Patients who’ve had a knee or a hip replaced report an improved sex life after surgery, according to new research presented as a poster at the American Academy of Orthopaedic Surgery (AAOS) annual meeting in Chicago.

Doctors rarely ask arthritis patients about sex. Yet research shows that joint pain and stiffness can have a profound effect on physical and emotional intimacy. For example, in a British study, published in the journal Rheumatology in 2002, more than half of respondents said arthritis pain reduced their ability to experience or enjoy lovemaking, and for many, relationships, self-esteem and self-identity also suffered.

To learn more about the effect of total knee and hip replacement surgery on sexual function and emotional well-being in people with severe osteoarthritis, or OA, researchers at Lenox Hill Hospital in New York undertook a study.

"Other studies [on this subject] have been retrospective – asking patients about postoperative function," says senior study author José A. Rodriguez, MD, director of Lenox Hill Hospital's Center for Joint Preservation and Reconstruction. "The quality of what we did lies in its prospective nature, looking at patients both before and after surgery. We also wanted to understand not just positional issues, but also emotional ones."

Dr. Rodriguez and colleagues invited nearly 400 patients to participate anonymously in the study. Close to 150 responded by returning preoperative questionnaires. Of these, 116 also returned postoperative questionnaires and 65 submitted 6-month and 1-year reports. Patients ranged in age from 35 to 70; slightly more women than men responded.

Before surgery, 67 percent of patients reported problems with sexual function, including joint pain and stiffness, lowered libido and trouble achieving the proper position. More than 90 percent reported psychological issues related to their sexual self-image and well-being.

Dr. Rodriguez says neither result was unexpected, pointing out that arthritis-related limitations clearly have both physical and emotional consequences. “When people can't rotate their hips without pain, it's bound to affect sexual function," he notes. "And since these patients tend to be older with less estrogen and testosterone, sexuality is less frankly hormonal and instead has a greater emotional aspect to it."

The postoperative responses were more surprising. Ninety percent of patients who underwent either knee or hip replacement surgery reported improved overall sexual function; improvement was greater after hip replacement compared to knee replacement, and a higher number of women reported benefits than men. Forty-two percent of participants reported a stronger libido and 41 percent reported increased frequency of intercourse. Sixteen percent of study participants however reported the surgery had a dampening effect on intimacy, with 10 percent saying they feared sex would damage the implant. Further, 84 percent of patients noted an increase in general well-being and 55 percent in sexual self-image.
 
"One thing that surprised me was the large improvement in self-esteem and well-being; that's really quite impressive," Dr. Rodriguez says, adding that it's possible the answers were influenced by the setting or phrasing of the questions.

Still, he says arthritis-related sexual dysfunction can cause great emotional suffering, citing a patient he met as an orthopaedic fellow.

"She had severe arthritis that required her to use a wheelchair, and she was hoping to undergo hip replacement surgery," Dr. Rodriguez says. "My mentor turned her down because she was so young. Hearing this, she started crying. 'You have no idea how it affects me not to be able to make love to my husband,’ she said. ‘Please give me the opportunity to make love to my husband.' That really influenced me. The issue is always in my mind, and I bring it up with more and more patients."

He sees the current study as a way to ease into a discussion of sexuality with future patients, though he's uncertain it will prompt other physicians to do the same. "This is something that isn't talked about and needs to be," he says.

"We inflicted them with that restriction," Dr. Rodriguez says. "We need to explain to patients that what they do in the postoperative period depends on their comfort – whether it's exercise or intimacy – and that it's safe to participate in these things."

Jeffrey N. Katz, MD, director of the Orthopaedic and Arthritis Center for Outcomes Research at Brigham and Women's Hospital in Boston and a professor of medicine and orthopaedic surgery at Harvard Medical School, notes that the results of the current study "align with other studies showing that advanced arthritis of the lower extremity may be associated with impaired sexual function in many patients."

But he adds, "This study also suggests that joint replacement results in improvement in sexual function. The very low response rates raise the possibility that the results of the study are biased [and] more rigorous studies addressing this important question are warranted."

Dr. Rodriguez agrees that the study numbers are small but says they are in line with those of similar studies. "When we ask strictly orthopaedic questions, we get better responses," he says.