NSpine is surveying female patients to investigate the effects of anterior spinal surgery with regards to scars, sexual function and relationships as part of a pilot study. The group is also looking at the prevalence of sexual dysfunction in patients with chronic back pain. Bronek Boszczyk talks to Spinal News International about NSpine’s research, and about the “Sex and the Spine” symposium at SpineWeek (16–20 May; Singapore). This multidisciplinary symposium covered topics from physiology to body image with regards to the impact of spinal surgery on sexual health.
How can spinal health affect sexual health in general?
Somewhere in the region of 60–80% of people who have ongoing back pain have some form of disturbance in their sexual health. Whilst only a few studies address this, surveys of our own patients have found that the incidence is quite high. And then, of course, there are conditions complicated by neurological compromise such as spinal cord injury and cauda equina involvement. These patients have a very high incidence—virtually 100%—of some manner of sexual health disturbance.
A further aspect is sexual health and body image. The impact thereof is very, very poorly understood—even evaluated—in adolescents, for example, who are affected by scoliosis or kyphosis.
How can spinal surgery itself affect sexual health?
We know that performing anterior spinal surgery in men leads to certain difficulties, such as retrograde ejaculation. What we do not understand is the impact that such surgery can have specifically on women. Some preliminary results have shown that up to 40% of our patients have changes in their menstrual cycle, and roughly 30% have changes in their sexual activity after anterior spinal surgery. But, these results are yet to be properly evaluated. A further finding is that the placement of incisions on the abdomen has a far higher impact on women’s body image and sexual health than we have been aware of.
What kind of research has been done in this area?
Specific to spine, not very much. There are some validated questionnaires, but they have not really been used prospectively in spinal research. Our research is probably one of the first to specifically assess these aspects in women. We intend, after our pilot study, to do a number of investigations on the impact of low back pain, the impact of post-surgery, and the specific impact of anterior surgery.
Are there are cases in particular which might require the consideration of sexual health, or is it something which affects spinal surgery generally?
Back pain generally correlates with sexual health issues. The other area in particular that we have come across which can be related to sexual health is cauda equina syndrome—where patients have neural impairment of their sacral roots with neurological dysfunction. For those that have complete dysfunction, it is very difficult to find treatment. But it is probably possible to find treatment for those with partial dysfunction.
Some therapeutic attempts are being made but, again, accessing this is very difficult, and many people simply do not talk about this kind of problem.
We are also not adequately aware of the effects of anterior spinal surgery. When we perform lumbar disc replacements or anterior fusions in women, we do not fully understand the impact this can have, yet many of us are going more and more down the route of offering these kinds of procedures, due to the favourable outcome in relation to back pain.
Are there any postoperative treatments available to promote sexual function?
There are, but not specifically for spine. Within spinal cord injury and severe cauda equina there are individual therapists who address this. Patients can tap into these options if already in treatment for one of these conditions. But, many of our patients have less severe cauda equina syndrome where sexual dysfunction is not obviously apparent to their clinicians. These issues are often never raised in consultation. People feel uncomfortable talking about them, which can lead to the failure of relationships and marriages, simply because people do not know where to turn.
When patients—or our physiotherapists—do ask us what can be done, we know that there is a plethora of tools on the market. We have no collected information about patients who have successfully gone through treatments—often by trial and error. We simply do not have the insight to say what may or may not work.
How do you think physicians can encourage communication about what is often a very sensitive issue?
This is one of the big problems; none of us is trained how to do this. As consultants, we very rarely have these discussions—we sometimes have them with men—but with virtually never with women. We have found that women tend to speak to their physiotherapist and, whilst our physiotherapists recognise the problem, they struggle with the lack of knowledge of what resources they can tap into.
This goes down to such basic issues as when can you re-engage in sexual activity after you have had spinal surgery, and how you should do so. And, more importantly, what help is available for people who have some sort of neurological dysfunction? What is normal and what is not normal in the case of cauda equina syndrome? We struggle tremendously to know what resources are available and what actually works.
What are the biggest issues that spinal disorders and spinal surgery can raise for body image?
We have come across three body image issues, really. One is in cases of adolescents with scoliosis; we simply do not know to what degree this affects healthy body image in adolescence.
The second issue is with scar placement. Whilst this appears to be completely irrelevant for men, the location of scars on the abdomen seems to have a far higher impact than we have understood before for women. Interestingly, virtually all of these patients—nearly 100%—had not discussed this with their healthcare providers. When our physiotherapists contacted patients to follow up on their questionnaires, however, they started reporting a whole range of issues of which we had not been aware.
The third issue we have come across is in the adult deformity group—and this goes more towards mature women with regards to body-shape image when they develop a progressive adult deformity. We know from clinical practice that losing posture or waistline can have a real impact on women, but this has simply not been addressed at all with regard to sexual health.
How can physicians address issues of body image and sexual health?
This is something we have to establish. We need to create forums which talk about openly about body image issues, and perhaps offer additional training in these areas. I think there is a need for training so that physiotherapists and surgeons can recognise problems and encourage people to discuss them openly. In many cases, too, you will need male and female practitioners available for patients to speak with.
We also need to engage in research questionnaires which can serve as resources for us to tap into. We really need to establish a working relationship with sexual counsellors, therapists—all of these professionals that are already available, but perhaps are not directing their assets specifically to spinal patients.
Is spinal surgery failing to address the impact of spinal disorders and treatment on sexual health?
It is entirely failing to address this. Spinal surgery as a subspeciality is simply not systematically assessing sexual health. The Oswestry Disability Index includes a question on sexual health, but it is a very simple one: “does this affect your sex life?” Nothing follows on from that in a more detailed manner.
I am not aware of any institution routinely assessing this as part of the whole treatment aspect of spinal disorders. We are far more likely to address peoples’ psychosocial behaviour in accordance with back pain than their sexual health, for example. We simply are not addressing the impact of spinal surgery at all—especially in women.
The Sex and the Spine symposium in Singapore got together sexual therapists, physiotherapists, spinal surgeons, and other healthcare professionals involved in this treatment. We hope to address the topic again at a multidisciplinary session at the 2017 NSpine meeting. We need to begin to share ideas and experiences in this way to better address sexual health issues.
Bronek Boszczyk is a consultant spinal surgeon at Nottingham University Hospitals, Nottingham, UK. He is also the director of NSpine, which ran the symposium “Sex and the Spine: Everything you always wanted to know about sex and the spine but were afraid to ask” during SpineWeek 2016, Singapore
Support for the NSpine pilot study comes from Premia Spine