|Year : 2014 | Volume
| Issue : 2 | Page : 81-86
Assessment of the sexual functions of males with chronic liver disease in South West Nigeria
Olusegun Adekanle1, Dennis A Ndububa1, Ernest O Orji2, Oluwasegun Ijarotimi1
1 Department of Medicine, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals, Ile-Ife, Osun State, Nigeria
2 Department of Obstetrics and Gynaecology, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals, Ile-Ife, Osun State, Nigeria
|Date of Web Publication||2-Apr-2014|
Department of Medicine, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospital, Ile-Ife, Osun State
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: Patients with chronic liver disease (CLD) have been reported to have sexual dysfunction irrespective of etiology. There is little or no report from Nigeria on this disorder. This study looked at sexual dysfunction among male patients with CLD.
Materials and Methods: Patients with chronic viral hepatitis B, liver cirrhosis (LC) and hepatocellular carcinoma (HCC) were interviewed using the international index of erectile function questionnaire. Their responses were compared with an age and sex matched healthy controls. Bio-data and body mass index were obtained for both groups and liver disease severity was graded for patients using the Child-Pugh score. Analysis was done using SPSS (SPSS Inc., Chicago, IL, USA, 2004) for frequencies and means while comparison of means was done using Student's t-test. Significance level was put at P < 0.05.
Results: There were 120 subjects consisting of 60 patients aged from 28 to 71 years; mean (SD) 45. 3 ± 9.4 and 60 controls aged from 29 to 79 years with mean (SD) 45.5 ± 10.1 years. Sexual dysfunctions were seen in patients with HCC and LC in the domains of sexual desire and sexual satisfaction respectively when compared with controls. When patients were divided into the various liver disease severities, patients in Child-Pugh Grade B scored low in the domain of arousal, whereas the domains of erectile functions, orgasm, resolution and satisfaction were affected in patients in Grade C when compared with controls.
Conclusions: Male patients with CLD have significant sexual dysfunctions when compared with controls. The dysfunctions are more pronounced in those with Grade C liver disease. Sexual concerns of CLD should be inquired of in those with advanced liver disease.
| Abstract in Spanish|| |
Contexte : Les patients atteints de maladie chronique du foie (CLD) ont été signalés pour dysfonctionnement sexuel indépendamment d'étiologie. Il y a peu ou pas de rapport du Nigéria sur ce trouble. Cette étude a examiné de dysfonctionnement sexuel chez les patients de sexe masculin avec CLD.
Patients et Méthodes : Les patients atteints d'hépatite virale chronique B, la cirrhose du foie (LC) et le carcinome hépatocellulaire (CHC) ont été interrogés à l'aide l'indice international de la fonction érectile questionnaire. Leurs réponses ont été comparés avec l'âge et le sexe lettré contrôles sains. Bio-data et indice de masse corporelle ont été obtenues pour les deux groupes et les maladies du foie gravité a été évaluée pour les patients utilisant le score de Child-Pugh. L'analyse a été effectuée à l'aide de SPSS version windows 13 (SPSS Inc., de Chicago, USA, 2004) pour des fréquences et des moyens tout en comparaison avec des moyens était effectuée à l'aide t de Student- test. Niveau significatif était mis à P < 0,05 .
Résultats : Il y a 120 sujets composé de 60 patients âgés de 28 à 71 ans; moyenne (SD) 45. 3 ± 9,4 et 60 contrôles âgés de 29 à 79 ans avec une moyenne (SD) 45,5 ± 10,1 ans. Dysfonctions sexuels ont été observés chez les patients avec HCC et LC dans les domaines du désir sexuel et à la satisfaction sexuelle respectivement par rapport aux contrôles. Lorsque les patients ont été répartis dans les diverses maladies du foie gravités, les patients Child-Pugh grade B a obtenu de faibles dans le domaine de l excitation, tandis que les domaines de la dysfonction érectile fonctions, orgasme, la résolution et la satisfaction ont été touchés dans les patients de grade C lorsqu'on les compare avec les contrôles.
Conclusions : Les patients masculins avec CLD ont des dysfonctions sexuels lorsque comparé avec les contrôles. Les dysfonctionnements sont plus prononcées dans ceux de grade C maladie du foie. Préoccupations sexuelles de CLD devrait être demandé à des patients qui sont à un stade avancé du foie.
Mots-clés : Évaluation, maladie chronique du foie, les mâles, sexuelle
Keywords: Assessment, chronic liver disease, males, sexual
|How to cite this article:|
Adekanle O, Ndububa DA, Orji EO, Ijarotimi O. Assessment of the sexual functions of males with chronic liver disease in South West Nigeria. Ann Afr Med 2014;13:81-6
|How to cite this URL:|
Adekanle O, Ndububa DA, Orji EO, Ijarotimi O. Assessment of the sexual functions of males with chronic liver disease in South West Nigeria. Ann Afr Med [serial online] 2014 [cited 2019 Jul 15];13:81-6. Available from: http://www.annalsafrmed.org/text.asp?2014/13/2/81/129884
| Introduction|| |
Chronic liver disease (CLD) is a disease of the liver resulting from an inflammatory, infiltrative, immunologic, circulatory or metabolic injury to the liver, a process which has been going on for a long time, usually for a period of 6 months or longer without complete resolution.  CLD is an important cause of morbidity and mortality in Nigeria.  CLD in Nigeria has been said to be of four major types, namely liver cirrhosis (LC), hepatocellular carcinoma (HCC), chronic viral hepatitis B (CHB) and hepatosplenic schistosomiasis, from studies in different parts of the country.  Chronic hepatitis B is the most common cause of CLD in Nigeria.  Most cases of chronic hepatitis B either progress to LC or HCC. Majority of HCC occur on a background of LC in up to 70-80% of cases in Nigeria.  Sexual dysfunction is a common condition in people with chronic diseases like diabetes mellitus and hypertension among others.  Erectile dysfunction is an important determinant of relationship to health.  Erectile dysfunction has been reported in male patients with CLD among Caucasians, which improved with liver transplantation  and in cirrhotic patients independent of alcohol etiology.  Moreover erectile dysfunction has been found to correlate with the degree of liver disease as measured by the Child-Pugh score among Japanese patients with CLD.  There is a paucity of data in Nigeria on the sexual functions of patients with CLD and hence the need for this study. The study is focused on three out of the four major types of CLD reported in Nigeria namely; LC, HCC and CHB. The aim of the present study therefore was to assess the sexual functions of patients with CLD in South West Nigeria.
| Materials and Methods|| |
A comparative cross-sectional study of male patients with CLD presenting to the gastroenterology clinics of both the Obafemi Awolowo University Teaching Hospital Complex, Ile-Ife and the Federal Medical Centre, Owo, Ondo State, Nigeria, between August 2009 and May 2012. Stable patients with CLD consenting to participate in the study and diagnosed with any of CHB, LC or primary HCC were included in the study. Liver disease was diagnosed using either clinical, ultrasonographic, biochemical or histology or a combination of all or some of these criteria for inclusion. All patients were married and living with their spouses with a steady partner relationship. In addition, recruited patients and controls were 18 years of age or above at the time of inclusion. Respondents were interviewed with a sexual function questionnaire using a modified international index of erectile function questionnaire. The questionnaire assessed for sexual desire, arousal, orgasm, erectile function, sexual satisfaction and resolution. The items under each stem were assigned scores and scored according to standard guidelines. The responses were compared with age and sex matched normal subjects recruited consecutively. Liver disease severity was graded using the Child-Pugh grading system for all patients. , Body mass index (BMI) was calculated using the weight in kilograms divided by the square of the height in meters for both patients and controls. Bio-data was obtained for both patients and controls. Patients were excluded if they refused to participate in the study, confused or comatose, unmarried or staying apart from their partners. Ethical approval was obtained from the hospital for the study. Data obtained was analyzed by means of SPSS 13.0 for frequencies, means and comparison of mean, using the Student's t-test. χ2 was used to compare categorical variables significant level.
| Results|| |
A total of 120 subjects (60 cases and 60 controls) completed the study. The age of the index group ranged from 28 to 71 years with a mean (SD) 45.3 ± 9.4 and for the controls, their ages ranged from 29 to 79 years with a mean (SD) 45.5 ± 10.1 [Table 1]. The age groups for both study and controls were matched. BMI values for the two groups are also shown in [Table 1]. One patient could not be weighed for BMI.
The type and number of cases of CLD studied were chronic hepatitis B (6), LC (29) and HCC (25) [Table 2]. The etiology of the different types CLD is as shown in [Table 1]. When the cases were graded according to the Child-Pugh score, 17 of them were in Class A, 26 were in Class B and 17 were in Class C [Table 3],[Table 4] and [Table 5]. The performance of the different types of CLD on the sexual functions questionnaire showed that patients with HCC performed poorly in the domain of desire when compared with the control subjects P < 0.05. Patients with LC on the other hand had very poor performance in the domain of satisfaction when compared with the control subjects P < 0.05 [Table 2]. When the patients were divided into the various grades of liver disease severity using the Child-Pugh score, there was a progressive decline in the sexual functions of patients from Grade B to C showing that worsening liver disease impacts negatively on sexual functions [Table 4]. There was no difference in the performance of patients in Child-Pugh Class A and the control subjects in all the domains of the sexual function questionnaire. Patients in Child-Pugh Class B on the other hand performed poorly in the domain of arousal compared with the control subjects P < 0.05. Patients in Child-Pugh Class C performed poorly in many of the domains of the sexual functions questionnaire, namely those of erection, orgasm, resolution and satisfaction and all these were statistically significant when compared with controls (P < 0.05).
|Table 3: Sexual functions of patients in Child - Pugh Class A and controls|
Click here to view
|Table 4: Sexual functions of patients in Child - Pugh Class B and controls|
Click here to view
|Table 5: Sexual functions of patients in Child - Pugh Class C and controls|
Click here to view
| Discussion|| |
In this study, sexual dysfunction occurred in patients with advanced liver disease like LC and HCC and this agrees with a previous study among Caucasians.  Though sexual dysfunction has been demonstrated in patients with liver disease independent of alcohol etiology; similarly this has also been demonstrated in patients with CLD which are of dual etiology, alcohol and hepatitis B infection. This has further confirmed previous reports that sexual dysfunction occur in CLD of both alcohol and non-alcohol etiology. ,,
This form of sexual dysfunction may be peculiar to our environment where sometimes the two types may occur together. The degree of sexual dysfunction seen in this study increased progressively with increasing liver disease severity as graded by the Child-Pugh score. This shows that advanced liver disease impacts negatively on sexual function. This finding agrees with reports in the literature. , The discomfort of abdominal distension due to ascites and sometimes pain associated with HCC may also have contributed to these patients sexual dysfunction, besides diuretic therapy as well as in those taking other drugs.
The poor sexual performance of these patients with advanced liver disease could also have been due to other factors such as hormonal problems, besides pain, discomfort and drugs. Zifroni et al.,  as well as Cornely et al.,  found reduced total and free testosterone levels in patients with liver disease having Child-Pugh Grades B and C and alcoholic LC respectively in their studies of CLDs which may have accounted for their low sexual performance. Similarly Wang et al.,  on the other hand also found reduced testosterone in hepatitis B cirrhotic men thus linking reduced sexual performance to reduced testosterone level. In this study, we did not assay for testosterone level and as such we may not be able to say this could have been the cause of their low sexual performance, especially in those with advanced liver disease.
The quality-of-life of patients with advanced or decompensated CLD is generally poor and this might also have affected their physical functions like their sexual activity.  The sexual performance of the patients with CHB was apparently not affected, even though they had biochemical evidence of CLD. The reason for this may not be unconnected with the fact that they had very few or no symptoms and as such their sexual performance were not affected. A study has reported the absence of sexual dysfunction in patients with chronic hepatitis B especially stable non decompensated cases.  Thus our finding supports previous reports. Though patients with chronic hepatitis B have reduced quality-of-life but this may not affect their sexual performance.  Again since these are in the early stages of the disease that is, Child-Pugh Grade A, patients with early disease have been documented not to have any sexual dysfunction;  though many of these harbor liver disease in varying degrees.  The patients with HCC had poor sexual desire when compared with controls and this was statistically significant. A study by Steel et al.,  however did not find any difference in the sexual performance of patients with HCC and other types of CLDs and the general population. HCC occurs on a background of LC in Nigeria.  Lack of sexual desire and erectile functions have been documented as the most common sexual problems in patients with alcoholic cirrhosis by Jensen et al.  The patients with LC in this cohort had reduced sexual desire and erectile functions, though this did not reach statistical significance, it is not surprising therefore that patients with HCC also had poor sexual desire. Thus, poor sexual desire may be a finding among our patients with HCC because of underlying cirrhosis.
In this study, our patients could not be properly matched for BMI; the difference is not unconnected with the nature of the disease in the study group, where some of the patients had lost weight significantly especially those with HCC and some with LC. Obesity and sexual dysfunction are related,  however the difference in the BMI may not have made any difference in their sexual performance. Only one subject in the control group in our study was severely obese and the number in the moderate obesity range was almost matched.
Limitations of this study
We did not measure waist circumference alongside BMI as this may have picked some cases of obesity with normal BMI among both subjects and controls.
| Conclusion|| |
Patients with HCC have reduced sexual desire, while those with LC have reduced sexual satisfaction. Advanced liver disease in addition is associated with poor erectile functions, orgasm, resolution and satisfaction. Sexual concerns of patients with advanced liver disease should be inquired of with the aim of possible treatment.
| References|| |
|1.||Bojuwoye BJ. Chronic liver diseases in Nigeria: An overview. Dokita 1996;23:1-4. |
|2.||Seleye-Fubara D, Jebbin NJ. Hepatocellular carcinoma in Port Harcourt, Nigeria: Clinicopathologic study of 75 cases. Ann Afr Med 2007;6:54-7. |
|3.||Ndububa DA, Ojo OS, Adeodu OO, Adetiloye VA, Olasode BJ, Famurewa OC, et al. Primary hepatocellular carcinoma in Ile-Ife, Nigeria: A prospective study of 154 cases. Niger J Med 2001;10:59-63. |
|4.||Droupy S. Epidemiology and physiopathology of erectile dysfunction. Ann Urol (Paris) 2005;39:71-84. |
|5.||Pommerville P. Erectile dysfunction: An overview. Can J Urol 2003;10 Suppl 1:2-6. |
|6.||Coelho JC, Matias JE, Zeni Neto C, de Godoy JL, Canan Júnior LW, Jorge FM. Sexual function in males undergoing liver transplantation. Rev Assoc Med Bras 2003;49:413-7. |
|7.||Cornely CM, Schade RR, Van Thiel DH, Gavaler JS. Chronic advanced liver disease and impotence: Cause and effect? Hepatology 1984;4:1227-30. |
|8.||Toda K, Miwa Y, Kuriyama S, Fukushima H, Shiraki M, Murakami N, et al. Erectile dysfunction in patients with chronic viral liver disease: Its relevance to protein malnutrition. J Gastroenterol 2005;40:894-900. |
|9.||Child CG, Turcotte JG. Surgery and portal hypertension. In: Child CG, editor. The Liver and Portal Hypertension. Philadelphia: Saunders; 1964. p. 50-64. |
|10.||Pugh RN, Murray-Lyon IM, Dawson JL, Pietroni MC, Williams R. Transection of the oesophagus for bleeding oesophageal varices. Br J Surg 1973;60:646-9. |
|11.||Bannister P, Oakes J, Sheridan P, Losowsky MS. Sex hormone changes in chronic liver disease: A matched study of alcoholic versus non-alcoholic liver disease. Q J Med 1987;63:305-13. |
|12.||Zifroni A, Schiavi RC, Schaffner F. Sexual function and testosterone levels in men with nonalcoholic liver disease. Hepatology 1991;14:479-82. |
|13.||Jensen SB, Gluud C. Sexual dysfunction in men with alcoholic liver cirrhosis. A comparative study. Liver 1985;5:94-100. |
|14.||Durazzo M, Premoli A, Di Bisceglie C, Bo S, Ghigo E, Manieri C. Male sexual disturbances in liver diseases: What do we know? J Endocrinol Invest 2010;33:501-5. |
|15.||Wang YJ, Wu JC, Lee SD, Tsai YT, Lo KJ. Gonadal dysfunction and changes in sex hormones in postnecrotic cirrhotic men: A matched study with alcoholic cirrhotic men. Hepatogastroenterology 1991;38:531-4. |
|16.||Otegbayo JA, Yakubu A, Akere A, Igetei R, Aje AO. Quality of life among primary liver cell carcinoma patients in Ibadan, Nigeria. Afr J Med Med Sci 2005;34:51-4. |
|17.||Simsek I, Aslan G, Akarsu M, Koseoglu H, Esen A. Assessment of sexual functions in patients with chronic liver disease. Int J Impot Res 2005;17:343-5. |
|18.||Ndububa DA, Ojo OS, Adekanle O, Adetiloye VA, Famurewa OC, Aladegbaiye AO. Prevalence of liver disease in Nigerian asymptomatic HBsAg carriers-A preliminary report. Paper Presented at Second Scientific and Annual Meeting of the Society for Gstroenterology and Hepatology, Benin, 2009; Nigeria. Book of Abstract Page 12. |
|19.||Steel J, Hess SA, Tunke L, Chopra K, Carr BI. Sexual functioning in patients with hepatocellular carcinoma. Cancer 2005;104:2234-43. |
|20.||Bajos N, Wellings K, Laborde C, Moreau C, CSF Group. Sexuality and obesity, a gender perspective: Results from French national random probability survey of sexual behaviours. BMJ 2010;340:c2573. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]