Our key results are that after THA patients experienced less pain and an improvement in hip range of motion. The patients resumed their sexual activities after 6 weeks, and 89% of patients expressed a desire for more detailed and specific information on the subject. Likewise, the two main causes of difficulty in sexual activity before surgery were pain and limitation of the range of motion on the hip joint. After 4 years follow-up our patients presented a significant improvement of the mHHS from 34.1 preoperative to 92.6 after THA.
We conducted a retrospective study for which we developed and used a web-based questionnaire (via SurveyMonkeyâ). The reason for this decision is that in our society talking about sex is still a sensitive and embarrassing topic, so a direct interview with the patient may be less methodologically biased, but it is more difficult for patients to answer these questions personally and directly (6,15).
The topic of sexual problems in the quality of life, in relation to stress or unhappiness in the relationship, is more easily and frankly mentioned when alone or not in the presence of another person. However, in this type of questionnaire, there is a risk that the patient may interpret the questions differently, so special emphasis should be placed on keeping the questions simple and with closed answers. Our response quote was 78.3%, which is, , one of the highest (30 – 80%)(6,7,11,15).
Historically, THA has been associated with improvement of the patient-reported outcome measurements (PROMs), and the development of surgical techniques and implants has led to an increase in patient expectations and postoperative improvement, with substantial attention given to biodynamic joint reconstruction for improved hip range of motion, resulting also in increased physical activity after surgery.
Concerning PROMs, the mean postoperative mHHS after one year in the general population was 88.6 (preoperative 50.8) points(16). Patients who underwent THA under 40 years of age after 4 years follow-up showed a significant improvement of the mHHS from 34.1 preoperative to 92.6 after THA (17). Patients with a mean age of 31 years of age showed a mean postoperative Harris Hip Score (HHS) of 84.6 points at 7 year follow-up(18). Our data was in line with these results, even when our patient cohort was slightly older(16,19,20).
52% of the included patients reported some grade of difficulty with sexual activity after onset of symptoms which was slightly lower than reported rates in the literature(21). In our study the two main causes of difficulty were referenced primarily to pain and limitation of the range of motion on the hip joint, while other studies also report fatigue and negative body image (2,3,6,11,15).
On the basis of the SHIM questionnaire, none of our patients suffered of ED.
50% of patients reported difficulties during sex. What is remarkable here, the main cause of difficulty was back and/or hip pain. Additionally, patients resumed their sexual activities after 6 weeks. This all can be presumed because of the need of less joint mobility during sex (less abduction and external rotation, which are initially limited). In addition, patients who underwent surgery with a direct anterior approach, present less risk of early postoperative dislocation, due to the preservation of the periarticular stabilizing structures (22).
In many studies THA showed beneficial effects in the increase of the frequency of sexual activity after surgery (7,11,23–26). Our study does not show a significant increase in the frequency of sexual activity, as well as in the coital position before and after surgery, presumably due to the fact that the patients, because of the same discomfort before surgery, became accustomed to other coital positions that they maintained after THA.
One study reported a decrease in sexual desire before surgery, presumably because of an antalgic posture during sex, which in an attempt to modify positions may have a severe effect in the spinal column resulting in fatigue and decrease in sexual desire. Our population didn’t report loss of libido as a relevant cause (7).
For positions in which the patient raises the hip ROM, it could be shown that the risk of dislocation and impingement increases (3). Another study could demonstrate that after surgery patients implicitly preferred positions with decreased hip ROM (positions with abduction and external rotation in a supine position) (12). However, patients used the same positions before and after THA (3). Our study confirmed these findings. Men's sexual positions required less mobility and could therefore be considered safer.
An additional important aspect between THA and sexual activity is the possibility of relevant information for patients, before and after surgery. In 2014 a study found that 48% of patients preferred written instructions (27). Other studies reported that most of the patients who underwent THA would profit from a detailed discussion with the orthopedic surgeon in charge (11,15). In 2004, a consensus of members of the AAHKS found that specific information was only available when the patients request for it, with a general recommendation to resume sexual activity after 1 to 3 months after THA(3). In our cohort the majority of patients obtained the information from internet, followed from medical staff and other patients with the same symptoms. Likewise our patients consider primarily for these aspects their surgeon or family doctor, and secondarily their physiotherapist, which is in concordance with other study(3), in which 89% of patients expressed a desire for more detailed and specific information on the subject. Apart from that, the few surgeons who actually discussed the issue spent an average of less than 5 minutes on the subject(3). We found that patients foremost concern about muscle weakness, surgical scar, fear of dislocation and noise from the prosthesis. Whereas a lack of understanding on the part of the partner was seen as unproblematic. A study in Korean population showed that the greatest sorrow of patients was a dislocation during sexual activity(2).
First of all, it should be mentioned that this is a web-based questionnaire survey (via SurveyMonkey), where the patient can interpret the questions differently, and that there is only the option of closed answers. Second, we included only patients who underwent uncemented short femoral stem (Nanos, Smith and Nephew) THA, that reduces our cohort considerably. Third talking about sex in our society remains a sensitive and embarrassing topic which, despite a web-based questionnaire, may lead to information bias.