New research is helping couples find the most comfortable sexual positions to minimize their pain.

Sexual problems affect an alarming number of patients with chronic pain, yet are an overlooked and undertreated aspect of care. While sexual health often is discussed with patients in the context of infectious diseases, these discussions do not occur often in the management of musculoskeletal disability.

Fortunately, there are a variety of strategies to help physicians discuss sexual function and make sex satisfying again for patients with chronic pain.

Sexual dysfunction in this population may stem from various causes, including pain exacerbation during sexual activity, lack of arousal, lack of orgasm, sexual issues secondary to the use of opioids and other commonly-used medications (eg, certain antidepressants and cardiovascular medications), a history of sexual abuse, and intimacy/communication issues.1-3

The Scope of the Issue

In surveys of patients with low back pain, for example, nearly 50% of patients reported that pain affects their sexual enjoyment, 72% reported having sex less frequently following the onset of back pain, 70% found their sex life less satisfying after the onset of back pain, and 61% said that their back pain made their relationship with their partner more difficult.4,5

Despite this high rate of sexual issues, nearly 67% of patients had never discussed the impact of their back pain on sexual function with their spine specialist, most commonly because the patients were uncomfortable discussing the subject or because the doctor did not raise the issue.5 Further compounding the problem, 56% of patients who did discuss the impact of back pain on sex with their physician reported that the conversation was not helpful.5

Importance of Addressing Sexual Dysfunction In Chronic Pain

Sexual activity plays an important role in quality of life and is considered an integral factor in the World Health Organization’s classification of disability and health.6 Thus, the influence of sexual dysfunction on health has important implications for the more than 120 million Americans with chronic pain.

Importantly, sexual activity may reduce pain levels by stimulating an analgesic process that is separate from distraction. Referring to research by Beverley Whipple,7 Hilda Hutcherson, MD, Professor of Obstetrics and Gynecology at Columbia University College of Physicians and Surgeons, in New York City, told PPM that orgasm raises the pain threshold such that “people who had pain found that they lowered their amount of pain with orgasm.” Dr. Hutcherson noted that in her practice, she recommends “that female patients who have chronic pain issues try [masturbation] to obtain orgasms to see if it helps.”

Sexual functioning also mediates the association between depressive symptoms and pain intensity.8 In addition, discussions of sexual history may elicit information about sexual abuse, which also is linked to an increased risk of chronic pain, greater pain intensity, and greater risk for addiction (Sexual Therapy for Patients With Chronic Pain).

Tips for Talking About Sex With Your Patients

“The first step is for health care providers to recognize that sex is important to all patients,” Dr. Hutcherson said. “Once you recognize this, it makes it much easier to make asking about sex just a natural, normal part of the discussion … every time you see a patient,” she added.

For practitioners who have difficulty discussing sexual activity with patients, putting questions related to sexual functioning on standard intake forms is one way to approach the topic. “Included in that set of questions would be, ‘How is your sex life? Are you having any difficulties sexually? Are you satisfied?,’” Dr. Hutcherson said.

Strategies for Making Sex Satisfying Again for Your Patients

Offer Advice on Positions

For patients whose pain is exacerbated by specific positions and postures, choose positions that put less pressure on the area that causes pain and use pillows to support that area, Dr. Hutcherson said.

“For my female patients with pelvic pain, I find that often a side-to-side position or a sitting position tends to give less pain …. One of the benefits of using pillows for support is that sometimes a patient will discover new areas of the body that are stimulated, because people tend to have sex the same way their entire lives,” Dr. Hutcherson said.

For pain that is more severe or is exacerbated by intercourse, such as chronic pelvic pain, Dr. Hutcherson recommends other ways for couples to have sexual pleasure without intercourse. “I try to get them to think about oral sex or mutual/individual masturbation, use of a sex toy, fantasy, and massage,” Dr. Hutcherson said.

Insights from recent biomechanical studies suggest that certain positions are better than others for patients with chronic low back pain.9,10 The researchers recruited 10 heterosexual couples to have sexual intercourse in a controlled laboratory setting while fitted with remote sensors that tracked how their spines moved in 5 common sexual positions.

Infrared and electromagnetic motion capture systems showed how the men and women flexed and extended their backs as well as when core and gluteal muscles were activated in each position.

“There are so many different types of back pain and so many different ways that people experience back pain symptoms,” noted lead author of the studies, Natalie Sidorkewicz, a PhD candidate at the University of Waterloo, Ontario. “Our studies have allowed us to develop general guidelines for people with low back pain as well as more specific guidelines for common subtypes of back pain,” according to Ms. Sidorkewicz, who collaborated on this study with Stuart McGill, PhD, Professor of Kinesiology, University of Waterloo.

For patients trying to have spine-sparing sex who are in control of the movements, “the general recommendation is to try to use more hips and knees versus thrusting the spine to get that movement,” Ms. Sidorkewicz told PPM.

“For patients who aren’t controlling the movement, the goal is to help people find ways to keep a more neutral spine position. For example, for men or women who are lying on their back during sex, an easy way to keep more of that neutral spine position is putting a rolled up towel behind their back. Another example is for women to be in a tabletop position while keeping a bit of an arch in their back for a neutral spine position,” Ms. Sidorkewicz said.

More-specific recommendations based on whether the back pain is triggered by flexion or extension are shown in the Table.

“We now have scientific data to suggest specifically which sexual positions are the safest and most comfortable for low back pain patients, with a biomechanical explanation,” Ms. Sidorkewicz said. The researchers are hoping that the findings will help facilitate conversations on this topic between the patient and practitioner. Physicians who are uncomfortable having these discussions verbally now can provide patients with a resource on sexual positions that is based on more than just clinical experience.

Prepare in Advance

“It is important for patients to understand that sexual activity often takes a lot of planning. There is not as much spontaneity as there used to be,” Dr. Hutcherson said. Patients may need to plan ahead to take their pain medication, apply heat, or stretch before sexual activity. “However, while patients are preparing for it, they can use that time to increase their arousal by reading erotica, watching a video, or having their partner give them a massage in the area of their pain,” Dr. Hutcherson said.

“I recommend choosing the time of day when you have less pain as a time to be sexually active. For some people as the day goes on, the pain gets worse, but the opposite also may be true” for other patients, Dr. Hutcherson said.

Refer Patients for Sexual Therapy

When physicians are not experienced or do not have the time to work with patients who have sexual issues, referral to a sexual therapist or psychologist trained in sexual therapy is warranted. In addition, referral to sexual therapy should be the next step for patients who have tried different positions and strategies without relief or whose issues are causing relationship difficulties, Dr. Hutcherson said.

Options for Opioid-Induced Hormone Suppression

Opioids can have hypogonadal and androgen-inhibiting effects, which can lead to sexual dysfunction in both men and women. Symptoms of opioid-induced hormone suppression may include decreased sexual desire, impotence, infertility, depression, anxiety, loss of muscle strength/mass, and menstrual irregularities.1,11

In a recent cross-sectional study of more than 11,300 men with back pain, long-term use of opioids was associated with a significantly greater likelihood of taking medications for erectile dysfunction or testosterone replacement therapy compared with no opioid use (odds ratio, 1.45; P<0.01).12

Thus, physicians should counsel patients about the potential adverse effects of opioids on sexual functioning before prescribing these agents and should routinely evaluate patients for endocrine deficiency, including sexual dysfunction. Management options for opioid-induced hormone suppression should include testosterone and hormone replacement and switching to a different opioid that is not likely to impact hormone levels.11 Stopping opioids or reducing the dose would be a last resort.

Take Away Message

“I think it is important for patients to realize that sex is good for them and is part of the human experience,” Dr. Hutcherson concluded. “I tell patients ‘you deserve a good sex life, and there are things that can be done to help you. Speak up and get answers to the questions you have, so you can continue to have a good sex life.’ ”

Last updated on: November 9, 2015

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Opioid-induced Sexual Dysfunction