Background
One of the most common but least talked about effects of stroke is sexual dysfunction, with 50% or more of stroke survivors experiencing a degree of sexual decline post stroke. This is not always well recognised, and it is often poorly managed. Management options are very broad and can include medications, counselling, and physical therapy.
Review question
We wanted to find out whether some treatments are better or worse than alternatives.
Search date
The evidence is current to 27 November 2019.
Study characteristics
Population: we included studies in which participants were adults who had had a stroke.
Intervention: interventions included medications or other treatments, such as rehabilitation, used to manage sexual problems following stroke.
Comparison: we compared interventions such as medications against 'fake' medications, which do not contain active substances that affect sexual function. We compared interventions such as rehabilitation, education, or therapy to usual care or alternative treatment.
Outcome: we divided outcomes into primary and secondary outcomes. Primary outcomes focused on sexual function or sexual satisfaction in stroke survivors and their partners. Secondary outcomes focused on quality of life, psychological well-being (anxiety, depression, stress), satisfaction with intervention, sexual knowledge, and marital/relationship satisfaction (including partner satisfaction) in stroke survivors and their partners. We also reported adverse events.
Time/duration: we included studies of all durations: short (≤ 6 months), medium (between 6 and 18 months), and long (≥ 18 months).
Key results
We found three trials designed to reduce sexual dysfunction after stroke. One trial compared a medication called sertraline to methylcobalamin (vitamin B12) to help with premature ejaculation. A second trial compared a structured rehabilitation programme (which had face-to-face counselling and written education) to written education alone and found no clear difference in terms of sexual function, mood, stress, or quality of life. A third trial compared pelvic floor training (exercises to strengthen pelvic floor muscles) to standard rehabilitation and found no clear differences in terms of erection and quality of life. We were uncertain of the results because all three trials were small and of low or very low quality. Also, each trial compared different treatments, which meant that results could not be combined.
Side effects (mostly nausea or diarrhoea) were reported for sertraline (20 of 58 participants). No harmful events were reported with pelvic floor training, and no information was provided on harmful events related to sexual rehabilitation.
Study funding sources
The study that compared the medication (sertraline) to vitamin B12 did not describe any funding sources. The study that compared pelvic floor training to standard rehabilitation was funded through grants from the Association of Danish Physiotherapists Research Foundation, the Association of Danish Physiotherapists Practise Foundation, the Foundation of 12.12.1981, Lykkefeldts Grant, the Foundation of Lundbeck (UCSF), and the Department of Physiotherapy and Occupational Therapy Glostrup Hospital, University of Copenhagen. The study that compared a structured rehabilitation programme to written education alone was funded by the Victor Hurley Medical Research Grant-in-Aid and by the AFRM Ipsen Open Research Fellowship.
Quality of evidence
We are uncertain of the results because all three studies were small and of poor quality. Also, each of the three studies compared different treatments, which meant that we could not combine study results.
Conclusion
All three treatments (sertraline, structured sexual rehabilitation, and pelvic floor physiotherapy) need to be tested in further studies. Further research is needed to assess the effectiveness of treatments for sexual problems after stroke.
Use of sertraline to treat premature ejaculation needs to be tested in further RCTs. The lack of benefit with structured sexual rehabilitation and pelvic floor physiotherapy should not be interpreted as proof of ineffectiveness. Well-designed, randomised, double-blinded, placebo-controlled trials of long-term duration are needed to determine the effectiveness of various types of interventions for sexual dysfunction. It should be noted, however, that it may not be possible to double-blind trials of complex interventions.
Sexual dysfunction following stroke is common but often is poorly managed. As awareness of sexual dysfunction following stroke increases as an important issue, a clearer evidence base for interventions for sexual dysfunction is needed to optimise management.
To evaluate the effectiveness of interventions to reduce sexual dysfunction following stroke, and to assess adverse events associated with interventions for sexual dysfunction following stroke.
We conducted the search on 27 November 2019. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; from June 2014), in the Cochrane Library; MEDLINE (from 1950); Embase (from 1980); the Cumulative Index to Nursing and Allied Health Literature (CINAHL; from 1982); the Allied and Complementary Medicine Database (AMED; from 1985); PsycINFO (from 1806); the Physiotherapy Evidence Database (PEDro; from 1999); and 10 additional bibliographic databases and ongoing trial registers.
We included randomised controlled trials (RCTs) that compared pharmacological treatments, mechanical devices, or complementary medicine interventions versus placebo. We also included other non-pharmacological interventions (such as education or therapy), which were compared against usual care or different forms of intervention (such as different intensities) for treating sexual dysfunction in stroke survivors.
Two review authors independently selected eligible studies, extracted data, and assessed study quality. We determined the risk of bias for each study and performed a 'best evidence' synthesis using the GRADE approach.
We identified three RCTs with a total of 212 participants. We noted significant heterogeneity in interventions (one pharmacological, one physiotherapy-based, and one psycho-educational), and all RCTs were small and of 'low' or 'very low' quality. Based on these RCTs, data are insufficient to provide any reliable indication of benefit or risk to guide clinical practice in terms of the use of sertraline, specific pelvic floor muscle training, or individualised sexual rehabilitation.