing sex Mann-Whitney U, χ2 , crosstab χ2 Complete dissatisfaction reported by 14% at
N = 38 M SD = 8.2 function, penile gauge Kruskal-Wallis 2 m, by 19% at 6 m; Moderate dissatisfaction
N = 12 F R = 32–65 reported by 26% at 2 m & by 23% at 6 m (90%
of sample satisfied pre- stroke)
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression Moderate to complete dissatisfaction reported by
N = 117 M SD = 10.2 function marginal homog., Kruskal-Wallis 49% of sample (89% of sample satisfied
N = 75 W pre-stroke)
Cheung, 2002 N = 139 M = 56.2 Self-administered non validated χ2 , Student t-test, logistic regression Dissatisfaction reported in 25.7% of the sample;
N = 63 M SD = 11.8 questi. on sex function men report SIG more dissatis-faction than
N = 53 W women
Bener et al., 2008 N = 605 M M = 56.1 IIEF-5 Mann-Whitney, Student t-test, χ2 , 49% reported being satisfied with post-stroke
SD = 9.8 Fisher’s exact test, Pearson’s sex function vs. 89% pre-stroke
Tanam et al., 2008 N = 103 M = 57.9 Non- standardized questionnaire on χ2 , Mann-Whitney U Student t-test, Dissatisfaction reported by 37.9% of the sample
N = 40 W R = 40–80 sex function one-way ANOVA, McNemar
N = 63 M
Yilmaz et al., 2017 N = 51 W M = 43.33 FSFI Kolmogorov-Smir. χ2 , FSFI Satisfact. scores SIG < than for controls
SD = 8.82 Mann-Whitney U Student t-test,
Spearman’s r
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

Asses.: Assessment; Eval.: Evaluation; Funct.: Function; homog.: homogeneity; IIEF-5: International Index of Erectile Function; FSFI: Female Sexual Function Index; m: months; M: men; questi.:
questionnaire; R: age range; RS: Rankin Scale; SA: Sexual Activity (non standardized questionnaire about sexual activity); Satisf.: Satisfaction; SD: sexual dysfunction; SIG: Significant; Standard;
Standardized; W: women.
305
 306

Table 10
Physical sequelae and sexual functioning post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Hawton, 1984 N = 50 M >65 Semi-structured interview Physical NA 83% of men who have had sex activity
Dependency, non-standard eval. post-stroke report interference of their
assessing 16 routines physical sequelae; level of physical
disability not related to resumption of sex
activity
Cheung, 2002 N = 139 M = 56.2 Self-administered non validated χ2 , Student t-test, logistic regression Disability SIG predictive of EF, EJ, and
N = 63 M SD = 11.8 questi. on sex function, RS Barthel sexual satisfaction
N = 53 W Index
Choi-Kwon & Kim, 2002 N = 70 R = 40–80 Neuro eval. structured interview, Descriptive stats, Student t-test, χ2 Participants w/severe motor disabilities
N = 56 M Barthel Index MRC Scale, SA & Fisher, McNemar, Logistic report low intercourse frequency; 2-year
N = 14 W CFBS regression post-stroke severe motor disabilities are
asso-ciated w/drop in libido, intercourse
frequency, EF, lubrication; 27-months
post-stroke, low Barthel Index score
associated w/drop in libido
Giaquinto et al., 2004 N = 62 M = 64 FIM, structured interview about sex. Descriptive, t-test, correlations, Disability score is a SIG predictor of sex
N = 46 M SD = 9.2 Non-validated questi., on sexuality multiple regressions activity
N = 16 W
Jung et al., 2008 N = 109 M M = 64.93 Neuro eval., MRI/CT, IIEF-5 + 9 χ2 , Mann-Whitney U, Spearman Physical discomfort ranked as 2nd reason for
SD = 8.81 ads-on questions partial r absence of sex activity
Seymour & Wolf, 2014 N = 13 M = 62 NIHSS, QSF, ISI, PHQ-9 Correlations SDs correlated w/hand mobility and hand
N=4W SD = 15.10 function
N=9M R = 36–82
Yilmaz et al., 2015 N = 16 NA Qualitative interview, Yildirim & Simsek methods (2011) Physical difficulties reported as reason for
semi-structured questi. drop in sexual desire
Bugnicourt et al., 2014 N = 104 M = 48 Neuro eval., MRS, BDAE, NIHSS, Student t-test, χ2 , Mann-Whitney, 50% of participants repor-ting drop in sex
N = 62 M SD = 9.4 non-standard questi. on sex stepwise regression activity have motor dysfunctions
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

N = 42 F function
BDAE: Boston Diagnostic Aphasia Examination; CFBF: Coital Frequency Before Stroke (non-standardized questionnaire); CT: Computerized Tomography; EF: Erectile Function; FIM: Functional
Independence Measure; IIEF-5: International Index of Erectile Function; ISI: Stroke Impact Scale; M: men; MRC: Medical Research Council; MRI: Magnetic Resonance Imaging; MRS: Modified
Rankin Scale; NIHSS: National Institutes of Health Stroke Scale; PHQ-9: Patient Health Questionnaire 9-Item; questi.: questionnaire; QSF: Quality of Sexual Function Scale; R: age range; RS:
Rankin score; SA: Sexual Activity (non-standardized questionnaire); SD: Sexual Dysfunction; sex: Sexual; SIG: Significant; VL: Vaginal Lubrication; w/: with; W: women.
 Table 11
Urinary Incontinence and sexual functioning post-stroke
Authors Participants Age Methods Analyses SD rates/Results
Barrett, 2002 NA NA Literature review NA Urinary incontinence reported in 40–60% of patients
post-stroke
Kolomsinky-Rabas et al., N = 484 R = 23–95 Interview Mann-Whitney U, Kruskal-Wallis, 54% of patients are incontinent at 7-day post-stroke;
2003 N = 223 M χ2 logistic regression, Cox 42% of them are fully incontinent & 12% are
N = 261 W regression model partially incontinent; 32% of patients are
incontinent at 1-year post-stroke 50% of them are
fully incontinent & 50% are partially incontinent
Bekker et al., 2010 N = 326 W M = 47.7 GRISS χ2 , Student t-test Women w/urinary incontinence show higher SD
SD = 13.45 scores and more avoiding behaviors; partners of
women w/urinary incontinence show poorer sex
functioning, greater ED, poorer sex frequency and
greater sex dissatisfaction
Nilsson et al., N = 147 W R = 18–74 Semi-structured interview, χ2 , Holm-Bonferroni logistic Women w/urinary inconti- nence report concerns
B-FLUTS, Clinical assessment regression about leaks and drop in sex satisfaction; 34% of
(urine test, vaginal exam) participants report having consistent leaks during
orgasm and intercourse
Williams et al., 2012 N = 340 W M = 72.1 Interview, Urinary Symptoms Test-t, χ2 , logistic regression Over 80% of participants report urinary
questionnaire incontinence symptoms at 3- & 12-m post-stroke
B-FLUTS: Bristol Female Lower Urinary Tract Symptoms; ED: Erectile Dysfunction; GRISS: German version of the Golombok Rust Inventory of Sexual Satisfaction; HADS: Hospital Anxiety
and Depression Scale; IIEF-5: International Index of Erectile Function; ISI: Stroke Impact Scale; M: men; R: age range; SD: Sexual Dysfunction; sex: Sexual; w/: with; W: women.
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
307
 308

Table 12
Psychological sequelae and sexual functioning post-stroke – Depression & Well-being
Authors Participants Age Methods Analyses SD rates/Results
King, 1996 N = 86 M = 63.3 Interviews, MMSE, QLI, CES-D Student t-test, χ2 correlation, Dissatisfaction/low life satisfaction reported
SD = 13.2 stepwise multiple regression by 23% of the sample; 30% scored in the
R = 23–88 depressed range of the CES-D
Korpelainen et al., 1998 N = 50 M = 53.5 Non-standard questi. assessing sex Mann-Whitney U, χ2 , crosstab χ2 At 2 m post-stroke, 34% depression is minor
N = 38 M SD = 8.2 function SDS, penile gauge Kruskal-Wallis in 34%, moderate in 14%, severe in 4%;
N = 12 F R = 32–65 depression scores not related to SDs
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression Depression level explains drop in desire,
N = 117 M SD = 10.2 funct., GDS marginal homog., Kruskal-Wallis erectile capacity, sex frequency, orgasm,
N = 75 W sex satisfaction
Forsberg Wärleby et al., 2001 N = 83 M = 58 Semi-structured interv. PGWB, Fisher’s exact test, Pitman’s test, At 1-year post-stroke, depression associated
N = 62 M R = 23–75 LISAT-9, Spearman’s correlation w/partner’s drop in sex satisfaction;
N = 21 W severity of sensorimotor difficulties
associated w/depression
Forsberg Wärleby et al., 2004 N = 67 M = 58 Neuro assessment, SSS items, Wilcoxon, χ2 w/Yates correction, Drop in life satisfaction at 4 m & 1-year
N = 47 M R = 37–75 LISAT-9 Spearman correlation, post-stroke reported by patient and
N = 20 W Mann-Whitney U partner; cognitive deficits linked to drop in
partners’ relational satis
Kimura et al., 2001 N = 100 M = 58.8 HAM-D, MMSE Wilcoxon, t-test, χ2 , logistic Post-stroke depression correlated
N = 75 M SD = 13.5 regression w/frequency of SDs
N = 25 W R = 25–89
Kim & Kim, 2008 N = 67 M M = 55.76 CES-D, Sexual Frequency Scale Descriptive stats, multiple regression Sexual frequency SIG predictive of
SD = 4.59 depression
Duits et al., 2009 N = 19 W M = 58.8 IIEF-5, SIS/SES, SCL-90 Spearman correlation w/Bonferroni, SDs not correlated w/depression
SD = 6.1 (depression subscale) stepwise regression
Seymour & Wolf, 2014 N = 13 M = 62 QSF, PHQ-9, SIS Correlations Higher depression scores correlated w/SD,
N=4W SD = 15.10 w/level of sexual activity
N=9M R = 36–82
Yilmaz et al., 2015 N = 16 NA Qualitative interview, Yildirim & Simsek methods (2011) Depressive symptoms reported to cause drop
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

semi-structured questi. in sexual desire

CES-D: The Center for Epidemiologic Studies Depression Scale; EF: Erectile Function; GRISS: German version of the Golombok Rust Inventory of Sexual Satisfaction; HADS: Hospital Anxiety
and Depression Scale; HAM-D: Hamilton Rating Scale for Depression; homog.: homogeneity; IIEF-5: International Index of Erectile Function; interv.: interview; ISI: Stroke Impact Scale; LISAT-
9: Life Satisfaction Questionnaire; M: men; MMSE: Mini Mental State Examination; PGWB: Psychological General Well-Being Index; PHQ-9: Patient Health Questionnaire 9-Item; questi.:
questionnaire; QLI: Quality of Life Index-Stroke; QSF: Quality of Sexual Function Scale; R: age range; SA: Sexual Activity (non-standardized questionnaire); SCL-90: Symptom Checklist-90;
SD: Sexual Dysfunction; SDS: Zung Self-rating Depression Scale; sex: Sexual; SIG: significant; SIS: Stroke Impact Scale; sympt.: symptoms; w/: with; W: women.
 Table 13
Psychological sequelae and sexual functioning post-stroke – Anxiety
Authors Participants Age Methods Analyses SD rates/Results
Hawton, 1984 N = 50 M >65 Semi-structured interview Physical NA Partners fear triggering new stroke during sex
Dependency activity
Brandstater, 1988 NA NA NA NA Anxiety associa. w/fear that physical stress or rise in
BP during sex activity cause another stroke
Korpelainen et al., 1999 N = 192 M = 59.1 Non-standard questi. assessing sex χ2 , logistic & stepwise regression Men’s drop in sex desire/libido partly explained by
N = 117 M SD = 10.2 function marginal homog., Kruskal-Wallis fear of ED
N = 75 W
Forsberg Wärleby et al., 2001 N = 83 M = 58 Semi-structured interv. assessing Fisher’s exact test, Pitman’s test, Sensorimotor difficulties severity associated
N = 62 M R = 23–75 neurological deficits Spearman’s r w/anxiety
N = 21 W
Jung et al., 2008 N = 109 M M = 64.93 IIEF-5 + 9 ads-on questions χ2 , Mann-Whitney U, Spearman No major fears reported regarding sex activity
SD = 8.81 partial r
Duits et al., 2009 N = 19 W M = 58.8 IIEF-5, SCL-90 (anxiety subscale) Spearman correlation w/Bonferroni, SDs not correlated w/anxiety
SD = 6.1 stepwise regression
Thompson & Ryan, 2009 N = 16 M = 56 Qualitative interviews Morse & Field’s methods (1996) Fear of triggering other stroke named as possible
N=7W R = 33–78 cause of drop in sex desire; drop in sex desire
N=9M leading to drop in sex frequency may cause
feelings of guilt and fear regarding relationship
Yilmaz et al., 2015 N = 16 NA Qualitative interview, Yildirim & Simsek methods (2011) Fear of triggering other stroke and causing death;
semi-structured questi. fear that partner be unfaithful for lack of sex
Bugnicourt et al., 2014 N = 104 M = 48 HADS, non-standard questi. on sex Student t-test, χ2 , Mann-Whitney, 43% of participants reporting drop in sex activity
N = 62 M SD = 9.4 function stepwise regression show anxiety sympt.; only 15% of participants
N = 42 F who do not report drop in sex activity show
anxiety symptoms
A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review

ED: Erectile Dysfunction; homog.: homogeneity; HADS: Hospital Anxiety and Depression Scale; IIEF-5: International Index of Erectile Function; M: men; questi.: questionnaire; R: age range;
SCL-90: Symptom Checklist-90; SD: Sexual Dysfunction; sex: Sexual; sympt.: symptoms; w/: with; W: women.
309
310 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
due to those post-stroke physical changes report being
less likely to initiate physical contacts with roman-
tic partners (Thompson & Ryan, 2009). Moreover,
women recovering from a stroke indicate neglect-
ing their personal hygiene and physical appearance,
which in turn affects their sexual lives (Thompson &
Ryan, 2009).
Psychological factors also contribute to the etiol-
ogy of post-stroke sexual dysfunction. In fact, a large
proportion of patients recovering from a stroke report
poor well-being (King, 1996; Forsberg Wärleby et al.,
2004) and high rates of mood disorders (Choi-Kwon
et Kim, 2002), particularly depression (Korpelainen
et al., 1998, 1999; Forsberg Wärleby et al., 2001;
Kimura et al., 2001; Duits et al., 2009; Bugnicourt
et al., 2014; Seymour et Wolf, 2014; Yilmaz et al.,
2015) (see Table 12) as well as frequent bouts of anxi-
ety (see Table 13) (Hawton, 1984; Brandstater, 1988;
Korpelainen et al., 1999; Forsberg Wärleby et al.,
2001; Jung et al., 2008; Duits et al., 2009; Thompson
& Ryan, 2009; Bugnicourt et al., 2014; Yilmaz et al.,
2015). As evidenced by the research available, these
psychological factors can have a strong impact on
patients’ sexual functioning, sexual desire, and sexual
satisfaction. Inversely, post-stroke sexual frequency
may be significantly predictive of depressive states
in some men (Kim & Kim, 2008). Emotional lability
has been highlighted as being particularly problem-
atic. In fact, emotional lability has previously been
linked to a drop in intercourse frequency as well as
erectile function at 3-month follow-up: this link was
shown to be maintained at the two-year mark as well
(Choi-Kwon & Kim, 2002).
4. Post-stroke sexual rehabilitation
Recent research has attempted to document the
barriers that prevent rehabilitation personnel from
addressing sexuality issues with patients recovering
from a stroke. One of the major findings of this new
line of research points to the lack of training reported
by the staff (McLaughlin & Cregan, 2005; Steinke
et al., 2013). In fact, this lack of training is reflected
in the level of discomfort with this topic reported by
medical professionals as well as in their overall con-
cern that they might say or do something offensive
to the patient (McLaughlin & Cregan, 2005; Steinke
et al., 2013). A lack of self-efficacy with regards to
professionals’ ability to address such issues effec-
tively (Steinke et al., 2013), combined with a lack of
standardized practices makes for a difficult follow-up
in terms sexual rehabilitation (McLaughlin & Cregan,
2005). Moreover, the question of the timing at which
this topic should be addressed as well as a sense that
other professionals – psychiatrists – are perhaps bet-
ter equipped to deal with these issues contribute to
the barriers currently in place in rehabilitation cen-
ters (McLaughlin & Cregan, 2005; Guo et al., 2015).
More importantly, some rehabilitation personnel are
under the impression that sexuality is not something
patients are keen on discussing (Steinke et al., 2013)
and would rather wait for patients to bring up these
issues (Guo et al., 2015), rather than introducing the
topic themselves. Finally, administrative consider-
ations such as schedule conflicts, time restrictions
(Mick et al., 2004; Steinke et al., 2013) and the weight
of other professional obligations (McLaughlin & Cre-
gan, 2005) are reportedly contributing to the status
quo with regards to addressing sexuality with patients
recovering from a stroke.
Interestingly, patients themselves report some
reserves vis-á-vis bringing up issues pertaining to
their sexual functioning post-stroke. The discom-
fort reported by rehabilitation personnel is shared by
patients themselves who fear being judged upon shar-
ing their concerns. Older patients or patients who do
not identify as heterosexual are particularly wary of
the social stigma at times reflected in society at large
(Steinke et al., 2013). Moreover, physical limitations
resulting from the stroke, such as aphasia, may con-
tribute to the barriers preventing patients from sharing
their concerns or questions with regards to post-stroke
sexuality (Guo et al., 2015). Similar to the rehabili-
tation personnel’s experience, patients also wonder
who to go to in order to get answers to their ques-
tions. Research indicates that they would rather attend
regular, official information sessions about sexuality
(Steinke et al., 2013), where they could be taught
about the particular sexual positions recommended
to avoid further strokes, the effects of medication on
their sexual function, as well as the impact of poten-
tial comorbidities such as diabetes and hypertension
on their sexual function post-stroke (Steinke et al.,
2013, Ng et al., 2017).
Research also indicates that partners of individuals
having suffered a stroke are often left aside despite
a dire need of answers or follow-up in some cases
(Steinke et al., 2013). With no one to answer their
questions about sexual activity with their partner, or
to develop new coping strategies as they take on a role
of caregiver in some cases, partners are often shown
to be left along the road to recovery (Steinke et al.,
2013).
 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
5. Sexual rehabilitation intervention
programs
Several sexual rehabilitation programs have been
designed to help professionals address and assess
sexual function in patients suffering from various
medical conditions, including neurological condi-
tions like multiple sclerosis. Such programs are
equally useful for individuals working with patients
recovering from strokes. PLISSIT (Annon, 1976),
Ex-PLISSIT (Davis & Tailor, 2006) and BETTER
(Steinke et al., 2013) provide precious guidelines for
professionals.
Developed in the 1970s, PLISSIT (Permission,
Limited Information, Specific Suggestion, and Inten-
sive Therapy) provides a theoretical and clinical
framework to health professionals who wish to
address the issue of sexual rehabilitation with their
patients. This model is comprised of four distinct
steps:
• Firstly, an opportunity (i.e. the permission) to
address the sexual component of their reha-
bilitation process is provided to patients by
professional themselves, rather than waiting for
them to address the issue.
• Secondly, information about the impact of their
neurological condition on sexual functioning is
provided in small quantity (limited information).
Educational material for the patient to take home
such as pamphlets can also be provided at this
time.
• Thirdly, following a thorough assessment, spe-
cific suggestions may be provided by health
professionals to their patients (specific sugges-
tions). These suggestions may pertain to the
management of their sexual difficulties, the
implementation of a routine before sexual activ-
ity, etc.
• Lastly, in the event that patients recovering from
a stroke present severe sexual difficulties, health
professionals may refer them to appropriate ser-
vices (intensive therapy).
Recent research has tested the efficacy of this inter-
vention with patients recovering from stroke in the
context of a randomized controlled trial (Ng et al.,
2017). Findings revealed that patients assigned to the
intervention group did not report significant improve-
ments by comparison with the control group in the
areas of sexual functioning, anxiety and depression,
quality of life, and functional independence. The lack
311
of significant differences between groups in these
areas was maintained at 6-weeks and 6-month follow
up (Ng, et al., 2017).
The PLISSIT model previously discussed has
recently been refined and expanded into the Ex-
PLISSIT model (Davis & Tailor, 2006). In this
framework, “permission” has been integrated to each
separate step so as to make it an integral part of
the model. Moreover, unlike its predecessor, the Ex-
PLISSIT model encourages health professionals to
review their interactions with their patients, hence
the Review & Reflect component of the model. This
is meant to ensure that the information provided to
patients about sexuality and sexual rehabilitation is
properly conveyed and integrated, and also to address
potential subsequent questions.
The BETTER model (Steinke et al., 2013) fol-
lows the same general principles, while adding a
record-keeping part to the information provided.
Accordingly, it is comprised of the following steps:
• Similar to the PLISSIT model, health profes-
sionals are first encouraged to address the issue
of sexuality, rather than wait on patients to do so
(Bring the topic).
• A second step involves addressing their concerns
(Explain concerns).
• A third step invites health professional to
describe the available resources to patients in
need (Tell about resources).
• This is to be followed by specifying any time
and location constraints (Timing).
• Health professionals are then to provide educa-
tional material to patients with regards to the
impact of their neurological condition on their
sexual functioning (Educate).
• Lastly, the model encourages health profes-
sional to document the information shared with
patients in their medical file in order to provide
optimal follow-up care (Record).
While these models offer health professionals a
systematic framework to integrate sexuality into the
sexual rehabilitation process, other models have since
been developed. A 5-step model designed recently
(Song et al., 2011) offers an alternative to the frame-
works discussed previously:
• Information about the impact of the neurological
condition of patients’ sexuality are provided.
• General information about sexual health is also
provided.
312 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
• Specific concerns about sexuality and strokes are
addressed, such as the fear of triggering another
stroke.
• Suggestions and hands-on strategies are pro-
vided to patients for them to manage their sexual
dysfunction.
• Overall, the model stresses the importance of
probing patients with questions in order to
ensure the proper integration of the informa-
tion provided. This is particularly pertinent in
the case of older individuals and/or individuals
presenting cognitive deficits.
This program has been empirically tested with
a sample of 46 participants, among which 12 cou-
ples were presenting with a partner recovering from
a stroke (Song et al., 2011). Results were promis-
ing and yielded a significant increase in frequency
of intercourse (p < 0.001), frequency of sexual activ-
ity (p < 0.001), and sexual satisfaction (p < 0.02) at
one-month post-intervention.
Overall, stepwise sexual rehabilitation inter-
vention programs implemented with neurological
populations, including individuals recovering from
a stroke, may provide a welcome bridge between
patients and health professionals. A core feature of
those programs concerns the importance for health
professionals to be the ones to address directly the
issue of sexuality with patients, preferably by provid-
ing specific information to them (Guo et al., 2015).
In the face of some professionals’ discomfort, it has
been suggested to them to disclose their inability to
provide answers while remaining open for discussion
(Mick et al., 2004).
Other components of sexual rehabilitation inter-
vention programs for patients recovering from a
stroke may include a thorough anamnesis and sex-
ual history of the patient (Steinke et al., 2013).
This is particularly crucial to assess any changes
attributed to the neurological condition. In addition,
this component provides a rich opportunity to address
any myth or stereotype associated with sexuality
and sexual satisfaction (Song et al., 2011). This is
also a useful medium to provide patients with addi-
tional information regarding stroke symptomatology
(motor and sensitive deficits, communication diffi-
culties and aphasia) as well as regarding stroke direct
and/or indirect impact on sexuality (incontinence,
body and self-esteem, relationship difficulties) (Mick
et al., 2004; Song et al., 2011; Steinke et al., 2013). In
order to optimize information retention, health pro-
fessionals are strongly encouraged to use multi-media
during this component of the sexual rehabilitation
intervention program, such as PowerPoint presenta-
tions, pamphlets, videos, and online modules (Guo
et al., 2015). Several sessions might be required to
cover the entirety of the material provided as research
shows that it is recommended to limit the amount
of information provided per session (Steinke et al.,
2013). Recent data indicate that patients would rather
receive such information during individual appoint-
ments with a health professional (27.7%, n = 18) or
via pamphlets (21.5%, n = 14). Only a small fraction
of those surveyed would like to take part in a group
session (1.5%, n = 1) or receive this information via
Internet (6.2%, n = 4) (Ng et al., 2017).
Sexual education is also a crucial aspect of sexual
rehabilitation intervention programs. Sexual edu-
cation sessions provide an opportunity to address
any concerns or fears associated with the stroke,
which research shows is a recurrent point experi-
enced by patients (Song et al., 2011; Steinke et al.,
2013). Patients recovering from stroke indicate many
sources of concerns such as the fear to be rejected by
their partner or to trigger another stroke by engag-
ing in sexual activity (Song et al., 2011). These fears
warrant discussion as they might be unfounded. In
fact, research indicates a very low risk of triggering
another stroke at 6-month follow-up (Muller, 1999).
Addressing these issues may also provide profession-
als with an opportunity to reiterate the importance
of engaging in physical exercise post-stroke (Muller,
1999). It may also open the discussion about expand-
ing patients’ sexual repertoire and deconstructing the
emphasis placed on intercourse by suggesting part-
ners engage into different types of sexual activities,
thereby promoting their sexual satisfaction (Song
et al., 2001; Steinke et al., 2013).
The provision of specific suggestions with regards
to the patient’s sexuality allows for patients to
consider their sexual needs, to make room for
sexual activity with their partner, which enhances
their sexual satisfaction. During this step, health
professionals may provide patients with specific
information regarding medication and its impact of
the neurophysiology of the sexual response and safe
sexual positions, particularly for those presenting
with moderate to severe motor and sensory deficits
(Song et al., 2011; Steinke et al., 2013). Patients may
be invited to adopt a routine prior to engaging in sex-
ual activity, such as avoiding to drink large quantities
of liquids in order to minimize the risk of urinary
incontinence or using specific wedges so as to mini-
mize pain and gain additional support during sexual
 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
activity (Steinke et al., 2013). The practice of keep-
ing a record of the information provided to patients is
particularly useful considering the interdisciplinary
aspect of most rehabilitation programs, and the vari-
ety of professionals that comes with it. This is also a
useful medium for health professionals to review the
information integrated or perhaps misunderstood by
patients, and to gain an accurate sense of the topics
covered and those that are left to be addressed (Mick
et al., 2004; Song et al., 2011; Stein et al., 2013).
While the appropriate timing of these programs
remains a contentious issue for the scientific com-
munity, research does point out to the importance of
providing at least some information to patients during
the rehabilitation process. Overwhelmed by anxiety,
studies show that some patients will prefer addressing
their concerns at the beginning of the rehabilitation
process (Steinke et al., 2013; Guo et al., 2015; Ng
et al., 2017), while others will favor addressing these
issues later on once a rapport has been established
with their physicians (Steinke et al., 2013; Guo et al.,
2015; Ng et al., 2017). For others, being faced with
their imminent discharge from the rehabilitation cen-
ter and the prospect of returning home will provide
a preferable opportunity to address sexuality-related
concerns (Steinke et al., 2013; Guo et al., 2015; Ng
et al., 2017).
Research and clinical experience both suggest that
the adoption of an interdisciplinary perspective is
optimal for patients’ recovery (Clarke, 2013; Clarke
& Forster, 2015). Aside from fostering a holistic
approach to patient care in rehabilitation services, an
interdisciplinary framework allows patients to turn
to the team member (s) they are most comfortable
with to share their concerns and obtain much needed
answers with regards to post-stroke sexual function-
ing (McLaughlin & Cregan, 2005; Clarke, 2013;
Clarke & Forster, 2015).
6. Conclusion and recommendations
The present review provides empirical evidence for
the prevalence of sexual dysfunction in this neurolog-
ical population. Both men and women report multiple
types of sexual dysfunction following stroke, along
with significantly diminished levels of sexual desire,
satisfaction and activity. The present review also
highlights the existence of various inconsistencies
with regards to the existence of significant rela-
tionships between stroke characteristics and SDs.
Methodological issues as well as the paucity of
313
research in this area prevent us from drawing solid
conclusions on the topic: further research in this
area is evidently needed, with special attention to
methodology. Finally, indirect physical and psycho-
logical factors warrant further consideration as they
carry significant impacts on post-stroke patients’ sex-
ual lives. Although this review did not specifically
address the role of partners as well as relationship fac-
tors as potential factors affecting SDs, these are worth
considering, both in research and clinical practice.
Combined with patients’ request for special-
ized sexual rehabilitation intervention programs, this
research is pointing at the need to adjust current
rehabilitation services to fit patients’ needs. Few reha-
bilitation programs have been developed and tested,
and some may provide appropriate guidelines to med-
ical professionals not necessarily at ease with the
topic of sexual rehabilitation. The diversity of sex-
ual sequelae affecting directly or indirectly patients
recovering from a stroke is calling for interdisci-
plinary action and efforts from the rehabilitation
community, and for the optimization of health pro-
fessionals’ training with regards to sexuality.
Conflict of interest
The authors declare no conflict of interest with
respect to this paper.
References
Akinpelu, A. O., Osose, A. A., & Odunaiya, N. A. (2013). Sex-
ual dysfunction in Nigerian stroke survivors. African Health
Sciences, 13(13), 639-645.
Allsup, G. J. (1981). Sexual dysfunction of stroke patients. Sexu-
ality and Disability, 4(3), 161-168.
Avery, K., Donovan, J., Peters, T. J., Shaw, C., Gotoh, M., Abrams,
P. (2004). ICIQ: A brief and robust measure for evaluating the
symptoms and impact of urinary incontinence. Neurourology
and Urodynamics, 23, 322-330.
Azanmasso, H., Alagnidé, É., Hounmenou, J. G., Natta, D.
N., & Kpadonou, T. G. (2016). Sexual disorders in stroke
patients compared with control subjects in Benin: A prospec-
tive study. Annals of Physical and Rehabilitation Medicine, 59,
69-70.
Baird, A. D., Wilson, S. J., Bladin, P. F., Saling, M. M., & Reutens,
D. C. (2007). Neurological control of human sexual behaviour:
Insights from lesion studies. Journal of Neurology, Neuro-
surgery, and Psychiatry, 78(10), 1042–1049.
Barrett, J. A. (2002). Bladder and bowel problems after stroke.
Reviews in Clinical Gerontology, 12, 253-267.
Bekker, M. D., Beck, J. J. H., Putter, H., van Driel, M. F., Pel-
ger, R. C. M., Weijmar, Schultz. W. C, . . . & Elzevier, H. W.
314 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
(2010). Sexual experiences of men with incontinent partners.
The Journal of Sexual Medicine, 7(5), 1877-1882.
Bener, A., Al-Hamaq, A. O., Kamran, S., & Al-Ansari, A. (2008).
Prevalence of erectile dysfunction inmale stroke patients, and
associated co-morbidities and risk factors. International Urol-
ogy and Nephrology, 40(3), 701-708.
Boldrini, P., Basaglia, N. & Calanca, M. C. (1991). Sexual changes
in hemiparetic patients. Archives of Physical Medicine and
Rehabilitation, 72(3), 202-207.
Bonita, R., Beaglehole, R. (2007). Stroke prevention in poor coun-
tries: Time for action. Stroke, 38, 2871-2872.
Bornstein, N. M. (2009). Stroke: Practical guide for clinicians.
Basel, CH: S. Karger AG.
Bradac, G. B. (2011). Cerebral angiography: Normal anatomy
and vascular pathology. Berlin, Heidelberg: Springer Berlin
Heidelberg.
Brandstater, M. E. (1988). Sexuality following stroke. Western
Journal of Medicine, 149(2), 207.
Braun, C. M. J., Dumont, M., Duval, J., Hamel, I., & Godbout, L.
(2003). Opposed left and right brain hemisphere contributions
to sexual drive: A multiple lesion case analysis. Behavioural
Neurology, 14, 55-61.
Brittain, K. R., Peet, S. M., & Castleden, C. M. (1998). Stroke and
incontinence. Stroke, 29(2), 524-528.
Brittain, K. R., Peet, S. M., Potter, J. F., & Castleden, C. M. (1999).
Prevalence and management of urinary incontinence in stroke
survivors. Age and Ageing, 28, 509-511.
Bugnicourt, J. M., Hamy, O., Canaple, S., Lamy, C., & Legrand,
C. (2014). Impaired sexual activity in young ischaemic stroke
patients: An observational study. European Journal of Neurol-
ogy, 21, 140-146.
Caplan, L. R. (2009). Caplan’s stroke: A clinical approach.
Philadelphia, PA: Saunders.
Chambon, X. (2011). Testimony on the sexuality of post-stroke
hemiplegic patients. Sexologies, 20, 102-105.
Cheasty, M., Condren, R., & Cooney, C. (2002). Altered sexual
preference and behaviour in a man with vascular ischemic
lesions in the temporal lobe. International Journal of Geriatric
Psychiatry, 17(1), 87-88.
Cheung, R. T. (2202). Sexual functioning in Chinese stroke patients
with mild or no disability. Cerebrovascular Diseases, 14(2),
122-128.
Choi-Kwon, S., & Kim, J. S. (2002). Post-stroke emotional
incontinence and decreased sexual activity. Cerebrovascular
Diseases, 12(1), 31-37.
Clarke, D. J. (2013). The role of multidisciplinary team care in
stroke rehabilitation. Progress in Neurology and Psychiatry,
17(4), 5-10.
Clarke, D. J., & Forster, A. (2015). Improving post-stroke recovery:
The role of the multidisciplinary health care team. Journal of
Multidisciplinary Healthcare, 8, 433–442.
Coslett, H. B., & Heilman, K. M. (1986). Male sexual function:
Impairment after right hemisphere stroke. Archives of Neurol-
ogy, 43(10), 1036-1039.
Donnan, G. A., Fisher, M., Macleod, M., & Davis, S. M. (2008).
Stroke. Lancet, 371, 1612-1623.
Duits, A., van Oirschot, N., van Oostenbrugge, R. J., & van
Lankveld, J. (2009). The relevance of sexual responsiveness
to sexual function in male stroke patient. Journal of Sexual
Medicine, 6(12), 3320-3326.
Edwards, D. F., Hahn, M., & Dromerick, A. (2006). Post stroke
urinary loss: Incontinence and life satisfaction: When does
post-stroke urinary loss become incontinence? Neurourology
and Urodynamics, 25, 39-45.
Esther Han, M. H., Shoshana, B. C., Rutner, D., Kapoor, N., Ciuf-
freda, K. J., & Suchoff, I. B. (2008). Medications prescribed
to brain injury patients: Retrospective analysis. Optometry, 79,
252-258.
Forsberg Wärleby, G., Moller, A., & Blomstrand, C. (2001).
Spouses of first-ever stroke patients: Psychological well-being
in the first phase after stroke. Stroke, 32(7), 1646-1651.
Forsberg Wärleby, G., Moller, A., & Blomstrand, C. (2004). Life
satisfaction in spouses of patients with stroke during the first
year after stroke. Journal of Rehabilitation Medicine, 36(1),
4-11.
Gelber, D. A., Good, D. C., Laven, L. J., & Verhulst, S. J. (1993).
Cause of urinary incontinence after hemispheric stroke. Stroke,
24(3), 378-382.
Geyer, J. D., & Gomez, C. R. (2008). Stroke: A practical approach.
Philadelphia, PA: Lippincott Williams & Wilkins.
Giaquinto, S., Buzzelli, S., Di Francesco, L., & Nolfe, G. (2003).
Evaluation of sexual changes afterstroke. Journal of clinical
Psychiatry, 64, 302-307.
Guo, M., Bosnyak, S., Bontempo, T., Enns, A., Fourie, C., Ismail,
F., & Lo, A. (2015). Let’s Talk About Sex! – Improving sex-
ual health for patient in stroke rehabilitation. BMJ Quality
Improvements Reports, 4(1), 1-4.
Haines, D. E. (2012). Neuroanatomy: An atlas of struc-
tures, sections, and systems. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins.
Hawton, K. (1984). Sexual adjustment of men who have had
strokes. Journal of Psychosomatic Research, 28(3), 243-249.
Jawad, S., Sidebothams, C., Sequira, R., & Jamil, N. (2009).
Altered sexual orientation following dominant hemisphere
infarct. Journal of Neuropsychiatry & Clinical Neurosciences,
21(3), 353-354.
Jung, J. H., Kam, S. C., Choi, S. M., Jae, S. U., Lee, S. H., & Hyun,
J. S. (2008). Sexual dysfunction in male stroke patients: Cor-
relation between brain lesions and sexual function. Urology,
71(1), 99-103.
Kelley, R. E., & Borazanci, A. P. (2009). Stroke rehabilitation.
Neurological Research, 31, 832-840.
Kim, J. H. & Kim, O. (2008). Influence of mastery and sexual
frequency on depression in Korean men after a stroke. Journal
of Psychosomatic Research, 65(6), 565-569.
Kimura, M., Murata, Y., Shimoda, K., & Robinson, R. G. (2001).
Sexual dysfunction following stroke. Comprehensive Psychi-
atry, 42(3), 217-222.
King, R. B. (1996). Quality of life after stroke. Stroke, 27, 1467-
1472.
Kissela, B. M., Khoury, J. C., Alwell, K., Moomaw, C. J., Woo,
D., Adeoye, O., . . . & Kleindorfer, D. O. (2012). Age at stroke:
Temporal trends in stroke incidence in a large, biracial popu-
lation. Neurology, 79(17), 1781-1787.
Kolominsky-Rabas, P. L., Hilz, M. J., Neundoerfer, B., &
Heuschmann, P. U. (2003). Impact of urinary incontinence after
stroke: Results from a prospective population-based stroke reg-
ister. Neurourology and Urodynamics, 22, 322-327.
Korpelainen, J. T., Kauhanen, M. L., Kemola, H., Malinen, U., &
Myllylä, V. V. (1998). Sexual dysfunction in stroke patients.
Acta Neurologica Scandinavica, 98(6), 400-405.
Korpelainen, J. T., Nieminen, P., & Myllyä, V. V. (1999). Sexual
functioning among stroke patients and their spouses. Stroke,
30(4), 715-719.
 A. Grenier-Genest et al. / Stroke and sexual functioning: A literature review
Langhorne, P., Bernhardt, J., & Kwakkel, G. (2011). Stroke reha-
bilitation. Lancet, 377(9778), 1693-1702.
Lecroy, C. (2006). Urinary incontinence occurring during inter-
course: Effect on sexual function in women. Urologic Nursing,
26(1), 53-56.
McLaughlin, J., & Cregan, A. (2005). Sexuality in stroke care: A
neglected quality of life issue in stroke rehabilitation? A pilot
study. Sexuality and Disability, 23(4), 213-226.
Mick, J., Hughes, M., & Cohen, M. (2004). Using the BETTER
Model to Assess Sexuality. Clinical Journal of Oncology Nurs-
ing, 8(1), 84-86.
Monga, T. N., Lawson, J. S., & Inglis, J. (1986). Sexual dys-
function in stroke patients. Archives of Physical Medicine &
Rehabilitation, 67(1), 19-22.
Muller, J. E. (1999). Sexual activity as a trigger for cardiovascular
events: What is the risk? The American Journal of Cardiology,
84(5B), 2N-5N.
Mutarelli, E. G., Omuro, A. M. P., & Adoni, T. (2006). Hyper-
sexuality following bilateral thalamic infarction. Arquivos de
Neuro-Psiquiatria, 64(1),146-148.
Nakayama, H., Jørgensen, H. S., Pedersen, P. M., Raaschou, H.
O., & Olsen, T. S. (1997). Prevalence and risk factors of incon-
tinence after stroke. The Copenhagen Stroke Study. Stroke,
28(1), 58-62.
NG, L., Sansom, J., Zhang, N., Anatya, B., & Khan, F. (2017).
Effectiveness of a structured sexual rehabilitation programme
following stroke: A randomized controlled trial. Journal of
Rehabilitation Medicine, 49, 333-340.
Nilsson, M., Lalos, O., Lindkvist, H., & Lalos, A. (2011). How
do urinary incontinence and urgency affect women’s sexual
life? Acta Obstetricia et Gynecologica Scandinavica, 90(6),
621-628.
Pfaus, J. G. (1999). Neurobiology of sexual behavior. Current
Opinion in Neurobiology, 9(6), 751-758.
Rosenbaum, T., Vadas, D., & Kalichman, L. (2013). Sexual func-
tion in post-stroke patients: Consideration for rehabilitation.
Journal of Sexual Medicine, 11(1), 15-21.
Schmitz, M. A. & Finkelstein, M. (2010). Perspectives on post-
stroke sexual issues and rehabilitation needs. Top Stroke
Rehabilitation, 17(3), 204-213.
315
Seymour, L. M., & Wolf, T. J. (2014). Participation changes in
sexual functioning after mild stroke. Occupation, Participation
and Health, 34(2), 72-80.
Sjögren, K., & Fugl-Meyer, A. R. (1982). Adjustment to life after
stroke with special reference to sexual intercourse and leisure.
Journal of Psychosomatic Research, 26(4), 409-417.
Song, H., Oh, H., Kim, H., & Seo, W. (2011). Effects of a sexual
rehabilitation intervention program on stroke patients and their
spouses. NeuroRehabilitation, 28, 143-150.
Spinella, M. (2004). Hypersexuality and dysexecutive syndrome
after a thalamic infarct. International Journal of Neuroscience,
114(12), 1581-1590.
Steinke, E. E., Jaarsma, T., Barnason, S. A., Byrne, M., Doherty, S.,
Dougherty, C. M., . . . & Moser, D. (2013). Sexual counselling
for individuals with cardiovascular disease and their partners.
European Heart Journal, 34, 3217-3235.
Strong, K., Mathers, C., & Bonita, R. (2007). Preventing
stroke: Saving lives around the world. Lancet Neurology, 6,
182-187.
Suffren, S., Braun, C. M. J., Guimond, A., & Devinsky, O. (2011).
Opposed hemispheric specializations for human hypersexual-
ity and orgasm? Epilepsy & Behavior, 21, 12-19.
Tamam, Y., Tamam, L., Akil, E., Yasan, A., & Tamam, B. (2008).
Post-stroke sexual functioning in first stroke patients. Euro-
pean Journal of Neurology, 15(7), 660-666.
Thompson, H. S., & Ryan, A. (2009). The impact of stroke con-
sequences on spousal relationships from the perspective of the
person with stroke. Journal of Clinical Nursing, 18, 1803-1811.
Williams, M. P., Srikanth, V., Bird, M., & Thrift, A. G. (2012).
Urinary symptoms and natural history of urinary continence
after first-ever stroke - A longitudinal population-based study.
Age and Ageing, 41, 371-376.
Wityk, R. J., & Llinas, R. H. (2006). Stroke. Philadelphia, PA: The
American College of Physicians.
Yilmaz, S. D., Gumus, H., & Yilmaz, H. (2015). Sexual life of
post-stroke women with mild or no disability: A qualitative
study. Journal of Sex & Marital Therapy, 41(2), 145-154.
Yilmaz, S. D., Gumus, H., Yilmaz, S. D., Akkurt, H. E., & Odabas,
F. O. (2017). The evaluation of sexualfunction in women with
stroke. Neurology India, 65(2), 271-276.