At this year’s United European Gastroenterology meeting in Italy, Prof. Marco Romano, from the University of Campania in Naples described the results of a new survey, which showed that “Sexual dysfunction (SD) in patients with gastrointestinal disorders is undermanaged, with a lack of clinician education, time constraints, and embarrassment preventing constructive discussions to improve patient care and quality of life. Overall, 71% of gastroenterologists do not ask their patients about sexual dysfunction, the survey finds. While patients with gastrointestinal disorders often experience sexual dysfunction, discussions around the matter are not routine in gastroenterological care.” The main reasons why gastroenterologists do not discuss sexual dysfunction are:
- lack of knowledge (80%)
- insufficient experience (58%)
- time constraints (44%)
- embarrassment (30%).
There has been a long neglect of this issue. Still, now focus is increasingly being given to how some of the most common gastrointestinal disorders are playing havoc with the general sexual functions of the sufferers.
In October 2022, the website Sexual Medicine Reviews detailed how several chronic health disorders in the gastrointestinal systems are associated with impaired sexual function and interfering with normal sexual activity.
As defined by the World Health Organization (WHO), sexual health “is a state of physical, emotional, mental and social well-being in relation to sexuality and not merely as the absence of dysfunction.”
In men, the sexual dysfunctions that WHO refers to can broadly be classified as erectile dysfunction (ED). In some cases, particularly in younger men, it may primarily reflect purely psychological concerns. In the past, it was accepted that ED could result from organic disease – notably, cardiovascular disease, diabetes, hyperlipidemia, and hypertension. In this case, ED may serve as a signal that some medical conditions require treatment. Now, research is adding gastrointestinal disorders to be both the possible cause of, and an outcome of, ED.
In women, sexual dysfunction can include painful intercourse, lack of arousal and failure to reach orgasm, all of which can result in increased levels of emotional stress.
Regardless of the actual cause, sexual dysfunctions are known to negatively impact any patients’ overall self-esteem, relationships, and quality of life.
How do gastrointestinal disorders affect sexual functions?
There are several ways in which GI disorders can disrupt the sex life of both men and women.
- The disease could itself be causing fatigue, anxiety or depression with the consequential alteration of the sense of self-worth
- The disease could be altering some basic endocrine processes which are essential for normal sexual functionality, particularly concerning ED in men
- A chronic disease that causes inflammation can result in abnormal vascular responses or endothelial dysfunction.
Which are the primary gastrointestinal disorders now known to affect sexual performance?
Gastrointestinal Reflux Disorder (GERD) is caused by the reflux of stomach contents into the esophagus. It may be due to Hiatal hernias or disorders that affect the workings of the lower esophageal sphincter (LES). Either of these can result in the exposure of the mucosal lining of the esophagus to the acidic gastric contents.
GERD can both cause sexual dysfunction and can be exacerbated by regular sexual activity. In the first case, most frequently, sexual activity will take place with participants reclining or lying down. In this position, there is a natural increase in acid reflux. In the second case, the physical activity involved, especially when vigorous, can increase acid production in the stomach.
Lower gastrointestinal disorders that may cause sexual dysfunction
The most common gastrointestinal disorders associated with sexual dysfunction are Crohn’s disease and IBD (inflammatory bowel disease), Celiac disease, and chronic liver diseases.
As reported on the website of the National Center for Biotechnology Information, “sexual function is a constant concern in IBD patients … especially if we consider that the prevalence of sexual dysfunction in IBD is higher than that reported in the general population. The etiology of SD in patients with IBD remains unclear but is likely to be multifactorial, where biological, psychosocial, and disease-specific factors are involved. Currently, there are no formal recommendations in the IBD clinical guidelines on how to manage SDs in these patients.”
Several drugs are commonly prescribed to patients with lower GI tract disorders and may affect sexual function. Among these are antidepressants, opioids, and antianxiety medications. Benzodiazepines are primarily used in Irritable Bowel System cases because they target the Gamma-aminobutyric acid (GABA) system. The drug is involved in intestinal hypersensitivity and for regulation of bowel motility, thereby reducing IBS symptoms. Benzodiazepines may decrease sexual desire, worsen erectile function and lower sexual satisfaction.
In people who are genetically susceptible to Celiac disease triggered by the ingestion of gluten, there may be an inflammatory process involving the lower intestine. Both sexual dysfunction and hypogonadism have been found in patients with celiac disease. Endocrine dysfunctions such as hyperprolactinemia or androgen resistance may contribute to sex disorders in celiac disease patients. The failure to convert testosterone to dihydrotestosterone in about one out of five men with untreated coeliac disease results in androgen resistance. Unusually, the patient may have raised testosterone levels. Still, it seems not to be converted into the more active form of dihydrotestosterone (DHT).
Chronic liver diseases, including hepatitis, mainly affect sexual performance through their effect on hormones. In chronic liver disease, sexual dysfunction is primarily due to the abnormality of the physiology of the hypothalamic-pituitary-gonadal axis and the origin of liver disease. It has been demonstrated that alcohol abuse and alcoholic liver disease may play a role in hormone alterations affecting sexual performance.
Like many other chronic disorders, chronic diseases of the gastrointestinal tract and liver may result in adverse effects on sexual activity in both females and males. These may come from different pathogenic mechanisms, including the play-out of the underlying GI disorder which may produce inflammatory pathways leading to SD, reactions to the medication that is prescribed for treatment of the GI or liver disorder, or the psychological distress caused by the outcome of the GI symptoms on behavior.
It’s important to understand that, as found in the survey, few gastroenterologists prescribe the most widely used medications for the treatment of ED, which are Viagra, Levitra, and Cialis all of which are based on PDE5i (phosphodiesterase type 5 inhibitors). However, no serious side effects are reported for GI disease sufferers, and no dosage modifications are recommended for patients with mild to moderate chronic liver diseases. However, this drug is not normally prescribed for patients with severe hepatic impairment.