This is not an unusual question to ask, but unfortunately there is not a clearcut simple answer. There are many factors that may be contributing to this situation. I’ve outlined some of the possibilities below. The most important factor to remember is that you and your wife should feel comfortable asking this question to your physician. It is a valid question that deserves the proper evaluation.

Both doctors and patients recognize the serious cardiovascular and metabolic consequences of chronic kidney disease (CKD). However, the effects of CKD on sexual function are not well understood. Decreased sexual desire, difficulty in becoming aroused, a lack of vaginal lubrication and difficulty achieving orgasm are common problems in women with CKD. But there are many unanswered questions. Does sexual function decline as CKD gets worse? Are the declines proportional to the degree of worsening of kidney function?

There have been very few studies of sexual function in patients with CKD, and none of them actually tested the sexual response. Instead, sexual function in patients with CKD was assessed with questionnaires where a patient reported his or her own opinion about sexual function and satisfaction. In those
studies, CKD usually correlates with lower physical function overall. In one study, the ability to walk a block or two, climb a flight of stairs and do moderate housework all declined as kidney functioned lowered, and sexual function also dropped with diminishing kidney function.

But physical function is only one part of sexual function. The other part is psychosocial function, meaning psychological function and social interaction. Psychosocial factors have a large effect on the sexual function of patients with CKD. In patients with end stage renal disease (ESRD), depression is a very common psychological problem that can affect marital and family relationships. Depressed patients express pessimism, loss of enjoyment, sadness and say they feel helpless and hopeless. These symptoms can result in changes in sleep, appetite, activity level and sexual desire. The patients who are most depressed are those with the most severe degree of sexual dysfunction; patients who exhibit the fewest depressive symptoms are those with the least sexual dysfunction. When depression and sexual health dysfunction occur together, it may be important to treat both at the same time. Relief of depression often improves sexual function, but improved sexual function also helps depression. Improvement in both depression and sexual function may not only affect quality of life. Studies have shown there is strong relationship between quality-of-life and the likelihood of future illness or death.

There are a variety of psychosocial stressors that affect the life of a CKD patient. Body image is also a source of concern for many patients. For example, patients with CKD may be worried about gaining weight from excess fluid or the possibility of being connected to a machine. These concerns can negatively affect a patient’s relationship to his or her body. This negative body image can lower self-esteem and make the patient feel less desirable and
more self-conscious than before, which might result in avoidance of sexual activity. Other stressors include following a CKD diet, taking medications, possible loss of employment and possible financial difficulties. Patients need time to adjust to complex life changes. In the absence of adequate coping strategies, the quality intimate relationships can suffer, and patients may experience loss of sexual desire and reduced sexual function.

Both a thorough medical history and a physician examination are essential for assessment of sexual function. Doctors are often uncomfortable initiating a frank discussion about sexuality and patients are even more reluctant or embarrassed to raise the subject! Bringing your concerns to the attention of your physician is the most important first step in helping with sexual dysfunction.

In assessing a patient’s sexual function, a doctor should ask the patient about his/her sexual history and assess his/her level of current function. It is important to determine the time of onset of these problems in relation to the CKD diagnosis and other medical and psychosocial difficulties. The doctor must also determine if the patient is concerned about sexual problems! And the doctor should assess the patient’s satisfaction with his/her current function. Specific symptoms of sexual dysfunction, particularly lack of sexual desire, as well as problems with sexual arousal, problems with vaginal lubrication, painful intercourse and difficulties with orgasm all need to be discussed. Physical examination should focus on uncovering medical problems other than CKD but commonly found in CKD patients. The doctor should be sure to evaluate for the presence of blood vessel dysfunction, nerve dysfunction and hormonal changes. Current medications should also be reviewed in health detail for potential impact on sexual function. Laboratory testing for anemia, diabetes mellitus and other chemical imbalances should be ordered.

The doctor should evaluate the patient for psychosocial stressors that may be contributing to sexual dysfunction. Screening for depression is essential because of the strong association between this condition and sexual dysfunction. The doctor may refer the patient to a mental health professional (a psychiatrist, psychologist, social worker or other professional) for a more detailed assessment of stressors affecting his/her sexual desire.

Treating sexual dysfunction in patients with CKD is complicated. Since sexual dysfunction is frequently the result of both physical and psychosocial factors, there is often no one, single primary cause. Treatment for sexual dysfunction should be part of the overall management of the various medical and psychosocial problems uncovered by the evaluation. For example, treatment of anemia will not likely succeed in improving sexual desire if critical marital issues are not also addressed!

You have taken a very good first step in asking the question about sexual function in CKD that too many professionals and patients are afraid to ask. If the medical team, together with you and your wife, can uncover some of the physical, medical and psychosocial factors behind this problem, you will have a very good chance of finding ways to help your relationship.

Harini A. Chakkera, MD, is Assistant Professor of Medicine and Senior Associate Consultant at the Mayo Clinic Hospital in Phoenix, Ariz. She earned her MD at Bangalore University in Bangalore, India. Upon graduation, she fulfilled her internship and residency in internal medicine at Hennepin in Minneapolis, Minn., followed by completion of both a Nephrology Fellowship and Transplant Nephrology Fellowship at the University of California in San Francisco, Calif., and MPH degree at UC Berkley.

This article originally appeared in the February 2008 edition of Kidney Beginnings: The Magazine.

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