Sexual Dysfunction in Dialysis Patients: A Review

Review Article

Austin J Nephrol Hypertens. 2015;2(1): 1031.

Sexual Dysfunction in Dialysis Patients: A Review

Raza Mustafa* and Rebecca J Schmidt

Department of Medicine, Division of Nephrology and Hypertension, West Virginia University, USA

*Corresponding author: Raza Mustafa, Department of Medicine, Division of Nephrology and Hypertension, West Virginia University, Morgantown

Received: November 07, 2014; Accepted: January 28, 2015; Published: January 30, 2015


Normal sexual function is an important component of quality of life. Sexual dysfunction is common in patients with Chronic Kidney Disease (CKD), especially those with End Stage Renal Disease (ESRD) and sufficiently reduced kidney function to require renal replacement therapy. The symptoms of SD start early with declining Glomerular Filtration Rate (GFR) and are rarely improved after starting dialysis treatment. Erectile dysfunction in men and anovulation in women are the most common symptoms. The etiology of these symptoms is complex and multifactorial. While phosphodiestrase - 5 inhibitors are effective in men with erectile dysfunction, no effective therapy exists for women with SD and women on hemodialysis are generally counseled to avoid pregnancy. Renal transplantation is considered the best option for women of childbearing age planning to conceive. The following review is focused on the physiology SD in CKD and available treatment options available.

Keywords: Chronic kidney disease (CKD); Sexual dysfunction (SD)


Quality of life (Qol) has emerged as an important outcome measure in patients with chronic illnesses. The impact of chronic diseases on Qol is formidable but traditionally has focused on factors that are physical rather than those contributing to emotional and mental well-being. In the general population, physical Qol begins to decline in the fifth decade of life. Chronic diseases such as diabetes, coronary artery disease and chronic kidney disease (CKD) are known to accelerate this decline and, additionally, impact mental and emotional Qol. Sexual dysfunction (SD) is a common problem in patients with CKD and can significantly impact Qol.

Impaired sexual function can have damaging effects on selfconfidence, sense of wholeness, social and the marital relationship [1]. In a report from National Health and Social Life Survey (NHSLS), theprevalence of SD in general population was 43% and 31% in women and men, respectively, and SD was associated with lower Qol [2]. Diabetes mellitus, one of the main causes of CKD, have been associated with SD in both men and women [3]. Sexual dysfunction is common in men with CKD, with approximately 70% reporting erectile dysfunction, a percentage much higher than general population [4].

Little information exists about how patients with End-Stage Renal Disease (ESRD) cope with quality of life issues such as SD. Multiple co-morbid conditions are common in patients with ESRD including diabetes and cardiovascular disease as well as other debilitating conditions such as impaired vision, deafness, poor mobility, arthritis and cognitive dysfunction. Sexual dysfunction is also prevalent in this population. This review will cover some of the physiologic and social barriers to improve outcomes of SD in patients with CKD and ESRD.

Altered Reproductive Physiology in Men with Chronic Kidney Disease

Moderate reductions in glomerular filtration rate (GFR) result in disturbance of the pituitary – gonadal axis [5]. Uremia affectslocal amino acid neurotransmitter outflow in hypothalamus affecting the pulsatile release of gonadotropin releasing hormone (GnRH), leading to a hypogonadal state [6]. Total and free testosterone levels are typically reduced in CKD [5] and stimulation response of testosterone secretion by GnRH produces only a blunted response. Serum estradiol and total estrogens levels are usually elevated [6] Plasma levels of LH are elevated presumably due to prolonged halflife and diminished secretion of testosterone from Leydig cells [7]. Because plasma FSH levels are variably elevated, the ratio of LH/FSH generally remains normal. Serum prolactin levels are also increased in men on hemodialysis and are not suppressed by external dopamine infusion.

Chronic kidney disease is associated with decreased spermatogenesis and testicular damage, resulting in a decreased volume of ejaculate and low percentage of sperm motility. Interstitial fibrosis and calcifications can develop in the epididymis and corpora cavernoasa; particularly as time on hemodialysis becomes prolonged [8]. These abnormalities persist throughout the continuum of CKD and are not altered by dialytic therapy.

Altered Reproductive Physiology in Women with Chronic Kidney Disease

Follicle stimulating hormone and LH release are decreased in women [7]. However, it remains unclear whether the disturbance is in the hypothalamus (due to decrease GnRH release) or in anterior pituitary [5]. Pre-ovulatory LH and estradiol peaks are frequently absent. Circulating prolactin levels are also increased. In postmenopausal women with CKD, GnRH levels are higher compared to the women of similar age with normal GFR.

Menstrual cycles are irregular with scanty flow after the initiation of maintenance dialysis. Some women may experience hypermenorrhagia leading to significant blood loss, but anovulatory cycles are the rule in women with reduced renal function. There is an absence of progesterone effects and failure to increase the body temperature at the time of expected ovulation [5].

Clinical Manifestations of Sexual Dysfunction in Men

Erectile dysfunction (ED) is the most often reported symptom of SD in dialysis patients with reported rates as high as 90% in older patients. A study of 390 prevalent hemodialysis reported a prevalence of 82% in all HD subjects [4]. Forty-five percent of men had severe ED according to Sexual Health Inventory for Men (SHIM) questionnaire. Younger patients aged less than 50 also demonstrated a high prevalence of ED (63%). Another study [9] of dialysis patients with mean age of 49.3 years found a prevalence rate of 80.7% (Figure 1).