Eur Arch Otorhinolaryngol DOI 10.1007/s00405-015-3546-4
RHINOLOGY
Effects of nasal continuous positive airway pressure therapy on partners’ sexual lives Mustafa Acar • Coskun Kaya • Tolgahan Catli Deniz Hancı • Ozge Bolluk • Yunus Aydin
•
Received: 24 November 2014 / Accepted: 3 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract To assess sexual functioning in male and female partners before and after nasal continuous positive airway pressure (CPAP) therapy in men with obstructive sleep apnea (OSA). Twenty-one male patients with moderate to severe OSA and erectile dysfunction, and their female partner, were recruited into this prospective study. Males diagnosed with OSA were treated with nasal CPAP therapy for 12 weeks. Women were assessed for sexual functioning using the Female Sexual Function Index (FSFI), and for mood status using the Beck Depression Inventory (BDI), before and after their male partner underwent nasal CPAP therapy. Sexual functioning was assessed in men using the International Index of Erectile Function (IIEF), before and after nasal CPAP therapy. After nasal CPAP therapy for OSA in men, IIEF scores
were significantly higher than pre-treatment scores. Total pre- and post-treatment IIEF scores (mean ± standard deviation) were 50.28 ± 15.88 and 65.42 ± 7.47, respectively, P \ 0.01. Pre- and post-treatment FSFI scores in women were 21.54 ± 6.62 and 29.94 ± 3.76, respectively, P \ 0.01. Pre- and post-treatment BDI scores in women were 14.61 ± 9.69 and 12.42 ± 8.92, respectively, P \ 0.01. Following treatment of men with OSA, our data indicate benefits for nasal CPAP therapy on sexual functioning in both the male and female partners. Moreover, our findings indicate that improved sexual function in women after their male partner underwent nasal CPAP also had psychological benefits. Keywords Obstructive sleep apnea Sexual functioning Nasal CPAP IIEF BDI FSFI
M. Acar ENT Department, Yunus Emre State Hospital, Eskisehir, Turkey
Introduction C. Kaya (&) Department of Urology, Eskisehir State Hospital, Yenidog˘an ¨ zaydın Sokak No:9, Eskisehir, Turkey Mh. S¸ ehit Serkan O e-mail: [email protected] T. Catli ENT Department, Bozyaka Teaching and Research Hospital, Izmir, Turkey e-mail: [email protected] D. Hancı ENT Department, Liv Hospital, Istanbul, Turkey O. Bolluk Department of Biostatistics, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey Y. Aydin Department of Obstetrics and Gynecology, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey
Sleep-disordered breathing (SDB) describes a group of disorders characterized by abnormal respiratory patterns (including pauses in breathing) and reduced ventilation during sleep. Obstructive sleep apnea (OSA) is the most common SDB disorder, characterized by the repetitive or partial collapse of the pharyngeal airway during sleep [1]. OSA is potentially life-threatening due to repetitive episodes of upper respiratory tract obstruction, with consequent blood oxygen desaturation and related cardiovascular and neurovascular complications [2]. Moreover, OSA is associated with various comorbidities, such as hypertension, stroke, enuresis, obesity, insulin resistance, and sexual dysfunction (increased risk for these disorders can in large part be explained by periodic hypoxemia, increased sympathetic activity, and disrupted insulin metabolism)
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[3]. Among these comorbidities, sexual dysfunction may have a profound impact from an emotional perspective, with significant effects on mood and social functioning. In addition, other symptoms may result in decreased desire in the partner of men with OSA, exacerbating negative sexual effects [4]. For example, OSA-related snoring may lead to separation issues between cohabiting partners, due to adverse effects of snoring on sleep quality of the non-affected partner. In addition to heavy snoring, a negative impact of OSA-related erectile dysfunction (ED) on sexual qualityof-life has been documented. ED is an important health problem in the aging population, with prevalence reported at 52 and 20–45 % in the United States and European Union, respectively [5]. ED of any etiology may lead to negative sexual effects, and deterioration in sexual functioning may occur due to decreased desire or arousal (in both partners), difficulty achieving orgasm, reduced sexual satisfaction, or lower frequency of sexual activity [6]. In managing OSA, nasal continuous positive airway pressure (CPAP) is the gold standard. After implementation of CPAP, marked reductions in OSA-related morbidity and mortality have been achieved. In terms of OSA-related ED, the therapeutic effects of CPAP have been widely studied over a number of decades [10–12]. Validated methods in current clinical practice for studying sexual quality-of-life include the International Index of Erectile Function (IIEF) in men, and the Female Sexual Function Index (FSFI) in women [7, 8]. A common psychological effect in patients with sexual dysfunction is depression [9], which can be investigated using the Beck Depression Inventory (BDI). However, there are no data from prospective studies (to our knowledge) whereby validated outcome measures were used to assess sexual functioning in the
female partner of men with OSA. Furthermore, we are not aware of any studies that employed such measures to determine the effect of CPAP on sexual functioning in the female partner. Thus, the present study aimed to assess sexual functioning in women using the FSFI, as well as mood by applying the BDI, both before and after the male partner with OSA underwent therapy with nasal CPAP. In addition, erectile function in men with OSA and the effect of CPAP on erectile function were investigated using the IIEF.
Methods Three hundred and fifty male patients who had presented with complaints of nasal obstruction, snoring, and daytime somnolence were assessed for inclusion in this prospective study. The study protocol was approved by the University Ethics Committee, and all participants provided informed consent. Full-night polysomnography was used to test for OSA. Of the 350 patients initially assessed, 180 were diagnosed with OSA. An apnea–hypopnea index (AHI) greater than 15 was considered as moderate to severe OSA; this applied to 62 patients. Of these patients, 48 had ED based on the IIEF questionnaire. Twenty-one of these male patients fulfilled the inclusion criteria and these patients and their female partners were evaluated in the current study. Exclusion and inclusion criteria for male patients and their female partners are summarized in Table 1. Males with OSA who enrolled in this study were treated with nasal CPAP therapy for 12 weeks. The memory cards of each CPAP machine were checked to verify effective use. Only patients who had a usage time of C6 h were
Table 1 Inclusion and exclusion criteria of the partners
Male
Inclusion
Exclusion
[18 years of age
Receiving nitrates
AHI C15
ED treatment
Willingness to receive nasal CPAP for 12 weeks
Not having a heterosexual relationship Abnormal hormonal status
Body mass index (BMI) B40 kg/ m2
Diagnosed with hypertension, diabetes mellitus, peripheral neuropathic disease, prostate cancer
Normal male urogenital examination Female [18 years of age Normal female urogenital examination
Renal transplantation, aortic aneurysm, spinal cord injury, endocrine disturbances, penile deformity, alcohol abuse, psychotropic drug intake, presence of chronic and severe acute psychiatric disorders, chronic medical illness, cardiovascular diseases, metabolic and neurological disorders History of alcohol or other substances abuse Severe cardiac or pulmonary disease Uncontrolled hypertension, diabetes mellitus, thyroid diseases History of medication usage with sexual side effects such as psychotropic medications and oral contraceptives Severe pelvic organ prolapsus
AHI Apnea–hypopnea index, CPAP continuous positive airway pressure therapy, BMI body mass index
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enrolled in this study (no data are presented on sexual changes in patients who underwent C4 h of CPAP, as a minimum usage time of 6 h was recommended). Patients (and their partner) who did not apply CPAP according to our instructions were excluded from the study and did not receive post-treatment questionnaires. In total, the IIEF questionnaire consists of 15 questions that assess five principal domains of sexual function in males: erectile function (six questions), orgasmic function (two questions), sexual desire (two questions), intercourse satisfaction (three questions), and overall satisfaction (two questions). The FSFI and BDI were evaluated in females before and after their partner underwent nasal CPAP, to assess sexual functioning and mood and the effects of nasal CPAP on sexual and psychological functions. In total, the FSFI questionnaire consists of 19 questions that assess six principal domains of sexual functioning in females: lubrication (four questions), orgasmic function (three questions), sexual desire (two questions), intercourse satisfaction (four questions), arousal (three questions), and pain (three questions). The BDI test consists of 21 questions on items related to depression. Male patients and their female partner completed the questionnaires in separate rooms and were not informed about the results of their partner’s questionnaire. Statistical analysis Statistical analysis was performed using the Wilcoxon signed-rank test and 2-proportion test. Statistical significance was defined as P \ 0.05. The commercially available statistical package, SPSS 12.0 for Windows, was used to perform all statistical analyses.
Results Twenty-one adult men (with a mean age of 46.95 ± 8.58 years and a mean BMI of 31.29 ± 3.60 kg/ m2) diagnosed with OSA (mean AHI: 54.95 ± 21.25) who met the pre-specified inclusion criteria were included in this prospective study. The female partners of these men (21 women with a mean age of 42.14 ± 7.62 years) were also evaluated with regard to sexual functioning and mood status (Table 2). The mean pre-treatment total IIEF score in men with OSA was 50.28 ± 15.88. After nasal CPAP therapy, this increased to 65.42 ± 7.47. The pre- and posttreatment IIEF scores were significantly different (P \ 0.01). Based on the IIEF questionnaire, all aspects of male sexual functioning were significantly improved after nasal CPAP therapy (Table 3). In females, the mean pretreatment total FSFI score was 21.54 ± 6.62. After their male partner had undergone nasal CPAP therapy, this
Table 2 Demographic characteristics and polysomnographic results of male patients and their female partners Gender
Variables
Men
Age (years)
46.95 ± 8.58
BMI
31.29 ± 3.60
ESS
12.42 ± 2.56
AHI
54.95 ± 21.25
SE Number of Hipopne with SaO2 \90 % Mean SaO2 (%) Lowest SaO2 (%) Women
Mean ± SD
81.09 ± 14.54 154.61 ± 104.16 91.28 ± 3.46 78.14 ± 6.90
Age (years)
42.14 ± 7.62
BMI
27.26 ± 5.42
Duration of marriage (years)
22.04 ± 10.77
BMI body mass index, AHI apnea–hypopnea index (number of apnea and hypopnea/h of sleep), ESS Epworth sleepiness scale, Lowest SaO2 lowest oxygen saturation, SE sleep efficiency
increased to 29.94 ± 3.76. The pre-treatment mean BDI score in females was 14.61 ± 9.69. After their male partner had undergone nasal CPAP therapy, this decreased to 12.42 ± 8.92. For both FSFI and BDI in females, total scores were significantly different after their male partner had undergone nasal CPAP therapy (P \ 0.01). In addition, all domains of sexual functioning (evaluated using the FSFI; Table 4) and depression items (evaluated using the BDI; Table 6) were significantly improved in females after their male partner had undergone nasal CPAP therapy (Table 5).
Discussion In addressing the complications of OSA in men, data from previous studies that assessed the adverse effects on erectile function, and the potential benefits of nasal CPAP therapy in ameliorating erectile problems, have been inconsistent. For example, it was concluded based on a prospective study by Taskin and colleagues, that nasal CPAP therapy improves ED in most patients with severe OSA [13]. In contrast, Margel and colleagues suggested that nasal CPAP therapy may worsen ED in 20 % of OSA patients [14]. In the present study, however, 12 weeks of nasal CPAP therapy resulted in improvements in all domains of male sexual functioning, as assessed by the IIEF-5 questionnaire (consistent with other studies that support a beneficial effect for CPAP [2, 15] ). Although each domain of male sexual functioning was assessed (based on the IIEF questionnaire), an important feature of the present study is that ED assessment criteria were selected to enable comparisons with previous studies [16, 17]. In a randomized and prospective study undertaken by Budweiser and
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colleagues, the effect of CPAP on ED in OSA patients was examined by dividing patients into two groups: CPAP users and non-users. Based on IIEF-15 results, CPAP users showed significant improvements in the summary score and other subdomains (erectile function, orgasmic function, sexual desire, and overall satisfaction) compared with non-users. Moreover, CPAP non-users showed a significant long-term decline in summary score and the subdomain of sexual desire [18]. Significant improvements in subjective Table 3 Mean values and statistical analysis of IIEF questionnaire Pre-treatment
P
Mean ± SD
Posttreatment Mean ± SD
Erectile function
17.66 ± 7.45
23.71 ± 4.63
P \ 0.01
Intercourse satisfaction
10.80 ± 3.29
14.09 ± 1.81
P \ 0.01
7.57 ± 2.48 6.57 ± 1.98
9.33 ± 1.06 9.04 ± 0.92
P = 0.01 P \ 0.01
5.71 ± 2.19
8.28 ± 1.30
P \ 0.01
50.28 ± 15.88
65.42 ± 7.47
P \ 0.01
Orgasmic function Sexual desire Overall satisfaction IIEF-15 summary score
Table 4 Mean values and statistical analysis of FSFI questionnaire FSFI domain
Pre-treatment Mean ± SD
Post-treatment Mean ± SD
Desire
3.01 ± 1.17
5.17 ± 0.99
P \ 0.001
Arousal
5.57 ± 1.86
7.07 ± 1.40
P \ 0.001
Lubrication
2.01 ± 0.71
2.71 ± 0.33
P \ 0.001
Orgasm
3.77 ± 1.34
5.13 ± 0.85
P \ 0.001
Satisfaction
4.20 ± 1.26
5.05 ± 0.97
P \ 0.001
Pain
3.24 ± 1.60
4.76 ± 1.03
21.54 ± 6.62
29.94 ± 3.76
FSFI Toplam
Table 5 Sexual dysfunction status of female partners preand post-treatment period according to FSFI domain scores
FSFI domain
Desire Arousal Lubrication
P = 0.001 P \ 0.01
Dysfunction
Pre-treatment
Post-treatment
P
N
%
N
%
No
11
52.4
20
95.2
Yes
10
47.6
1
4.8
P \ 0.001
No
11
52.38
20
95.2
P \ 0.001
Yes
10
47.62
1
4.8
P \ 0.001
No
9
42.8
20
95.2
P \ 0.001
P \ 0.001
Yes
12
57.2
1
4.8
P \ 0.001
Orgasm
No
11
52.4
20
95.2
P \ 0.001
Satisfaction
Yes No
10 18
47.6 85.7
1 20
4.8 95.2
P \ 0.001 P = 0.287
Yes
3
14.3
1
4.8
P = 0.287
No
6
28.6
16
76.2
P \ 0.001
Yes
15
71.4
5
23.8
P \ 0.001
No
8
38.1
20
95.2
P \ 0.001
Yes
13
61.9
1
4.8
P \ 0.001
Pain Sexual dysfunction
123
P
indicators of ED after nasal CPAP therapy may be related to various factors. For example, alterations in vasoregulation (associated with decreased levels of nitric oxide, increased levels of endothelin, and impaired penile tumescence as a result of intermittent nocturnal hypoxemia) may be improved by nasal CPAP therapy [19–21]. In a study by Khafagy and colleagues [22] which examined penile tumescence using automated Rigiscan (which may be considered as an objective method for investigating male sexual functioning), nocturnal penile rigidity was significantly increased after nasal CPAP therapy or surgical intervention. Despite valuable insights from studies that examined the effects of OSA on sexual functioning in men (and the role of various treatments in improving OSA), data on the impact of this disorder on sexual functioning in the female partner—and the question of improvement after nasal CPAP therapy—are still lacking. To assess the impact on sexual functioning in the female partner of men with OSA, and the potential ameliorative effects of nasal CPAP therapy, the female partner of each of the 21 men enrolled in the present study was evaluated using questionnaires and subjective assessments. In cohabiting partners, the findings of the present study indicate that OSA in men is associated with negative consequences on sexual functioning in both male and female. The results of the FSFI questionnaire, in addition to showing that sexual functioning may be unsatisfactory in women whose partner has been diagnosed with OSA, support a beneficial role for CPAP therapy in improving these negative consequences. Thus, nasal CPAP therapy in men with OSA may confer benefits on sexual functioning to both the male and female partners. To our knowledge, this is the first study to show improved erectile function in men as well as improved sexual functioning in
Eur Arch Otorhinolaryngol Table 6 Mean values and statistical analysis of BDI questionnaire
BDI
Pre-treatment Mean ± SD
Post-treatment Mean ± SD
P
14.61 ± 9.69
12.42 ± 8.92
0.001
the female partner (following CPAP therapy for OSA in men). Considering the association between sexual dysfunction and depression, the finding that improvements in sexual functioning in women were accompanied by better mood scores (as assessed by the BDI questionnaire) is not unexpected. In addition to improving quality-of-life in men diagnosed with OSA, the results of the BDI questionnaire indicate that emotional benefits of nasal CPAP therapy extend, indirectly, to the female partner. A limitation of the present study is the relatively small sample size of only 21 participants. This is mainly because very stringent exclusion criteria were applied (to restrict inclusion to individuals with ED caused only by OSA), and the requirement that male participants closely adhered to treatment recommendations (in order that the effects of CPAP could be accurately assessed). Another limitation is the absence of a control group (pre- and post-treatment results of questionnaires were compared in the same patient to determine the effects of treatment). In conclusion, our data support that nasal CPAP therapy—the gold standard for treating OSA—is also beneficial for OSA-related sexual problems, both in males and (indirectly) females. Improved sexual functioning in women after their male partner with OSA underwent nasal CPAP therapy was also associated with improved psychological status. Conflict of interest interest.
The authors declare there is no competing
References 1. Friedman M, Maley A, Kelley K et al (2011) Impact of nasal obstruction on obstructive sleep apnea. Otolaryngol Head Neck Surg 144:1000–1004 2. Hoekema A, Stel AL, Stegenga B et al (2007) Sexual function and obstructive sleep apnea-hypopnea: a randomized clinical trial evaluating the effects of oral-appliance and continuous positive airway pressure therapy. J Sex Med 4:1153–1162 3. Perimenis P, Karkoulias K, Konstantinopoulos A et al (2007) The impact of long-term conventional treatment for overlap syndrome (obstructive sleep apnea and chronic obstructive pulmonary disease) on concurrent erectile dysfunction. Respir Med 101:210–216 4. Fanfulla F, Malaguti S, Montagna T et al (2000) Erectile dysfunction in men with obstructive sleep apnea: an early sign of nerve involvement. Sleep 23:775–780
5. Bai Q, Xu QQ, Jiang H, Zhang WL, Wang XH, Zhu JC (2004) Prevalence and risk factors of erectile dysfunction in three cities of China: a community-based study. Asian J Androl 6:343–348 6. Fisher WA, Rosen RC, Eardley I, Sand M, Goldstein I (2005) Sexual experience of female partners of men with erectile dysfunction: the female experience of men’s attitudes to life events and sexuality (FEMALES) study. J Sex Med 2:675–684 7. Rosen R, Brown C, Heiman J et al (2000) The Female Sexual Function Index (FSFI): a multi- dimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 26:191–208 8. Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A (1997) The international index of erectile function (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 49:822–830 9. Beebe D, Finer E, Holmbeck GN (1996) Low-end specificity of four depression measures: findings and suggestions for the research use of depression tests. J Pers Assess 67:272–284 10. Meston N, Davies RJ, Mullins R, Jenkinson C, Wass JA, Stradling JR (2003) Endocrine effects of nasal continuous positive airway pressure in male patients with obstructive sleep apnoea. J Intern Med 254:447–454 11. Bratel T, Wennlund A, Carlstrom K (1999) Pituitary reactivity, androgens and catecholamines in obstructive sleep apnoea. Effects of continuous positive airway pressure treatment (CPAP). Respir Med 93:1–7 12. Macrea MM, Martin TJ, Zagrean L (2010) Infertility and obstructive sleep apnea: the effect of continuous positive airway pressure therapy on serum prolactin levels. Sleep Breath 14:253–257 13. Taskin U, Yigit O, Acioglu E, Aricigil M, Toktas G, Guzelhan Y (2010) Erectile dysfunction in severe sleep apnea patients and response to CPAP. Int J Impot Res 22:134–139 14. Margel D, Tal R, Livne PM, Pillar G (2005) Predictors of erectile function improvement in obstructive sleep apnea patients with long-term CPAP treatment. Int J Impot Res 17:186–190 15. Karacan I, Karatas M (1995) Erectile dysfunction in sleep apnea and response to CPAP. J Sex Marital Ther 21:239–247 16. Pressman MR, DiPhillipo MA, Kendrick JI, Conroy K, Fry JM (1986) Problems in the interpretation of nocturnal penile tumescence studies: disruption of sleep by occult sleep disorders. J Urol 136:595–598 17. Hirshkowitz M, Karacan I, Arcasoy MO, Acik G, Narter EM, Williams RL (1990) Prevalence of sleep apnea in men with erectile dysfunction. Urology 36:232–234 18. Budweiser S, Luigart R, Jo¨rres RA et al (2013) Long-term changes of sexual function in men with obstructive sleep apnea after initiation of continuous positive airway pressure. J Sex Med 10:524–531 19. Ip MS, Lam B, Chan LY et al (2000) Circulating nitric oxide is suppressed in obstructive sleep apnea and is reversed by nasal continuous positive airway pressure. Am J Respir Crit Care Med 162:2166–2171 20. Phillips BG, Narkiewicz K, Pesek CA, Haynes WG, Dyken ME, Somers VK (1999) Effects of obstructive sleep apnea on endothelin-1 and blood pressure. J Hypertens 17:61–66 21. Verratti V, Falone S, Fano` G et al (2011) Effects of hypoxia on nocturnal erection quality: a case repot from the Manaslu expedition. J Sex Med 8:2386–2390 22. Khafagy AH, Khafagy AH (2012) Treatment of obstructive sleep apnoea as a therapeutic modality for associated erectile dysfunction. Int J Clin Pract 66:1204–1208
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RHINOLOGY
Effects of nasal continuous positive airway pressure therapy on partners’ sexual lives Mustafa Acar • Coskun Kaya • Tolgahan Catli Deniz Hancı • Ozge Bolluk • Yunus Aydin
•
Received: 24 November 2014 / Accepted: 3 February 2015 Ó Springer-Verlag Berlin Heidelberg 2015
Abstract To assess sexual functioning in male and female partners before and after nasal continuous positive airway pressure (CPAP) therapy in men with obstructive sleep apnea (OSA). Twenty-one male patients with moderate to severe OSA and erectile dysfunction, and their female partner, were recruited into this prospective study. Males diagnosed with OSA were treated with nasal CPAP therapy for 12 weeks. Women were assessed for sexual functioning using the Female Sexual Function Index (FSFI), and for mood status using the Beck Depression Inventory (BDI), before and after their male partner underwent nasal CPAP therapy. Sexual functioning was assessed in men using the International Index of Erectile Function (IIEF), before and after nasal CPAP therapy. After nasal CPAP therapy for OSA in men, IIEF scores
were significantly higher than pre-treatment scores. Total pre- and post-treatment IIEF scores (mean ± standard deviation) were 50.28 ± 15.88 and 65.42 ± 7.47, respectively, P \ 0.01. Pre- and post-treatment FSFI scores in women were 21.54 ± 6.62 and 29.94 ± 3.76, respectively, P \ 0.01. Pre- and post-treatment BDI scores in women were 14.61 ± 9.69 and 12.42 ± 8.92, respectively, P \ 0.01. Following treatment of men with OSA, our data indicate benefits for nasal CPAP therapy on sexual functioning in both the male and female partners. Moreover, our findings indicate that improved sexual function in women after their male partner underwent nasal CPAP also had psychological benefits. Keywords Obstructive sleep apnea Sexual functioning Nasal CPAP IIEF BDI FSFI
M. Acar ENT Department, Yunus Emre State Hospital, Eskisehir, Turkey
Introduction C. Kaya (&) Department of Urology, Eskisehir State Hospital, Yenidog˘an ¨ zaydın Sokak No:9, Eskisehir, Turkey Mh. S¸ ehit Serkan O e-mail: [email protected] T. Catli ENT Department, Bozyaka Teaching and Research Hospital, Izmir, Turkey e-mail: [email protected] D. Hancı ENT Department, Liv Hospital, Istanbul, Turkey O. Bolluk Department of Biostatistics, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey Y. Aydin Department of Obstetrics and Gynecology, Medical Faculty, Eskisehir Osmangazi University, Eskisehir, Turkey
Sleep-disordered breathing (SDB) describes a group of disorders characterized by abnormal respiratory patterns (including pauses in breathing) and reduced ventilation during sleep. Obstructive sleep apnea (OSA) is the most common SDB disorder, characterized by the repetitive or partial collapse of the pharyngeal airway during sleep [1]. OSA is potentially life-threatening due to repetitive episodes of upper respiratory tract obstruction, with consequent blood oxygen desaturation and related cardiovascular and neurovascular complications [2]. Moreover, OSA is associated with various comorbidities, such as hypertension, stroke, enuresis, obesity, insulin resistance, and sexual dysfunction (increased risk for these disorders can in large part be explained by periodic hypoxemia, increased sympathetic activity, and disrupted insulin metabolism)
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[3]. Among these comorbidities, sexual dysfunction may have a profound impact from an emotional perspective, with significant effects on mood and social functioning. In addition, other symptoms may result in decreased desire in the partner of men with OSA, exacerbating negative sexual effects [4]. For example, OSA-related snoring may lead to separation issues between cohabiting partners, due to adverse effects of snoring on sleep quality of the non-affected partner. In addition to heavy snoring, a negative impact of OSA-related erectile dysfunction (ED) on sexual qualityof-life has been documented. ED is an important health problem in the aging population, with prevalence reported at 52 and 20–45 % in the United States and European Union, respectively [5]. ED of any etiology may lead to negative sexual effects, and deterioration in sexual functioning may occur due to decreased desire or arousal (in both partners), difficulty achieving orgasm, reduced sexual satisfaction, or lower frequency of sexual activity [6]. In managing OSA, nasal continuous positive airway pressure (CPAP) is the gold standard. After implementation of CPAP, marked reductions in OSA-related morbidity and mortality have been achieved. In terms of OSA-related ED, the therapeutic effects of CPAP have been widely studied over a number of decades [10–12]. Validated methods in current clinical practice for studying sexual quality-of-life include the International Index of Erectile Function (IIEF) in men, and the Female Sexual Function Index (FSFI) in women [7, 8]. A common psychological effect in patients with sexual dysfunction is depression [9], which can be investigated using the Beck Depression Inventory (BDI). However, there are no data from prospective studies (to our knowledge) whereby validated outcome measures were used to assess sexual functioning in the
female partner of men with OSA. Furthermore, we are not aware of any studies that employed such measures to determine the effect of CPAP on sexual functioning in the female partner. Thus, the present study aimed to assess sexual functioning in women using the FSFI, as well as mood by applying the BDI, both before and after the male partner with OSA underwent therapy with nasal CPAP. In addition, erectile function in men with OSA and the effect of CPAP on erectile function were investigated using the IIEF.
Methods Three hundred and fifty male patients who had presented with complaints of nasal obstruction, snoring, and daytime somnolence were assessed for inclusion in this prospective study. The study protocol was approved by the University Ethics Committee, and all participants provided informed consent. Full-night polysomnography was used to test for OSA. Of the 350 patients initially assessed, 180 were diagnosed with OSA. An apnea–hypopnea index (AHI) greater than 15 was considered as moderate to severe OSA; this applied to 62 patients. Of these patients, 48 had ED based on the IIEF questionnaire. Twenty-one of these male patients fulfilled the inclusion criteria and these patients and their female partners were evaluated in the current study. Exclusion and inclusion criteria for male patients and their female partners are summarized in Table 1. Males with OSA who enrolled in this study were treated with nasal CPAP therapy for 12 weeks. The memory cards of each CPAP machine were checked to verify effective use. Only patients who had a usage time of C6 h were
Table 1 Inclusion and exclusion criteria of the partners
Male
Inclusion
Exclusion
[18 years of age
Receiving nitrates
AHI C15
ED treatment
Willingness to receive nasal CPAP for 12 weeks
Not having a heterosexual relationship Abnormal hormonal status
Body mass index (BMI) B40 kg/ m2
Diagnosed with hypertension, diabetes mellitus, peripheral neuropathic disease, prostate cancer
Normal male urogenital examination Female [18 years of age Normal female urogenital examination
Renal transplantation, aortic aneurysm, spinal cord injury, endocrine disturbances, penile deformity, alcohol abuse, psychotropic drug intake, presence of chronic and severe acute psychiatric disorders, chronic medical illness, cardiovascular diseases, metabolic and neurological disorders History of alcohol or other substances abuse Severe cardiac or pulmonary disease Uncontrolled hypertension, diabetes mellitus, thyroid diseases History of medication usage with sexual side effects such as psychotropic medications and oral contraceptives Severe pelvic organ prolapsus
AHI Apnea–hypopnea index, CPAP continuous positive airway pressure therapy, BMI body mass index
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enrolled in this study (no data are presented on sexual changes in patients who underwent C4 h of CPAP, as a minimum usage time of 6 h was recommended). Patients (and their partner) who did not apply CPAP according to our instructions were excluded from the study and did not receive post-treatment questionnaires. In total, the IIEF questionnaire consists of 15 questions that assess five principal domains of sexual function in males: erectile function (six questions), orgasmic function (two questions), sexual desire (two questions), intercourse satisfaction (three questions), and overall satisfaction (two questions). The FSFI and BDI were evaluated in females before and after their partner underwent nasal CPAP, to assess sexual functioning and mood and the effects of nasal CPAP on sexual and psychological functions. In total, the FSFI questionnaire consists of 19 questions that assess six principal domains of sexual functioning in females: lubrication (four questions), orgasmic function (three questions), sexual desire (two questions), intercourse satisfaction (four questions), arousal (three questions), and pain (three questions). The BDI test consists of 21 questions on items related to depression. Male patients and their female partner completed the questionnaires in separate rooms and were not informed about the results of their partner’s questionnaire. Statistical analysis Statistical analysis was performed using the Wilcoxon signed-rank test and 2-proportion test. Statistical significance was defined as P \ 0.05. The commercially available statistical package, SPSS 12.0 for Windows, was used to perform all statistical analyses.
Results Twenty-one adult men (with a mean age of 46.95 ± 8.58 years and a mean BMI of 31.29 ± 3.60 kg/ m2) diagnosed with OSA (mean AHI: 54.95 ± 21.25) who met the pre-specified inclusion criteria were included in this prospective study. The female partners of these men (21 women with a mean age of 42.14 ± 7.62 years) were also evaluated with regard to sexual functioning and mood status (Table 2). The mean pre-treatment total IIEF score in men with OSA was 50.28 ± 15.88. After nasal CPAP therapy, this increased to 65.42 ± 7.47. The pre- and posttreatment IIEF scores were significantly different (P \ 0.01). Based on the IIEF questionnaire, all aspects of male sexual functioning were significantly improved after nasal CPAP therapy (Table 3). In females, the mean pretreatment total FSFI score was 21.54 ± 6.62. After their male partner had undergone nasal CPAP therapy, this
Table 2 Demographic characteristics and polysomnographic results of male patients and their female partners Gender
Variables
Men
Age (years)
46.95 ± 8.58
BMI
31.29 ± 3.60
ESS
12.42 ± 2.56
AHI
54.95 ± 21.25
SE Number of Hipopne with SaO2 \90 % Mean SaO2 (%) Lowest SaO2 (%) Women
Mean ± SD
81.09 ± 14.54 154.61 ± 104.16 91.28 ± 3.46 78.14 ± 6.90
Age (years)
42.14 ± 7.62
BMI
27.26 ± 5.42
Duration of marriage (years)
22.04 ± 10.77
BMI body mass index, AHI apnea–hypopnea index (number of apnea and hypopnea/h of sleep), ESS Epworth sleepiness scale, Lowest SaO2 lowest oxygen saturation, SE sleep efficiency
increased to 29.94 ± 3.76. The pre-treatment mean BDI score in females was 14.61 ± 9.69. After their male partner had undergone nasal CPAP therapy, this decreased to 12.42 ± 8.92. For both FSFI and BDI in females, total scores were significantly different after their male partner had undergone nasal CPAP therapy (P \ 0.01). In addition, all domains of sexual functioning (evaluated using the FSFI; Table 4) and depression items (evaluated using the BDI; Table 6) were significantly improved in females after their male partner had undergone nasal CPAP therapy (Table 5).
Discussion In addressing the complications of OSA in men, data from previous studies that assessed the adverse effects on erectile function, and the potential benefits of nasal CPAP therapy in ameliorating erectile problems, have been inconsistent. For example, it was concluded based on a prospective study by Taskin and colleagues, that nasal CPAP therapy improves ED in most patients with severe OSA [13]. In contrast, Margel and colleagues suggested that nasal CPAP therapy may worsen ED in 20 % of OSA patients [14]. In the present study, however, 12 weeks of nasal CPAP therapy resulted in improvements in all domains of male sexual functioning, as assessed by the IIEF-5 questionnaire (consistent with other studies that support a beneficial effect for CPAP [2, 15] ). Although each domain of male sexual functioning was assessed (based on the IIEF questionnaire), an important feature of the present study is that ED assessment criteria were selected to enable comparisons with previous studies [16, 17]. In a randomized and prospective study undertaken by Budweiser and
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colleagues, the effect of CPAP on ED in OSA patients was examined by dividing patients into two groups: CPAP users and non-users. Based on IIEF-15 results, CPAP users showed significant improvements in the summary score and other subdomains (erectile function, orgasmic function, sexual desire, and overall satisfaction) compared with non-users. Moreover, CPAP non-users showed a significant long-term decline in summary score and the subdomain of sexual desire [18]. Significant improvements in subjective Table 3 Mean values and statistical analysis of IIEF questionnaire Pre-treatment
P
Mean ± SD
Posttreatment Mean ± SD
Erectile function
17.66 ± 7.45
23.71 ± 4.63
P \ 0.01
Intercourse satisfaction
10.80 ± 3.29
14.09 ± 1.81
P \ 0.01
7.57 ± 2.48 6.57 ± 1.98
9.33 ± 1.06 9.04 ± 0.92
P = 0.01 P \ 0.01
5.71 ± 2.19
8.28 ± 1.30
P \ 0.01
50.28 ± 15.88
65.42 ± 7.47
P \ 0.01
Orgasmic function Sexual desire Overall satisfaction IIEF-15 summary score
Table 4 Mean values and statistical analysis of FSFI questionnaire FSFI domain
Pre-treatment Mean ± SD
Post-treatment Mean ± SD
Desire
3.01 ± 1.17
5.17 ± 0.99
P \ 0.001
Arousal
5.57 ± 1.86
7.07 ± 1.40
P \ 0.001
Lubrication
2.01 ± 0.71
2.71 ± 0.33
P \ 0.001
Orgasm
3.77 ± 1.34
5.13 ± 0.85
P \ 0.001
Satisfaction
4.20 ± 1.26
5.05 ± 0.97
P \ 0.001
Pain
3.24 ± 1.60
4.76 ± 1.03
21.54 ± 6.62
29.94 ± 3.76
FSFI Toplam
Table 5 Sexual dysfunction status of female partners preand post-treatment period according to FSFI domain scores
FSFI domain
Desire Arousal Lubrication
P = 0.001 P \ 0.01
Dysfunction
Pre-treatment
Post-treatment
P
N
%
N
%
No
11
52.4
20
95.2
Yes
10
47.6
1
4.8
P \ 0.001
No
11
52.38
20
95.2
P \ 0.001
Yes
10
47.62
1
4.8
P \ 0.001
No
9
42.8
20
95.2
P \ 0.001
P \ 0.001
Yes
12
57.2
1
4.8
P \ 0.001
Orgasm
No
11
52.4
20
95.2
P \ 0.001
Satisfaction
Yes No
10 18
47.6 85.7
1 20
4.8 95.2
P \ 0.001 P = 0.287
Yes
3
14.3
1
4.8
P = 0.287
No
6
28.6
16
76.2
P \ 0.001
Yes
15
71.4
5
23.8
P \ 0.001
No
8
38.1
20
95.2
P \ 0.001
Yes
13
61.9
1
4.8
P \ 0.001
Pain Sexual dysfunction
123
P
indicators of ED after nasal CPAP therapy may be related to various factors. For example, alterations in vasoregulation (associated with decreased levels of nitric oxide, increased levels of endothelin, and impaired penile tumescence as a result of intermittent nocturnal hypoxemia) may be improved by nasal CPAP therapy [19–21]. In a study by Khafagy and colleagues [22] which examined penile tumescence using automated Rigiscan (which may be considered as an objective method for investigating male sexual functioning), nocturnal penile rigidity was significantly increased after nasal CPAP therapy or surgical intervention. Despite valuable insights from studies that examined the effects of OSA on sexual functioning in men (and the role of various treatments in improving OSA), data on the impact of this disorder on sexual functioning in the female partner—and the question of improvement after nasal CPAP therapy—are still lacking. To assess the impact on sexual functioning in the female partner of men with OSA, and the potential ameliorative effects of nasal CPAP therapy, the female partner of each of the 21 men enrolled in the present study was evaluated using questionnaires and subjective assessments. In cohabiting partners, the findings of the present study indicate that OSA in men is associated with negative consequences on sexual functioning in both male and female. The results of the FSFI questionnaire, in addition to showing that sexual functioning may be unsatisfactory in women whose partner has been diagnosed with OSA, support a beneficial role for CPAP therapy in improving these negative consequences. Thus, nasal CPAP therapy in men with OSA may confer benefits on sexual functioning to both the male and female partners. To our knowledge, this is the first study to show improved erectile function in men as well as improved sexual functioning in
Eur Arch Otorhinolaryngol Table 6 Mean values and statistical analysis of BDI questionnaire
BDI
Pre-treatment Mean ± SD
Post-treatment Mean ± SD
P
14.61 ± 9.69
12.42 ± 8.92
0.001
the female partner (following CPAP therapy for OSA in men). Considering the association between sexual dysfunction and depression, the finding that improvements in sexual functioning in women were accompanied by better mood scores (as assessed by the BDI questionnaire) is not unexpected. In addition to improving quality-of-life in men diagnosed with OSA, the results of the BDI questionnaire indicate that emotional benefits of nasal CPAP therapy extend, indirectly, to the female partner. A limitation of the present study is the relatively small sample size of only 21 participants. This is mainly because very stringent exclusion criteria were applied (to restrict inclusion to individuals with ED caused only by OSA), and the requirement that male participants closely adhered to treatment recommendations (in order that the effects of CPAP could be accurately assessed). Another limitation is the absence of a control group (pre- and post-treatment results of questionnaires were compared in the same patient to determine the effects of treatment). In conclusion, our data support that nasal CPAP therapy—the gold standard for treating OSA—is also beneficial for OSA-related sexual problems, both in males and (indirectly) females. Improved sexual functioning in women after their male partner with OSA underwent nasal CPAP therapy was also associated with improved psychological status. Conflict of interest interest.
The authors declare there is no competing
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