Effects of Haemodialysis and Peritoneal Dialysis Treatments on Female Sexual Function and Sexual Counselling Needs

Chronic Renal Failure (CRF) is the biochemical chronic and progressive deterioration of the kidney’s fluid-solute balance regulation and metabolic and endocrine functions due to decreased glomerular filtration value [1]. CRF can be caused by hypertension, diabetes, glomerulonephritis, cystic, hereditary, congenital diseases of the kidney, interstitial nephritis/pyelonephritis, secondary glomerulonephritis/vasculitis, renal artery disease, malignancy, nephrolithiasis / obstructive nephropathy, amyloidosis, idiopathic causes [2]. Kidney failure patients account for over 10% of the world’s population. The prevalence of the disease continues to increase at a steady rate. Hemodialysis and peritoneal dialysis are the treatment modalities for this disease [3].

Patients receiving hemodialysis treatment are affected by many physical or psychological symptoms such as constipation, nausea, vomiting, diarrhea, loss of appetite, muscle cramps, swelling in the legs, dizziness, restless leg syndrome, coughing, dry mouth, dry skin, itching, difficulty concentrating, sleep problems, chest and back pain, restlessness, irritability, and sexual dysfunction [4]. Depending on the symptoms they experience, patients may have difficulty controlling their activities of daily living, recreational and social activities, lose their independence, experience early retirement, economic problems, role changes, disruption in family life, and changes in body image and self-esteem [5]. In addition, their physical and psychological condition deteriorates, their quality of life decreases, and depression may be observed [6].

Sexuality, which is an indispensable part of a healthy lifestyle and a fundamental human right and requirement, can be significantly affected in patients with CRF [7]. Sexual dysfunction is a prevalent complication in patients with chronic renal failure. Organic and psychological causes are at the root of sexual dysfunction [8]. Endocrine changes, psychosocial factors, and depression in dialysis patients impair sexual functions at various rates [9]. In addition, various factors such as anemia, uremia, frequently used antihypertensive treatments, and fatigue are also reported to cause sexual dysfunction [10]. In studies conducted with female patients, sexual complaints were reported to be high [11].

Women with CRF have been reported to have decreased desire, vaginal dryness, dissatisfaction, and increased pain during sexual intercourse [12]. Although sexual dysfunction is one of the most important stress factors in patients with renal failure, it has been addressed minimally in hemodialysis/peritoneal dialysis patients in clinical practice and research [13].

In this review, changes that may occur in the sexual function of female patients receiving hemodialysis and peritoneal dialysis treatment were discussed. In addition, recommendations are presented to increase the awareness of nurses and all health professionals about sexual health and sexual counseling, which are not given enough importance in the hemodialysis and peritoneal dialysis treatment process, and to provide sexual counseling to women.

The Effect of Hemodialysis and Peritoneal Dialysis Treatments on Female Sexual Function

Sexual dysfunctions consist of problems such as decreased sexual desire, sexual aversion disorder, arousal and orgasm disorder, dyspareunia, and vaginismus in women. In the literature, it was found that 85.6% of dialysis patients, almost all of them 91.5%, experienced sexual dysfunction. Sexual dysfunction has been found to increase in patients who experience difficulty in maintaining sleep and the accompanying symptoms of insomnia, shortness of breath, feeling uncomfortable and who still smoke [8].

Women with CRF have decreased libido and vaginal lubrication, orgasm disorder, vaginismus, dyspareunia, disruption in the menstrual cycle, decreased ovulation, polymenorrhea, menorrhagia, oligomenorrhea, amenorrhea, and infertility [14]. In these patients, amenorrhea is observed between 50-100%. Early menopause is a common condition in female patients with CRF [8]. Vaginal atrophy, vaginal dryness, decreased pubic hair, and itching may be observed in patients receiving dialysis treatment due to low serum estradiol levels [14]. Drugs such as antidepressants affect sexual functions negatively. Antidepressants may cause problems such as decreased sexual desire in women, lack of arousal or insufficient arousal, insufficient vaginal lubrication, delay in orgasm, or inability to orgasm [8].

Most individuals with end-stage renal failure have one or more additional chronic diseases. In a study conducted by Sağduyu et al. [15], it was found that 35.3% of individuals with end-stage renal failure also had another chronic disease [8,15]. The high number of chronic diseases in these diseases also causes the use of drugs that negatively affect sexual functions, such as beta-blockers, alpha-blockers, sympatholytics, vasodilators, antidepressants, H₂ receptor antagonists, and diuretics [8,16].

Depression and anxiety in female patients receiving hemodialysis and peritoneal dialysis treatment cause sexual dysfunction [8]. In a study conducted by Çelik and Acar , 15.3% of individuals receiving hemodialysis treatment were found to have severe depression [17]. In the study conducted by Ünal, it was determined that patients undergoing hemodialysis had a high level of psychological problems [18]. Depression can cause sexual dysfunctions by causing a decrease in libido and frequency of coitus [8].

While fulfilling their sexual counseling roles, nurses should first talk to the individual/couple and take the initial history, fill out the necessary forms, and then perform a physical examination and, if necessary, descriptive tests according to the history.

While taking a sexual history, a comfortable environment should be provided, privacy should be protected, the sexual partner should be included in the interview as much as possible, individuals/couples should be open to individuals/couples, and the purpose of the questions should be explained [19].

When planning counseling for sexual dysfunction in female patients receiving hemodialysis and peritoneal dialysis treatment, medications that patients should use, general health status, and psychosocial health should be taken into consideration.

It is recommended to use the model for a comprehensive assessment of sexuality and to focus on solving sexual problems [20]. The use of models in the assessment of sexuality guides health professionals in facilitating the history-taking process and identifying sexual problems. Models used in the comprehensive assessment of sexuality;

1-ALARM (A= Activity, L= Libido, A= Arousal, R= Resolution, M= Medical information) model,
2-ALLOW (A= Ask, L= Legitimize, L= Limitations, O= Open up, W= Work together) model,
3-BETTER (B= Bring up the topic, E= Explain, T= Telling, T= Timing, E= Education, R= Recording) model,
4-PLISSIT and Ex-PLISSIT (Expanded PLISSIT) (P= Permission, Ll= Limited Information, SS= Specific Suggestions, IT= Intensive Therapy) models [20].

While providing sexual counseling to women who experience sexual dysfunction in Hemodialysis and Peritoneal Dialysis Treatments, The importance of sharing feelings, thoughts, and concerns with the spouse/partner should be explained; activities such as prolonged foreplay, erotic clothes, aromatic massages, erotic movies and bathing together can increase arousal before sexual intercourse should be explained; it should be stated that the sexual act does not carry any risk for women who are afraid of starting sexual intercourse, It should be stated that food, alcohol intake, and exercise should be avoided from 1-3 hours before sexual intercourse, stimulation of erogenous zones (breast, nipple, around the ear, legs, neck, groin, clitoris in women) increases orgasm, women should be informed about determining the most stimulated area during sexual intercourse and sharing it with their partner.

Strengthening the muscle structure of the vaginal area will also contribute to orgasm. Kegel exercise strengthens the perineal muscles and contributes to increased arousal and orgasm in sexual activity. The importance of the Kegel exercise should be explained to women, and their practice should be ensured. Especially the use of lubricants also increases comfort by eliminating vaginal dryness during sexual intercourse. Lubricants can be applied to the vulva, vagina, penis, or all three [21].

In Hemodialysis and Peritoneal Dialysis Treatments, which bring significant changes in the lives of individuals, changes in female sexual function, concerns, and fears of women lead to deterioration in sexual function. Therefore, it is essential to provide sexual counseling to women during the dialysis process. However, sexual counseling is often ignored due to reasons such as a lack of knowledge about sexual function, hesitation to talk about sexual issues, or thinking that patients do not need it. By increasing the level of knowledge and awareness of nurses and other health professionals about sexual health, it should be ensured that patients have a better sexual life and improve their quality of life during the Hemodialysis and Peritoneal Dialysis treatment process. Considering the individual characteristics of women receiving hemodialysis and peritoneal dialysis treatment, providing education, care, and social support to patients and their families may be recommended with a patient-oriented approach.

The study was presented orally at the Beykent 4th International Health Sciences Research Days Congress, which was held between 22 and 24 February 2024.

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