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The Clinical Respiratory Journal
Sexual function in male patients with obstructive sleep apnoeacrj_1731.6
Marian Petersen1,2, Ellids Kristensen3,4, Søren Berg2,5,6 and Bengt Midgren1,2 1 Department of Respiratory Medicine, Lund University, Lund University Hospital, Lund, Sweden2 Lund Sleep Study Group, Lund University, Lund University Hospital, Lund, Sweden3 Sexological Clinic, Psychiatric Centre Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark4 Department of Neurology, Psychiatry and Sensory Sciences, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark5 Department of ENT, Head and Neck Cancer, Lund University, Lund University Hospital, Lund, Sweden6 ScanSleep, Copenhagen, Aalborg, Aarhus, Denmark Abstract
Key words
Objective: Our objective was to investigate general and functional aspects of sexu- male obstructive sleep apnoea ality in male patients with a confirmed diagnosis of obstructive sleep apnoea (OSA) and compare the results with normative data.
Materials and Methods: We investigated 308 male patients (age 30–69) admitted to a sleep laboratory and receiving a diagnosis of OSA, using questions drawn from Respiratory Medicine, University Hospital of two self-administered questionnaires on sexuality [Fugl-Meyer Life satisfaction checklist (LiSat) and Brief Sexual Function Inventory (BSFI)].
Results: We found that both general (Fugl-Meyer LiSat) and functional (BSFI) aspects of sexuality were worse in patients with (untreated) OSA when compared with normative data. Both aspects were dependent on age, obesity, social factors and concomitant medication but not on the severity of OSA as reflected by the apnoea–hypopnoea index or subjective sleepiness.
Conclusion: We conclude that although sexual dysfunction is more prevalent inOSA patients than in the general population, it is a complex problem relating more to age, obesity, social factors and comorbidity than to the severity of OSA.
Marian Petersen initiated, designed and
Please cite this paper as: Petersen M, Kristensen E, Berg S, Midgren B. Sexual performed the study, collected and analysed function in male patients with obstructive sleep apnoea. The Clinical Respiratory Journal 2009; DOI:10.1111/j.1752-699X.2009.00173.x.
Kristensen contributed to the design, analysedthe data and wrote the paper. Søren Bergcollected and co-analysed the data and wrotethe paper. Bengt Midgren supervised theanalysis of data and the writing of the paper.
Informed consent was obtained, and the
study was reviewed and approved by the
Ethical Committee of Copenhagen.
Conflict of interest
Marian Petersen has received an
unconditioned research grant from Maribo
Ellids Kristensen has no conflicts of interest.
Søren Berg is one of the owners and
managers of ScanSleep; otherwise he has no
conflicts of interest.
Bengt Midgren has received payment from
ResMed Sweden for lectures and consultant
The Clinical Respiratory Journal (2009) • ISSN 1752-6981 Introduction
field, CO, USA). The recording montage includednasal airflow using a nasal pressure catheter, respira- Obstructive sleep apnoea (OSA) is characterized by tory movement with thoracic and abdominal bands repetitive cessation of breathing during sleep due to (XactTrace, Embla, Broomfield, CO, USA), pulse upper airway collapse. When this is associated with oximetry and body position. Apnoeas were diagnosed daytime sleepiness it is termed obstructive sleep as cessation of breathing more than 10 s. Hypopnoeas apnoea syndrome (OSAS). With regard to the effects of were diagnosed as reduction in airflow >40% associ- OSA on sexuality, different aspects have been investi- ated with a desaturation of 4% or more. The number gated. Sexuality has been reported to be affected by of apnoeas and hypopnoeas/hour (AHI) was calcu- decreased hormonal production (1), low sexual drive lated on estimated sleep time (as reported by the and satisfaction and decreased morning erection (2).
These effects may lead to misconceptions by the Data of self-reported daytime sleepiness were col- patient with regard to his or her relationship and lected using the Epworth Sleepiness Scale (ESS). The potentially lead to feelings of fault, blame and guilt, ESS assesses the likelihood of the patient dozing off or which may further negatively affect the relationship falling asleep in eight daily situations using a score (3). Erectile dysfunction is estimated to be present in between 0 and 3. The maximum score is thus 24, with 30% of untreated OSAS patients (4). O’Leary et al. a score of 11 or more being taken to indicate significant found that age is a main factor for erectile dysfunction levels of daytime sleepiness (7). ESS data were collected in a normative sample of men, but that sexual desire is from only 192 patients because of a late change of maintained in later years (5). Other studies have high- lighted the correlation between high respiratory dis- Data on sexual function were obtained using two turbance index and erectile dysfunction (2).
self-administered questionnaires. One was the Fugl- Most previous studies of the effects of OSA on sexu- Meyer Life satisfaction checklist (LiSat) (8), from ality in men have focused on erectile dysfunction. One which we selected four questions concerning general of the few other studies in this area was reported by satisfaction with life: Life as a Whole and three Hanak et al. (6). However, their study investigated only domains of closeness (Sexual Life, Partner Relation- elderly snorers (51–90 years) and their risk for sexual ship, Family Life). The referent population consisted of dysfunction. We therefore designed this study to inves- both sexes, but we used data on male only received tigate general and functional aspects of sexuality in from Fugl-Meyer (A. Fugl-Meyer, pers. comm.). Satis- male patients with untreated OSA and to compare faction was scored on a scale from 1 to 6, with higher these findings with normative data. We have per- scores indicating greater satisfaction. The other ques- formed a similar study on females with OSA (to be tionnaire was the Brief Sexual Function Inventory published), and follow-up studies (for both sexes) after (BSFI) (9) in which the first 10 items cover functional 1 year on continuous positive airway pressure (CPAP) aspects of male sexuality during the past 30 days: Sexual drive and level of sexual drive (two items),partial or full erection, capability to intercourse anddifficulties in getting erection (three items), difficulty Material and methods
ejaculating and satisfaction with the amount of semen(two items) and problem assessment concerning Male patients with OSA were consecutively recruited sexual drive, erection and ejaculation (three items).
from patients assessed in three sleep laboratories of The last item covers overall sexual satisfaction and con- one sleep clinic (ScanSleep) in Denmark from October sists of one question. The items were scored from 0 to 2005 to January 2008. The study comprised only 4, with higher scores indicating better function. The patients more than 18 years old, able to read and write total score was calculated for the first 10 items. Item 11 Danish and with a diagnosis of OSA [apnoea– (overall satisfaction) is not a functional question and hypopnoea index (AHI) >5] requiring treatment with was therefore analysed separately, and not included in CPAP. The material thus consisted only of patients the statistical analyses for total score.
where CPAP was considered as being the clinically rel- Socio-demographic data on age, body mass index evant treatment of choice as judged by an experienced (BMI), marital status and education were collected for specialist. Approximately 90% of the eligible patients all individuals, and their current use of medication was recorded as a proxy for comorbidity. No control data All patients were investigated for OSA using identi- on Fugl-Meyer LiSat or on BSFI has been reported for cal portable devices (EMBLETTA®, Embla, Broom- the Danish population. We therefore used normative The Clinical Respiratory Journal (2009) • ISSN 1752-6981 Table 1. Clinical and demographic characteristics of obstructive sleep apnoea male patients according to age
*Digoxin, antihypertensive, diuretics, beta blockers, calcium antagonists, ACE inhibitors.
†Anti-psychotics, anxiolytics, antidepressants.
BMI, body mass index (kg/m2); AHI, Apnoea Hypopnoea Index; ESS, Epworth Sleepiness Scale.
male data from Sweden and Norway since they are BMI was 31.5 (SD = 6.3) and AHI was 39.9 (SD = 24.2) countries linguistically, culturally and sociologically for the selected age groups. The mean score for ESS was closely related to Denmark. From Sweden, Fugl-Meyer 11.5 (SD = 4.0). Socio-demographic data for OSA LiSat-11 data were collected by questionnaires and patients showed that 84% lived with a partner, 54% face-to-face interviews, and participants were drawn had 10 or more years of education and 77% were from the Swedish Central Population Register (8) and employed. Ninety-two (29.9%) patients received from Norway (for BSFI) participants were recruited by medication for cardiovascular reasons. Thirty-three using public address lists and sending questionnaires (10.7%) received psychopharmaca and 20 (6.5%) were receiving treatment for diabetes. Data for age groups Statistical analysis was performed with SPSS (version 15.0 for Windows). Descriptive statistics [mean andstandard deviation (SD)] were used to summarize theclinical and socio-demographic data. A power analysis Fugl-Meyer LiSat
with respect to the 6-point scale Fugl-Meyer LiSat Scores on Life as a Whole were significantly lower in showed that 80 patients would be sufficient to demon- all OSA patients than in the control group (Table 2).
strate with 95% certainty a difference between normals For Family Life, the groups of 40–49 and 50–59 years and patients of 0.5 points at the 0.05 one-side signifi- scored significantly lower than the control group.
cance level, assuming that the patients had the same SD Regarding Partner Relationship, only the group of as the normal subjects. Regression analysis was per- 50–59 scored lower than the control group, and for formed for the Fugl-Meyer LiSat and BSFI, to assess the Sexual Life, the age groups 40–49, 50–59 and 60–69 specific impact of BMI, AHI, ESS, being in a relation- scored significantly lower than controls. To assess the ship, education, employment and medication. T-tests specific impact on OSA patients of BMI, AHI, ESS, were used when comparing study data with reference having a relationship, education, employment and subjects based on available data for n and SD. A sig- medication, a regression analysis was performed for nificance level of P Յ 0.05 was used for all statistical each of the four items: Life as a Whole, Family Life, Partner Relationship and Sexual Life. Lifeas a Whole was significantly negatively associated with age (P = 0.005), with cardiovascular medication(P = 0.012) and with psychopharmaca (P = 0.001).
Three hundred fifteen male patients aged 26–77 years No association with BMI, AHI, ESS, having a rela- (mean 50.6, SD 10.3) were included in the study.
tionship, education, employment or diabetes was Because of the low number of OSA patients in age found. For Family Life, being in a relationship had a groups 20–29 years (N = 5) and 70–79 years (N = 2), significant (positive) impact (P = 0.021) and for these age groups were excluded from the analyses. The Partner Relationship, living with a partner was the age distribution and other clinical data for the remain- only significant (positive) factor (P = 0.042). Sexual ing 308 OSA patients are presented in Table 1. Mean Life was significantly negatively affected by BMI The Clinical Respiratory Journal (2009) • ISSN 1752-6981 Table 2. Scores from Fugl-Meyer LiSat for obstructive sleep
ciated with cardiovascular medication (P = 0.008), psychopharmaca (P = 0.010) and age (P = 0.001).
No significant associations were found for OverallSatisfaction.
The present study is, to our knowledge, the first inves- tigation of general sexual activity and functional sexual aspects in patients with a confirmed diagnosis of OSA compared with age-matched controls. Most other studies focus on (self-reported) erectile function, whereas the present study also deals with self-reported sexuality in a wider context. Our results show that male patients with OSA severe enough to make them candi- dates for CPAP treatment score worse than control groups not only on questions regarding health in general but also on questions regarding general and The strength of our study is that it is based on a series of patients with a verified diagnosis of OSA with an age Statistical analysis performed with t-test. Scale is from 1 to 6, with ranging from 30 to 69, a group that we consider rep- higher scores indicating greater satisfaction.
resentative of the typical OSA patient seen in sleep clinics. These findings are not explained by the AHI, †Normative Swedish sample of male (8).
which is the most commonly used index of severity ofOSA.
The socio-demographic data of our patients were (P = 0.032), and positively affected by being in a rela- compared with the Danish Health and Morbidity tionship (P = 0.032). No other variables showed any Survey (SUSY2000) based on a random sample of 8188 Danish male citizens aged 16 or older (10). More of ourOSA patients (84%) lived with a partner versus SUSY2000 (68%). The percentage of patients living with a partner (84%) may reflect a selection bias, because The BSFI (Sexual Drive, Erection, Ejaculation, Sexual OSA patients living alone may go undetected. Other Problem Assessment, Total Score of the aforemen- socio-economic aspects that might influence sexual life (income, social status) were not covered by our ques- showed that OSA patients generally scored worse tionnaire. However, our results are based on a consecu- than the control group of comparable age (age 30–69, tive series of sleep apnoea patients from Denmark’s n = 1185) (Fig. 1). To assess the specific impact on largest sleep clinic. The public health care system of OSA patients of BMI, AHI, ESS, being in a relation- Denmark ensures that all patients are entitled to ship, education, employment and medication, a receive adequate investigations and treatment without regression analysis was performed. A significant nega- any financial restrictions. We therefore believe that the tive relationship was found between Sexual Drive socio-economic profile of our patients is likely to be and cardiovascular medication (P = 0.015). Erection representative of the Danish population as a whole. It showed a significant negative association with is difficult to draw any firm conclusions concerning employment (P = 0.038) and age (P = 0.001). Ejacula- the true prevalence of comorbidities from the data tion showed negative association with cardiovascular concerning cardiovascular or psychopharmacological medication (P = 0.016), psychopharmaca (P = 0.043) medication. However, it seems reasonable to assume and age (P = 0.017). Sexual Problem Assessment that OSA patients who already have regular contacts showed negative association with cardiovascular with the health care system also have a shorter way to medication (P = 0.012), psychopharmaca (P = 0.010) referral for OSA investigations, thereby creating a and age (P = 0.001). Total Score was negatively asso- The Clinical Respiratory Journal (2009) • ISSN 1752-6981 Figure 1. Age-related scores from the Brief Sexual Function Inventory for OSAS male patients: n = 308 and control group n = 1185.
Statistical analysis performed with t-test. OSAS, obstructive sleep apnoea syndrome. Values are expressed as mean. Scored from 0
to 4, with higher scores indicating better function. *P < 0.05, **P < 0.005, ***P < 0.0005.
Fugl-Meyer LiSat
OSA patients considered their Life as a Whole We found that age had a negative association with (Fugl-Meyer LiSat) to be worse than the control Sexual Drive, Erection, Ejaculation, Sexual Problem groups. This may be a consequence of disturbed Assessment and Total Score on the BSFI. Only Overall sleep. It has been reported that disturbed sleep Satisfaction (BSFI) showed no significant relationship may have a negative effect on immune response and with age. These findings are consistent with the results affect mood (11). When looking at specific sexual of O’Leary et al., who found an age-related decrease in items, we found that sexual life was negatively asso- erectile function and sexual functioning using BSFI ciated with BMI. This finding corresponds with the (5). Chung et al. conclude that obesity in itself does not results in Kolotkin et al., who found that a higher seem to be an underlying factor for erectile dysfunc- BMI was associated with greater impairment in tion, but does increase the risk of vasculogenic impo- sexual quality of life (12). However, we found no rela- tence through the development of chronic vascular tionship with AHI or ESS measures that are com- diseases of diabetes, hypertension, heart diseases and monly used to assess the severity of sleep apnoea hyperlipidaemia (13). Although we could not demon- strate any association with diabetes, our results con- The Clinical Respiratory Journal (2009) • ISSN 1752-6981 cerning BMI and cardiovascular medication support Maribo Medico for an unconditioned financial grant the conclusion by Chung et al. (13). In addition, and to our knowledge, this had not been investigated in OSA We thank Axel Fugl-Meyer for personal communi- patients before; psychopharmaca also has a negative cation and giving us access to unpublished details from association with Ejaculation, Sexual Problem Assess- A separate analysis only for those patients not on medication (thus eliminating a powerful confounding References
factor) was performed. This analysis also failed toreveal any effect of AHI or ESS on any of the outcome 1. Luboshitzky R, Aviv A, Hefetz A, et al. Decreased variables. Categorization of AHI with a cut-off of 30 pituitary-gonadal secretion in men with obstructive sleep gave essentially similar results to treating AHI as a con- apnea. J Clin Endocrinol Metab. 2002;87: 3394–8.
tinuous variable, i.e. no effect. Our findings are at vari- 2. Margel D, Cohen M, Livne PM, et al. Severe, but not ance with the results of Margel et al., who found a mild, obstructive sleep apnea syndrome is associated with relationship between severity of OSA and the degree of erectile dysfunction. Urology. 2004;63: 545–9.
3. Westheimer RK, Lopater S. Human Sexuality, (2nd erectile dysfunction (2). An explanation may be that Edition). Baltimore: Lippincott Williams & Wilkins, our recruitment process included only those patients who were scheduled for CPAP treatment. Some of 4. Gonςalves MA, Guilleminault C, Ramos E, et al. Erectile these patients were, after physicians’ evaluation, pre- dysfunction, obstructive sleep syndrome and nasal CPAP scribed CPAP because of significant symptoms of treatment. Sleep Med. 2005;6: 333–9.
OSA, even though they had only a moderate or even 5. O’Leary MP, Rhodes T, Girman CJ, et al. Distribution of low AHI. These patients were therefore likely to have the Brief Male Sexual Inventory in community men. Int J more symptoms or comorbidities, which might affect the outcome on sexual questionnaires.
6. Hanak V, Jacobson DJ, McGree ME, et al. Snoring as a Nevertheless, these data point to the fact that a risk factor for sexual dysfunction in community men. J simple quantitative relationship between AHI and 7. Johns MW. A new method for measuring daytime sexual dysfunction (lack of well-being, decreased sleepiness: the Epworth Sleepiness Scale. Sleep. 1991;14: general well-being, sexual problem) is an oversimplifi- cation. Sexual dysfunction in OSA is a complex 8. Fugl-Meyer AR, Melin R, Fugl-Meyer KS. Life satisfaction problem; for example, obesity and comorbidity may in 18- to 64-year-old Swedes: in relation to gender, age, interact through hormonal, vascular or psycho- partner and immigrant status. J Rehabil Med. 2002;34: 9. Mykletun A, Dahl AA, O’Leary MP, et al. Assessment of male sexual function by the Brief Sexual Function Conclusion
Inventory. BJU Int. 2005;97: 316–23.
The important finding in this study is that although 10. Kjøller M, Rasmussen NK. Danish Health and Morbidity Survey 2000. Copenhagen, Danish Government of Public OSA per se seems to be associated with an impairment in most aspects of male sexuality, not only erectile 11. Kawahara S, Akashiba T, Akahoshi T, et al. Nasal CPAP dysfunction, the degree of sexual problems was not improves the quality of life and lessens the depressive quantitatively related with AHI but rather with age and symptoms in patients with obstructive sleep apnea comorbidity and, to some extent, with obesity and syndrome. Intern Med. 2005;44: 422–7.
12. Kolotkin RL, Binks M, Crosby RD, et al. Obesity and sexual quality of life. Obesity. 2006;14: 472–9.
13. Chung WS, Shon JH, Park YY. Is obesity an underlying Acknowledgements
factor in erectile dysfunction? Eur Urol. 1999;36: We thank Dr Jan Ovesen and the staff in ScanSleep for their invaluable help in collecting data. We thank The Clinical Respiratory Journal (2009) • ISSN 1752-6981


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