TORONTO--Among the many potential causes of sexual dysfunction, pulmonary disease is often overlooked. "It may seem odd for a pulmonologist to be talking about sexual dysfunction," explained Paul A. Selecky, MD. "However, several pulmonary conditions do have either direct or indirect sexual consequences. As clinicians, we must be prepared to discuss these situations knowledgeably with our patients," he told physicians at the annual meeting of the American Thoracic Society.

CYSTIC FIBROSIS

Patients with cystic fibrosis (CF) have gender-specific types of sexual dysfunction. For example, male CF patients often have a congenital absence of the vas deferens and impaired spermatogenesis; as a result, they are generally azoospermic and thus cannot have children. Nevertheless, "young men with CF need to be counseled about sexual health," explained Dr. Selecky, who is Medical Director of the Pulmonary Department at Hoag Memorial Hospital in Newport Beach, California. "Sexually active young men with CF often do not use protection, assuming that they cannot get their partner pregnant, but they are still at risk for sexually transmitted diseases."

Many female CF patients are infertile, as a result of thick cervical mucus and/or ovulatory problems. However, the pregnancy rate is increasing in women with CF who are sexually active. These pregnancies are often unplanned and can be difficult to manage if the mother has severe functional abnormalities.

The risk that a child will inherit CF depends on several factors. "All parents with a CF child have a one in four chance of having another CF child," according to Dr. Selecky. "But if a parent with CF has a child with someone who is not a carrier, the chance of having a CF child is only one in 50 if they do not already have another child with CF."

CHRONIC LUNG DISEASE

Sexual function in a patient with chronic obstructive pulmonary disease (COPD) depends on a number of variables. These include age, personal health, sexual history, the nature and severity of the illness, the effect of medications and surgery, social circumstances (especially the availability of a partner), the partner's reaction to the illness, and the patient's coping ability.

"If you look at the psychosocial composite of pulmonary patients, you see a lot of problems smoldering under the surface," said Dr. Selecky. "Their roles are altered. They have limited ADLs [activities of daily living]; limited recreational ability; preoccupation with their bodies; decreased self-esteem; and a lot of anxiety, depression, and overdependence."

Other obstacles to sexual health in COPD patients can be classified as follows:

• Personal: Shortness of breath, cough, and medication side effects.
• Intrapersonal: Decreased self-esteem, altered sex role.
• Interpersonal: Fear of sexual failure and being overly dependent.

Research on the relationship between sexual dysfunction and COPD is limited and inconclusive. In one study, presented several years ago at a meeting of the American Thoracic Society, 52 male COPD patients (mean age, 72 years) were questioned about their sexual activities. No correlation was found between FEV1 and sexual function; 54% of those who were severely impaired said they were still sexually active. There was some correlation between exercise tolerance and sexual function, but no specific association with a sexual disability, such as erectile dysfunction.

Other studies have indicated a direct correlation between decreased lung function and decreased sexual activity, but little correlation between age and sexual function.[1]

A more recent study of 350 asthma patients has shown that two thirds reported some limitation in sexual function.[2] Factors that correlated with sexual dysfunction included age, low income, symptom severity, a high number of asthma triggers, and comorbid depression.

Medication use can also contribute to sexual dysfunction. "Numerous studies have shown that drugs such as antihypertensives, sedatives, and tranquilizers can induce sexual dysfunction," said Dr. Selecky. "However, medications used to treat patients with lung disease generally do not impair sexual function physically and, in fact, can ease the dyspnea that may occur during sexual activity." But it may be worthwhile to remind patients who smoke that tobacco use can interfere with sexual performance through its effects on the blood vessels, he said.

ROLE OF CAREGIVERS

Dr. Selecky noted that surveys of older patients with sexual concerns have shown that they want their physicians to spend more time with them when they have questions about this subject. They also want physicians to use easily understood words, help them feel comfortable, listen with an open mind, treat them with respect, and encourage discussion. "Many of us feel uncomfortable in getting into this subject," he acknowledged. "After all, we're not urologists or gynecologists. But what we have found to be invaluable in our own practice is to proceed in a stepwise fashion."

The first step is to simply communicate acceptance, and this is often best done in the pulmonary rehabilitation or office setting, according to Dr. Selecky. He recommends using open-ended questions, such as: "How have your breathing problems affected your love life?" An alternative might be: "Many people find that their breathing problems make it more difficult to make love--how has this affected you? How has this affected your partner?"

The next step is to provide some relevant information. This should include a discussion of the normal aging process and an attempt to dispel myths and fears, a review of the effects of medications that may impede sexual function, and a description of common sexual dysfunctions. Finally, "It is important to explain that sexuality is something that involves the total person. Sex is not something you do; it's something you are," said Dr. Selecky. This shifts the focus from genital function to the patient's total self.

SPECIFIC SUGGESTIONS

Patients may need more specific suggestions for improving lovemaking. For example, "Advise the patient to be physically and emotionally rested before sex and to choose the best breathing time; this may not be in the morning or at night, but in midafternoon," said Dr. Selecky. "Tell patients to avoid the 'touchdown mentality'--that they have to 'score' each time they make love. Talk about being creative and romantic, and focus on touch. Stress the need to avoid alcohol and heavy meals and to choose less stressful positions," he added.

Finally, intensive therapy is another option that should be discussed with patients. "The patient's relationship may be falling apart because of the illness, or there may be specific marital problems requiring counseling. If really intensive therapy is required, consult with a gynecologist or urologist or another member of the community who is knowledgeable about such matters," said Dr. Selecky. Such therapy can address physical and psychological problems.

--Stanley Nelson

References
1. Fletcher EC, Martin RJ. Sexual dysfunction and erectile impotence in chronic obstructive pulmonary disease. Chest. 1982;81:413-421.
2. Meyer I, Fagan J, Sternfels P, et al. Asthma-related limitation in sexual functioning among emergency department users [abstract]. Am J Respir Crit Care Med. 2000;161:A55.

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