Sexual dysfunction worsen both the general and specific quality of life of women with irritable bowel syndrome. A cross-sectional study

doi:10.21203/rs.3.rs-2093102/v2

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Research Article

Sexual dysfunction worsen both the general and specific quality of life of women with irritable bowel syndrome. A cross-sectional study

https://doi.org/10.21203/rs.3.rs-2093102/v2

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published 27 Mar, 2023

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Background: Irritable bowel syndrome (IBS) and sexual dysfunction (SxD) lowers quality of life (QOL) separately, but the effect of their overlap in unselected populations has not been studied.

Objective: To evaluate the QOL of IBS women with and without SxD and compare it with controls.

Methods: In this cross-sectional assessment, we studied 51 IBS women (Rome IV criteria) and 54 controls. SxD was determined using the female sexual function index questionnaire. QOL was evaluated by the Short Form 36 (SF-36) and IBS-QOL questionnaires.

Results: SxD prevalence was similar between IBS women (39.22%) and controls (38.89%). Compared with other groups, IBS patients with SxD showed lower scores in all domains as well as in the physical, mental summaries of the SF-36 and almost all domains (except for body image, food avoidance, and social reaction compared with IBS patients without SxD) and the total score of IBS-QOL.

Conclusions: These findings show that SxD worsens both general and specific QOL of women with IBS. The consideration of SxD in patients with IBS will allow us to make a more effective diagnostic and therapeutic approach. Clinical trial registry in Mexico City General Hospital: DI/19/107/03/080. Clinical trials registration: NCT04716738.

Irritable bowel syndrome

sexual dysfunction

quality of life

comorbidity

Notwithstanding that different consensus may cover up its exact frequency, irritable bowel syndrome (IBS), a disorder of the brain-gut interaction;[1] affects between 3.8% (Rome IV criteria) to 9.2% (Rome III criteria) of the general population [2] being almost twice (1.7 times)[3] as frequent in women than men. Only 67.7% seek information from their doctors,[4] but it still represents between 25% and 50% of the gastroenterological consultation in the United States.[5] Regardless of the high prevalence reported in Mexico (up to 35.5%),[6] its clinical presentation is similar to the rest of the world.

IBS patients have more physical and psychological abuse problems.[7] Additionally it has been recognized that sexual abuse may be related to IBS[8] with alterations in the perception of pain.[9] Since 1987, Guthrie et.al.[10] published that up to 83% of IBS patients might have sexual dysfunction (SxD). A recent study in Poland has shown that up to 48% of IBS female patients referred to an outpatient clinic have SxD.[11] SxD has been positively associated with the severity of gastrointestinal symptoms.[12] The problem is so significant that specific self-management programs for SxD in IBS patients have been developed.[13]

On the other hand, quality of life (QOL) that reflects subjective well-being, has been demonstrated to be lower in IBS[14] and SxD.[15] Recently, Sørensen et.al.[16] have shown that SxD in IBS has been studied mostly as a secondary endpoint on QOL studies, so further studies are needed. Characterizing QOL in the unselected population suffering both conditions would be meaningful. This study aimed to evaluate the QOL of IBS women and compared it with controls, both with and without SxD.

Subjects

This cross-sectional survey was conducted according to STROBE guidelines at the Gastroenterology Service, Hospital General de Mexico “Eduardo Liceaga”, and the Iberoamerican University following the Declaration of Helsinki and its subsequent declaration revisions. Informed consent of all subjects was obtained before the interview. This study, which investigates the prevalence of SxD in IBS patients as well as its influence on the quality of life in the Mexican female population, is part of a broader protocol that is running and has been approved by the local ethics and research committees (DI/19/107/03/080), and registered in Clinical trials (NCT04716738).

We recruited consecutive sexually active women in the open population by opportunity sampling from March to September 2019. To be included, the participants must have met the following criteria: between 18–50 years, provided informed consent, and accepted to answer the questionnaires. We excluded women with non-controlled systemic disease, pregnant, breastfeeding, menopausal, taking medications regularly in the previous 3 months, and patients with an established diagnosis of other sexual and/or gastrointestinal diseases. Patients who did not accept to give contact information, did not answer the complete questionnaires, failed to understand the instructions, and/or were unreachable after the application of questionnaires, were eliminated from the study.

To avoid selection bias, we applied the questionnaires in a single interview on consecutive women, and data were entered in a spreadsheet that was not analyzed immediately. We carried out the first analysis 2 months after the start of the study for the psychology students to make a presentation at the Iberoamerican University. We carried out a second analysis in July to participate in the Mexican Congress of Gastroenterology. In November 2019, we did the last interim analysis for DDW. Finally, between July-December 2020, we made the final analysis for this article.

Irritable bowel syndrome diagnosis

We use the Rome IV criteria, which requires that abdominal pain must be presented for more than 6 months, once a week in the last 12 and at least two of these three characteristics: (a) rxelated to defecation; associated with changes in the (b) frequency of defecation and/or in the (c) appearance of stool.[17]

Through drawings of the Bristol Scale, we recorded the most frequent type of stool consistency subjectively perceived by the patient (Bristol Subjective Scale, BSS) and the percentage of time in which the patient objectively observed their different consistencies (Bristol Objective Scale, BOS). To determine the BSS, we asked which of the drawings was the one that they perceived as the most frequent. After this question, we evaluated the BOS by requesting to remember the maximum number of recent bowel movements (they mentioned between 4 and 12) and to identify feces according to the Bristol scale, and finally, we assigned a percentage to each type of evacuation. IBS subtypes: constipation (IBS-C), diarrhea (IBS-D), mixed (IBS-M), or undetermined (IBS-U); were determined with the BOS as Rome IV suggests.[17]

Sexual dysfunction evaluation

We use the Female Sexual Function Index (FSFI) which has been validated in the Mexican population.[18] With 19 items, it evaluates six domains: desire, excitement, lubrication, orgasm, satisfaction, and pain. A higher score means better function. Sexual dysfunction was determined when the total score (adding the score of each domain) was less than 26.55.[19]

QOL measurements

We used the Short-Form 36 (SF-36) questionnaire for general QOL evaluating eight domains: physical function, physical role, body pain, general health, vitality, social functioning, emotional role, and mental health. The questions were coded, summarized, and transformed to a scale from 0 (worst) to 100 (best) health statuses. Also, there is a question about the change in the general health state. We also calculated physical (PCS) and mental (MCS) component summary through an orthogonal approximation. It has been validated in the Mexican population.[20]

Specific QOL was assessed by the Irritable Bowel Syndrome-Quality Of Life (IBS-QOL) questionnaire[21] which evaluate eight domains (Dysphoria, interference with the activity, body image, health concern, food avoidance, social reaction, sexual concern, and social relationship) and a total score (the sum of all domains). Higher scores mean better QOL.

Sample size and power of the study

Because there are no previous articles to address the overlap of IBS and SxD on the QOL using the SF-36 and IBS-QOL as main outcomes on the same population, we decided to recruit consecutive women as the first approach. In a posthoc analysis (StatMate 2 for Windows, version 2.00), we found a beta power higher than 80% (with alpha < 0.05) on the size effect of the main variables (domains and total summaries of the SF-36 and IBS-QOL questionnaires), so we conclude that the sample size was enough to get statistical validity (supplementaries files A & B).

Statistical analysis

The main outcomes were the differences in domains, component summaries, and total scores of the SF-36 and IBS-QOL. Secondary outcomes were age, body mass index (BMI), marital status, pain related to menses, frequency of defecation per week, IBS subtype, and the Bristol Scale (subjective and objective). Statistical analysis was done with IBM® SPSS® Statistics, version 26 (Registered for Iberoamerican University). When appropriate data indicate mean ± standard deviation, 95 % confidence intervals (CI), range, and/or percentages. Statistical differences were evaluated by Student’s t, Mann-Whitney, Chi-square tests, and Fisher’s Exact Test with Katz approximation for relative risk (RR) when appropriate (alpha = 0.05). We analyze the correlation between BSS and BOS through the Pearson test.

From 117 women recruited, we studied 105 (89.7%) women (see flowchart, Fig. 1). Age, BMI with cut points, pain related to menses, and marital status of the total sample, IBS and SxD patients are stated in Table 1. IBS women were older and more likely to be no-singles. Weekly frequency of defecation was lower in IBS vs. controls [9.33 ± 5.85 (7.73–10.94) vs. 13.15 ± 6.89(11.31–14.99) respectively, p = 0.002] but similar in women with SxD versus without SxD [11.24 ± 6.64 (9.21–13.28) vs. 11.15 ± 6.61(9.58–12.72) respectively, p = 0.94].

Table 1

Age, BMI with cut points, pain related to menses, and marital status in total population, IBS, and SxD subgroups.
	Total (n = 105)	IBS (n = 51)	Controls (n = 54)	p	SxD (n = 37)	No SxD (n = 68)	p
Age (years)	26.65 ± 7.08 (25.29–28)	28.45 ± 7 (26.53–30.37)	24.94 ± 6.79 (23.13–26.76)	0.0106	27.76 ± 8.39 (25.05–30.46)	26.04 ± 6.25 (24.56–27.53)	0.2385
BMI (kg/m²)	22.14 ± 2.91 (21.59–22.7)	22.56 ± 2.45 (21.89–23.24)	21.75 ± 3.26 (20.87–22.62)	0.1506	21.59 ± 2.42 (20.81–22.37)	22.45 ± 3.13 (21.7–23.19)	0.1507
BMI cut points (%)
Underweight (< 18)	6.67	1.90	4.76	0.6486	3.81	2.86	0.3078
Normal (18-24.9)	81.90	41.90	40.00		29.52	52.38
Overweight I (25-29.9)	9.52	3.81	5.71		1.90	7.62
Overweight II (30-39.9)	1.90	0.95	0.95		0.00	1.90
Pain related to menses (%)	41.90	47.06	37.04	0.3277	37.84	44.12	0.6792
Marital status (%)
Single	79.05	33.33	45.71	0.0227	24.76	54.29	0.1258
Married	14.29	8.57	5.71		5.71	8.57
Divorced	1.90	1.90	0.00		1.90	0.00
Free union	4.76	4.76	0.00		2.86	1.90
Data express mean ± standard deviation (95%CI) or percentages as appropriate. IBS, irritable bowel syndrome, SxD, sexual dysfunction, BMI, body mass index. Fischer exact test or non-paired student t-test, two-sided. significant statistical differences are bolded.

Quality of life and sexual dysfunction in IBS women and controls

General and specific QOL, as well as FSFI domains of IBS and SxD patients, is shown in Table 2. There were no differences in the domains and total score of the FSFI between IBS and controls.

Table 2

General (SF-36), specific (IBS-QOL) quality of life, and Sexual Function (FSFI) in total population, IBS and SxD subgroups.
	Total (n = 105)	IBS (n = 51)	Controls (n = 54)	p	SxD (n = 37)	No SxD (n = 68)	p
SF-36
Physical Function	93.38 ± 13.02 (90.89–95.87)	90.49 ± 16.01 (86.1-94.88)	96.11 ± 8.67 (93.8-98.42)	0.0263	88.24 ± 17.61 (82.57–93.92)	96.18 ± 8.6 (94.13–98.22)	0.0025
Physical Role	83.1 ± 29.72 (77.41–88.78)	78.43 ± 32.02 (69.64–87.22)	87.5 ± 26.93 (80.32–94.68)	0.1186	77.7 ± 35.74 (66.19–89.22)	86.03 ± 25.69 (79.92–92.14)	0.1714
Body Pain	74.57 ± 21.83 (70.4-78.75)	66.72 ± 22.25 (60.61–72.82)	81.99 ± 18.79 (76.98-87)	0.0002	68.99 ± 24.05 (61.24–76.73)	77.61 ± 20.06 (72.84–82.38)	0.0527
General Health	64 ± 18.7 (60.42–67.58)	58.63 ± 18.28 (53.61–63.64)	69.07 ± 17.81 (64.32–73.82)	0.0037	59.19 ± 17.18 (53.65–64.72)	66.62 ± 19.09 (62.08–71.16)	0.0514
Vitality	52.48 ± 16.44 (49.33–55.62)	50 ± 18.3 (44.98–55.02)	54.81 ± 14.24 (51.02–58.61)	0.1343	49.19 ± 15.75 (44.12–54.26)	54.26 ± 16.65 (50.31–58.22)	0.1314
Social Functioning	74.88 ± 22.3 (70.62–79.15)	68.14 ± 23.76 (61.62–74.66)	81.25 ± 18.93 (76.2–86.3)	0.0022	67.23 ± 22.51 (59.98–74.48)	79.04 ± 21.21 (74-84.09)	0.0088
Emotional Role	63.81 ± 41.63 (55.85–71.77)	53.59 ± 42.73 (41.87–65.32)	73.46 ± 38.52 (63.18–83.73)	0.0138	53.15 ± 41.91 (39.65–66.66)	69.61 ± 40.62 (59.95–79.26)	0.0526
Mental Health	67.7 ± 15 (64.83–70.57)	64.78 ± 16.57 (60.24–69.33)	70.44 ± 12.92 (67-73.89)	0.0529	63.03 ± 14.62 (58.32–67.74)	70.24 ± 14.7 (66.74–73.73)	0.0180
Physical Component Score (PCS)	59.45 ± 10.63 (57.42–61.49)	56.21 ± 11.28 (53.12–59.31)	62.51 ± 9.06 (60.1-64.93)	0.0020	56 ± 11.54 (52.28–59.72)	61.33 ± 9.67 (59.03–63.63)	0.0133
Mental Component Score (MCS)	45.16 ± 5.93 (44.02–46.29)	44.11 ± 6.78 (42.25–45.97)	46.14 ± 4.86 (44.85–47.44)	0.0791	43.89 ± 5.83 (42.01–45.77)	45.85 ± 5.91 (44.44–47.25)	0.1061
Health change (1 year, %)
Better/much better	32.38	12.38	20.00	0.0092	9.52	22.86	0.0097
Same	54.29	24.76	29.52		16.19	38.10
Worst/much worst	13.33	11.43	1.90		9.52	3.81
IBS-QOL
Dysphoria	87.62 ± 19.75 (83.84–91.4)	79.72 ± 23.99 (73.13–86.3)	95.08 ± 10.29 (92.34–97.83)	0.0000	79.9 ± 24.88 (71.88–87.91)	91.82 ± 14.91 (88.28–95.36)	0.0027
Interference with the activity	86.19 ± 19.77 (82.41–89.97)	77.87 ± 22.63 (71.66–84.08)	94.05 ± 12.41 (90.74–97.36)	0.0000	78.28 ± 23.65 (70.66–85.9)	90.49 ± 15.9 (86.72–94.27)	0.0021
Body image	80.24 ± 21.32 (76.16–84.32)	69.73 ± 22.34 (63.6-75.86)	90.16 ± 14.65 (86.25–94.07)	0.0000	75 ± 25.04 (66.93–83.07)	83.09 ± 18.58 (78.67–87.5)	0.0630
Health concern	79.13 ± 25.19 (74.31–83.95)	66.34 ± 27.13 (58.89–73.79)	91.2 ± 15.65 (87.03–95.38)	0.0000	72.07 ± 30.25 (62.32–81.82)	82.97 ± 21.23 (77.92–88.01)	0.0336
Food avoidance	72.86 ± 27.71 (67.56–78.16)	58.01 ± 29.39 (49.94–66.07)	86.88 ± 16.71 (82.42–91.34)	0.0000	65.54 ± 34.37 (54.47–76.61)	76.84 ± 22.62 (71.46–82.21)	0.0454
Social reaction	85.65 ± 21.41 (81.56–89.75)	77.33 ± 24.87 (70.5-84.15)	93.52 ± 13.63 (89.88–97.15)	0.0001	78.89 ± 25.36 (70.71–87.06)	89.34 ± 18.07 (85.04–93.63)	0.0161
Sexual concern	91.07 ± 17.91 (87.65–94.5)	85.05 ± 22.5 (78.87–91.22)	96.76 ± 9.15 (94.32–99.2)	0.0006	85.14 ± 21.62 (78.17–92.1)	94.3 ± 14.72 (90.8–97.8)	0.0115
Social relationship	86.9 ± 21.27 (82.84–90.97)	79.25 ± 24.8 (72.44–86.05)	94.14 ± 14.08 (90.38–97.89)	0.0002	80.18 ± 25.64 (71.92–88.44)	90.56 ± 17.63 (86.37–94.75)	0.0161
Overall Score	84.31 ± 18.89 (80.7-87.93)	75.06 ± 21.29 (69.21–80.9)	93.06 ± 10.59 (90.23–95.88)	0.0000	77.25 ± 23.68 (69.62–84.88)	88.16 ± 14.49 (84.72–91.6)	0.0042
FSFI Domains
Desire	3.82 ± 1.16 (3.59–4.04)	3.82 ± 1.05 (3.53–4.11)	3.81 ± 1.27 (3.47–4.15)	0.9567	2.89 ± 1.23 (2.49–3.28)	4.32 ± 0.74 (4.15–4.5)	0.0000
Excitement	4.19 ± 1.75 (3.86–4.53)	4.34 ± 1.47 (3.93–4.74)	4.06 ± 1.98 (3.53–4.58)	0.4146	2.44 ± 1.81 (1.86–3.03)	5.14 ± 0.59 (5-5.28)	0.0000
Lubrication	4.26 ± 1.84 (3.91–4.61)	4.46 ± 1.58 (4.03–4.9)	4.07 ± 2.04 (3.53–4.62)	0.2756	2.51 ± 2 (1.87–3.16)	5.21 ± 0.69 (5.05–5.38)	0.0000
Orgasm	4.09 ± 1.96 (3.72–4.47)	4.29 ± 1.74 (3.81–4.77)	3.9 ± 2.15 (3.33–4.48)	0.3150	2.14 ± 1.91 (1.53–2.76)	5.15 ± 0.87 (4.95–5.36)	0.0000
Satisfaction	4.7 ± 1.27 (4.46–4.95)	4.72 ± 1.25 (4.38–5.06)	4.69 ± 1.3 (4.34–5.04)	0.8958	3.51 ± 1.27 (3.1–3.92)	5.35 ± 0.65 (5.2–5.51)	0.0000
Pain	4.05 ± 2.01 (3.66–4.43)	4.38 ± 1.74 (3.9–4.85)	3.74 ± 2.21 (3.15–4.33)	0.1057	2.11 ± 2.12 (1.42–2.79)	5.11 ± 0.8 (4.91–5.3)	0.0000
FSFI Total Score	25.12 ± 8.69 (23.46–26.78)	26.01 ± 7.45 (23.97–28.06)	24.27 ± 9.71 (21.68–26.86)	0.3074	15.6 ± 7.95 (13.04–18.16)	30.29 ± 2.45 (29.71–30.88)	0.0000
Data express mean ± standard deviation (95%CI) or percentages as appropriate. IBS = Irritable Bowel Syndrome, SxD = Sexual dysfunction. Fischer Exact test or Non-Paired Student t-Test, two-sided. Significant statistical differences are bolded.

General QOL (SF-36)

IBS women of our study show lower scores in the domains of body pain, general health, and emotional role meanwhile SxD women showed a difference in mental health. Both diseases have lower scores for physical function, social functioning, PCS, and deterioration in health compared with the previous year.

Specific QOL (IBS-QOL)

IBS women showed lower scores on the eight domains and total score meanwhile SxD patients showed lower scores on seven domains (except body image) and total score.

Overlap of IBS and SxD

IBS patients without SxD patients showed a higher BMI than SxD women. Patients with both diseases were older than controls, reported lower PCS and MCS, and showed health deterioration (Table 3). The IBS-QOL total score was lower in IBS women than controls, and additionally, IBS women with SxD showed the lowest score even vs IBS without SxD patients.

Table 3

Age, body mass index (BMI), physical and mental components scores and health change of the SF-36 and total score for IBS-QOL questionnaire between irritable bowel syndrome (IBS) women, controls (Ctl) with and without Sexual Dysfunction (SxD) subgroups
	IBS with SxD (n = 19)	IBS without SxD (n = 32)	Ctl with SxD (n = 18)	Ctl without SxD (n = 36)
Age (years)	30.42 ± 9.09 (26.33–34.51)	27.28 ± 5.22 (25.47–29.09)	24.94 ± 6.72 (21.84–28.05)*	24.94 ± 6.93 (22.68–27.21)*
BMI (Kg/m²)	21.68 ± 2.28 (20.66–22.7)#	23.09 ± 2.43 (22.25–23.93)	21.49 ± 2.62 (20.28–22.7)#	21.87 ± 3.57 (20.71–23.04)
SF-36
Physical Component Score	50.05 ± 10.2 (45.46–54.64)	59.87 ± 10.37 (56.28–63.47)*	62.28 ± 9.51 (57.89–66.67)*	62.63 ± 8.96 (59.71–65.56)*
Mental Component Score	41.51 ± 5.74 (38.93–44.09)	45.65 ± 6.96 (43.24–48.07)*	46.4 ± 4.92 (44.12–48.67)*	46.02 ± 4.89 (44.42–47.61)*
Health change (1 year, %)
Better/much better	15.79	31.25	38.89	38.89
Same	36.84	59.38	55.56	58.33
Worst/much worst	47.37	9.38*	5.56*	2.78*
IBS-QOL
Total Score	65.05 ± 24.23 (54.16–75.95)	81 ± 17.11 (75.07–86.93)*	90.11 ± 14.98 (83.19–97.03)*#	94.53 ± 7.36 (92.12–96.93)*#
Data express Mean ± Standard Deviation (95%CI). Fischer Exact test or Non-Paired Student t-Test, two-sided. * p < 0.05 vs. IBS with SxD. # p < 0.05 vs IBS without SxD.

Patients with IBS and SxD showed lower scores in the eight domains of the SF-36 (Fig. 2) and on five domains (except for body image, food avoidance, and social reaction that showed no differences compared with IBS women without SxD) of the IBS-QOL (Fig. 3).

IBS subtype analysis

Twenty-four (47.06%) patients were IBS-U type, 20 (39.22%) were IBS-C, 7 (13.73%) were IBS-D, and there were no IBS-M. No differences (p > 0.05) were found in SxD prevalence between IBS-U (29.17%), IBS-C (45%), and IBS-D (42.86%). IBS-C patients showed lower scores on physical function, general health, vitality, social functioning, and mental health domains than IBS-U (supplementary file C).

PCS was higher in IBS-U [61.7 ± 8.47 (58.32–65.09)] compared to IBS-C [50.62 ± 11.94 (45.38–55.85), p = 0.0008], but not with IBS-D [53.38 ± 9.94 (46.02–60.74), p = 0.5]. There were no differences (p > 0.05) in MCS between IBS-U [44.82 ± 6.77 (42.12–47.53)], IBS-D [45.29 ± 5.26 (41.4–49.19)], and IBS-C [42.84 ± 7.35 (39.62–46.06)]. Worst/much worst health change perception showed no difference (p > 0.05) within a year between IBS-U (12.5%), IBS-D (28.57%) or IBS-C (35%) groups.

Supplementary file D shows the lower specific quality of life of the eight domains in IBS-C women compared with IBS-U. Total score was lower in IBS-C [64.89 ± 25.26 (53.82–75.96)] compared with IBS-U [85.72 ± 10.41 (81.56–89.89), p = 0.0006] but not with IBS-D [67.54 ± 21.83 (51.37–83.71), p = 0.8].

Virtually all participants [total population (84%), IBS patients (84%), and controls (83%)] showed concordance between BSS and BOS (p > 0.3). Likewise, total population (r = 0.83), IBS patients (r = 0.9) and controls (r = 0.72) showed a direct correlation (p < 0.01) between BSS and BOS.

Predictive factors

Singleness decreases the RR of IBS on 0.772 (p = 0.01) but not for SxD (RR = 0.626, p = 0.1). BMI does not affect the IBS (RR = 1.3, p = 0.3) nor SxD (RR = 1.1, p = 0.7) women. Pain related to menses shows no differences between IBS versus controls (47.06% vs. 37.04% respectively; RR = 0.8, p = 0.3) nor SxD positive and negative (37.84% vs. 44.12% respectively; RR = 1.1, p = 0.6) group. The BSS type 3,4 and 5 were protective factors associated for IBS vs. controls (62.75% vs. 87.04% respectively; RR = 0.5543, p = 0.006).

Our study suggest that female SxD worsens both the general and the specific QOL of IBS.

We found that almost three out of ten women have SxD (IBS and control alike), which is lower than previously reported (48%).[11] We believe that our study reflects more accurately the prevalence of SxD because they recruited patients from an outpatient clinic and we from an open population.

IBS women were older than controls. These findings disagree with the literature data that shows a small protective factor in older than 50 years.[22] Apart from the fact that our population was younger than 50 years, a recent review shows that this difference is maintained in western countries but not in Taiwan, suggesting an alternate component (such as comorbidity).[23] Our analysis is congruent with this finding because this difference disappears when comparing patients with IBS alone and controls suggesting that the presence of SxD is more frequent in older IBS patients. Despite IBS patients without SxD having higher BMI versus IBS patients with SxD, BMI was in the normal range in all groups, which is congruent with the literature.[24]

Pain-related to menses shows no differences. Premenopausal IBS women report worsening of symptoms during menstruation compared with their follicular phase,[25] like healthy controls that report abdominal pain more frequently during menses.[26] These manifestations are believed to be caused by sexual hormonal changes. We did not compare sexual cycle phases; however, we can infer that the decrease in QOL is not associated with pain related to menses.

IBS is more common in women who have had or have partner relationships. This is congruent with a study that finds that married individuals had an increased odds ratio of IBS than non-married (OR = 1.19).[27] To our knowledge, this is the first report of singleness as a protective factor (22.7%) to develop IBS.

Our IBS patients showed a lower weekly frequency of defecation which is consistent with alterations in bowel movement as a diagnostic feature of IBS.[17] Interestingly, this difference disappears in SxD women, which perhaps indicates that the frequency of defecation does not influence SxD, a characteristic not reported hitherto. Consistently, IBS patients showed no difference on the FSFI questionnaire which suggest that SxD is not influenced by IBS in non-selected population although it has been reported lower scores on IBS outpatients.[11] This difference may be explained by the fact that; for example, IBS-C outpatients are predisposed to report more frequently comorbidities to an obstetrician/gynecologist; than other conditions, like inflammatory bowel disease.[4]

There was a direct correlation between subjective perception and objective remember of feces consistency which validates its clinical use. This outcome is consistent with previously reported findings.[28] We find out a protective factor of BSS 3,4 and 5 (50%) for IBS, a finding not reported previously.

When comparing general QOL of IBS and SxD women separately, they share a deterioration in physical function and PCS, suggesting a common pathophysiological characteristic that would explain the poor subjective well-being perception. These findings agree with a recent study of patients with major depressive disorder treated with antidepressant drugs in which symptom responders showed an increase of functional connectivity in the dorsal anterior cingulate cortex (dACC) relative to non-responders with improvement in physical QOL.[29] It has been demonstrated that SxD decreases brain activity of the dACC,[30] and IBS patients also show a decreased amplitude of low-frequency fluctuation in dACC.[31] We believe this is an interesting route to study for later research.[32] IBS-QOL has lower scores in IBS patients and it is almost similar in SxD women (except for body image). This finding is congruent with those previously reported.[16]

QOL is particularly important for IBS not only as a diagnostic or pathophysiological feature but also as a prognostic effectiveness factor. Latest clinical guidelines consider QOL and comorbidity as indicators for healthcare-seeking behavior and consequently as a diagnostic-therapeutic goal.[33] Our study adds a supporting feature for this strategy. Because SxD significantly decreases the general and specific quality of life, we ought to change the objectives to treat the SxD simultaneously as the main comorbidity of women with IBS to adopt an approach based on patient-centered medicine as a recent review sustains.[34]

IBS subtype analysis shows a similar prevalence of SxD, but IBS-C patients have a lower score on five domains than IBS-U. Because of the small sample, we are unable to make a definitive conclusion, but this approach will be interesting to investigate in future work.

Our study has some limitations to consider. We did not exhaust evaluation on clinical IBS or SxD. Although the diagnosis of IBS is clinical and the Rome IV criteria are enough to diagnose it, the possibility that abdominal pain may be secondary to another disease is latent. If we do not make a general laboratory evaluation, we will not be sure of the presence of IBS. Similarly, SxD requires a thorough psychiatric evaluation to determine which of the possible subtypes is present. Our approach was in the open population, so we only trusted what was declared per person and used self-administered questionnaires.

Sexual dysfunction could worsen both the general and the specific quality of life of irritable bowel syndrome women. Further investigation on clinical and pathophysiology mechanisms is needed to elucidate the relationship between both diseases if they have a common mechanism that explains this low quality of life. Considering sexual dysfunction in women with irritable bowel syndrome will allow us to make a more effective diagnostic and therapeutic patient-centered approach.

IBS: Irritable Bowel Syndrome, SxD: Sexual Dysfunction, QOL: Quality of Life, SF-36: Short Form 36 questionnaire, IBS-QOL: Irritable Bowel Syndrome-Quality of Life questionnaire, BSS: Bristol Subjective Scale, BOS: Bristol Objective Scale, dACC: Dorsal Anterior Cingulate Cortex.

Ethics approval and consent to participate: This study has been approved by the Mexico General Hospital ethics and research committees (DI/19/107/03/080) and registered in Clinical trials (NCT04716738).

Patient consent statement: All patients provided informed consent.

Consent for publication: Not applicable.

Availability of data and materials: The datasets used and/or analyzed during the current study available from the corresponding author on reasonable request. The raw data exclusive for review can be accessed here: https://data.mendeley.com/datasets/8mjftnssx4/draft?a=fe9d5569-8a28-4fda-b541-50f8eb319676

Competing interest: We declare no conflict of interest.

Funding: None.

Authors' contributions: SC had the original idea, was involved in the acquisition of the data, the execution of the protocol, the evaluation of the results, the statistical analysis, and the drafting of the manuscript. AD and PP were involved in the original idea, patient recruitment, and acquisition of data being undergraduate students of psychology. HB and YF were involved in patient recruitment, acquisition of data, and statistical analysis while they did their social service in medicine. EA participated in the design, analysis of the results, and drafting of the manuscript. MFHT, DM, and LGL participated in the design, evaluation of the results and drafting of the manuscript. All authors have seen and approved the final version of the report.

Acknowledgments: We thank MAPI Institute for their consent to use the IBS-QOL questionnaire free of charge for this study. We also thank Javier Reyes-Mendez for his administrative support.

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No competing interests reported.

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Sexual dysfunction worsen both the general and specific quality of life of women with irritable bowel syndrome. A cross-sectional study

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Abstract

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Background

Methods

Subjects

Irritable bowel syndrome diagnosis

Sexual dysfunction evaluation

QOL measurements

Sample size and power of the study

Statistical analysis

Results

Quality of life and sexual dysfunction in IBS women and controls

General QOL (SF-36)

Specific QOL (IBS-QOL)

Overlap of IBS and SxD

IBS subtype analysis

Predictive factors

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Supplementary Files

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