Introduction

Each year more than one million patients worldwide undergo total hip arthroplasty (THA) for symptomatic hip arthritis (HA) [1]. Lavernia et al. (2015) found that HA interfered with sexual function (SF) in 82% of THA patients (mean age 65; range 20–89). Authors suggest SF should be routinely addressed with all patients undergoing THA [2]. Within fifty years of research, only a few studies have examined the impact of HA on SF and improvement of SF after THA [3–9]. Since 1991, Stern et al. (1991) found that nearly 80% of patients (who were satisfied with the THA result) felt the need for more information about SF afterwards; and in 20% sexual dysfunction (SD) had been an argument to undergo THA [4].

To our knowledge, there are only two studies published addressing SF in THA patients [7, 10]. However, these studies are small with less attention for specific views on patients’ perspectives and safety matters.

In this context, the objectives of this study were to: (i) to explore practises of orthopaedic surgeons in addressing issues of sexual function (SF) in patients before and after total hip athroplasty (THA), (ii) surgeons’ views on patients’ perspectives of SF related issues, and (iii) surgeons’ opinions on safe return to sexual activity after THA. Differences between the surgeons’ gender and occupations (residents, practising surgeons, and retired surgeons) are of interest, in order to provide useful information to encourage communication about SF in future daily orthopaedic practice.

Methods

We conducted a cross-sectional survey among a group of orthopaedic surgeons with detailed measurements of SF related issues. We collected surgeons’ opinions on patient perspectives, communication, and questions about safety matters, especially related to the safe resumption of sexual activity after THA and the surgical technique.

Development of questionnaire

A 28-item Dutch questionnaire was developed by an urologist (HE) for questioning medical disciplines; and previously used in cardiology, radiotherapy, oncology, nephrology [11–15].

This questionnaire was modified for use in orthopaedic practice by three authors (RH, PN, TH), and piloted on eight orthopaedic surgeons, five retired surgeons and 12 residents. Two questions were removed. It covers demographic questions (questions 1–7) and questions on the three objectives: (i) surgeons’ views on patients’ perspectives of SF related issues (questions 8–11); (ii) surgeons’ practises in addressing SF issues and perceived barriers to communication (question 12–16); and (iii) surgeons’ opinions on safe return to sexual activity after THA (question 17–22). Finally, there were some additional questions (questions 23–26). An in English translated version can be found in Appendix 1.

Surgeons and procedure

The 26-item modified questionnaire was posted to practising orthopaedic surgeons performing hip surgery (n = 455), retired orthopaedic surgeons (n = 149), and orthopaedic residents (n = 245) in the Netherlands. Addresses were retrieved from the member list of the Netherlands Orthopaedic Association (Nederlandse Orthopedische Vereniging, NOV). After screening on “performing hip surgery” and “living in the Netherlands” 849 addresses were retrieved. Two reminders were sent after six and 12 weeks. Data were collected and analysed anonymously. For research not involving patients, approval from an ethical board is not required in the Netherlands. Figure 1 shows the procedure for the selection of eligible respondents and response rates.

Fig. 1
figure 1

Flowchart of the study procedure

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Statistical analysis

Statistical analyses were performed using IBM SPSS, version 22 for Mac/Windows. Most responses were scored on a visual analogue scale (VAS) ranging from no effect (1) to the strongest possible effect (10). For some questions an ‘I do not know’ option was available which was coded as ‘0’ in the analyses.

The results are presented using descriptive analyses. Continuous variables were found to be not normally distributed and are therefore summarized as median (interquartile range IQR). Distributional differences between the occupations and genders were tested using Pearson’s chi-squared tests or Mann-Whitney tests and Kruskal-Wallis test. Missing data were excluded from the percentage calculations; p-values of <0.05 were considered to be statistically significant.

Results

Of the 849 questionnaires sent out, 600 (70.7%) were returned. Of these, 74 respondents chose not to participate in the study. Reasons for non-participation were: no longer actively performing surgery (n = 43; 58.1%), lack of experience (n = 21; 28.4%), not relevant (n = 6; 8.1%), not interested (n = 3; 4.1%), and no time (n = 1; 1.4%). In total 526 respondents were included in the analysis (62.0%) Table 1.

Views on patients’ perspectives of SF related issues

Table 2A shows the respondents’ views regarding four questions: (i) the impact of HA on SF, (ii) improvement of SF after THA, (iii) the importance of SD in the decision to undergo surgery, and (iv) the need for information on the safe resumption of sexual activity. To each of those four questions, approximately 10% responded with “do not know” (range 7.0–13.5%). The beneficial effect of THA on SF was rated the highest in retired surgeons (p ≤ 0.001), in which male surgeons scored higher than female surgeons (p = 0.002). The importance of SD in the decision to undergo surgery was rated lowest by residents (p = 0.020).

Table 1 Characteristics of the respondents
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Table 2 Surgeons’ views and opinions
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Opinions on a safe return to sexual activity after THR

Table 2B shows surgeons’ opinions about six factors considered to be of influence in patients’ safe resumption of intercourse. Approximately 3% of the respondents did not answer to all questions (missing range: 5–34). Compared to all categories of orthopaedic surgeons, residents thought more often that “age” influences safe resumption (p = 0.001). For per-operative stability the distribution differed between the occupations (p = 0.001), although the medians were equal.

Rating the risk for dislocation within the first three months, 69 chose the option “I do not know” (13.1%). The total cohort rated the risk at median 3 (IQR 2–6). The rating varied widely between occupations: median for practising surgeons: 3 (IQR 2–5); for residents: 4 (IQR 3–6); and for retired surgeons: 4 (IQR 2–6.50) (p = 0.008), and also across gender: males: 3 (IQR 2–5); females: 5 (IQR 3–6.50) (p = 0.016).

Overall, 7.4% (n = 39) reported knowledge of patients who had experienced dislocation caused by sexual activity; a further 5.5% (n = 29) suspected this. One third (33.1%; n = 174) indicated that resuming was advisable whenever the patient felt ready. This was most often advised by surgeons who practised an anterior approach (48.4%) compared to those who performed a posterior (32.3%) or direct-lateral approach (29.8%) (p = 0.024). Recommendation to wait six to eight weeks after surgery was responded by 42.5% (n = 223/525) (p = 0.008). In case of per-operative instability of the implant, 19% would address precautions on safely resuming; 39.7% of respondents would do so only when patients would ask for.

Perceptions of barriers to communication

Table 3 summarizes the responses towards communication. Retired surgeons had addressed SF more often (41.8%) compared to residents (4.9%) and practising surgeons (24.8%) (p ≤ 0.001). We asked respondents who rarely address SF, to rank three out of eleven possible barriers. The most mentioned barrier was that “patients do not ask” (47.4%) followed by “I am not aware of possible needs” (38.6%).

Table 3 Surgeons’ addressing SF in THA patients and perceptions of barriers to communication
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Almost 90% (n = 467) of the respondents reported that in discussing SF, patients’ gender is not relevant. Of the 56 respondents who thought that gender could be an issue, discussing SF with female patients was perceived as more difficult in 8.6% (45/523) than with male patients (2.1%). Distribution on gender showed that in addressing SF, 9.5% (44/464) of male surgeons perceived female patients as more difficult, whereas 8.5% (5/59) of female surgeons perceived male patients as more difficult.

Addressing SF with senior patients >60 years of age was considered to be difficult in 25.9% (135/522): residents scored highest (44.3%; 54/122) compared to practising surgeons (23.8%; 77/324) and retired surgeons (5.3%; 4/76) (p ≤ 0.001). Female surgeons (37.3%) were less inclined to discuss SF with patients >60 years compared to male surgeons (24.4%) (p = 0.103).

A total of 284 (54.1%) respondents indicated that the orthopaedic surgeon was primarily responsible for addressing SF with patients before and after THA. Residents more often suggested nurse practitioners were responsible (19.5%) than did orthopaedic (15.0%) and retired surgeons (11.8%) (p = 0.002). The need for additional training in addressing SF was reported by 52.1% of respondents (p ≤ 0.001). Twenty-six percent did not consider SD as a relevant issue for hip patients in their practice, and 32.1% did not know (p = 0.026). Over half of respondents (55.1%) agreed that PROM questionnaires should include SF (p = 0.013).

Discussion

Surgeons show little attention to SF related issues in their THA patients. However, attention increases throughout career. We found divergent views and no “common advice” about safe resumption of sexual activity. Advices seem independent to surgical approach. Respondents rated the risk for dislocation during SA rather low.

Limitations and strengths of the study

The questionnaire was not psychometrically tested before use; this may have led to some shortcomings in validity and reliability, variables could have been misunderstood due to lack of formulating definitions. We suggest there were missing values for this reason in question 17 (3%). Not all respondents filled in second and third reasons (question 13). We, therefore, chose to analyse the first reason, only. Secondly, the cohort studied, is probably not generalizable. Sex-related issues are sometimes a ‘taboo’ topic for some cultures, considering that this activity may be seen as forbidden or sacred based on religious beliefs or morals. Therefore, the results should be considered as best-case estimates, not applicable to other populations.

Nevertheless, overall, this study contains very few missing values. Despite the inevitable risk of response and information bias, this study offers a high response rate, especially for this type of (sensitive) investigation. Furthermore, it benefits from a broad overview among attitudes and views of orthopaedic surgeons to SF related issues in THA patients, per occupation as well as per gender.

Addressing SF was difficult for 77.5% of the respondents and this finding is in line with the two available, previous studies: in the UK 69.0% [7] and in the USA 80.0% [10]. However, we found that retired surgeons had addressed SF more often (40.8%) than residents (4.9%), practising surgeons (24.8%), and female surgeons were less inclined to address SF (91.5%) as compared to their male colleagues (75.8%). That was a somewhat unexpected finding in view of previous research: Birkhoff et al. (2016) found that female physicians address a taboo topic (as sexual abuse) more frequently than do their male colleagues [16], and Bertakis (2009) reports about a more devoted attitude in female physicians (internal and general) spending more time to psychosocial counselling compared to their male colleagues, who were more technically oriented [17]. Although communication about SF in orthopaedic literature is limited [18], the importance of effective communication skills in the patient-doctor relationship is widely recognized [19].

We looked for barriers in communication. Although the most cited reason was because patients are not initiating SF issues themselves; the patients’ age (>60 years) was of influence too (25.9%). Interestingly, the factor no time was not indicated to be important (1.7%) compared to approximately 40% of respondents in other area’s of medical disciplines [11, 13, 14, 16]. It has been noted that patients do not raise the subject spontaneously [20]. We suggest surgeons should find effective standardized ways to provide “easy” communication about SF in their practises.

In an earlier systematic review, we published about improvements of sexual activity after THA (Δ 0–77%); and the patients’ need for more advice (range 57–89%) [18]. For 20% of the patients, SF appears to be an argument to undergo THA [4, 6]. It is important to know patients’ needs, motives and expectations about SF, and before starting the surgical procedure. Especially, since literature suggests that unfulfilled expectations will lead to dissatisfaction [21]. Even more, several studies indicate that some patients (2–17%) never resume sexual activity again after THA [6, 9, 22, 23]. It seems to be highly important to have better insights into the determinants of SF in THA patients.

The patients’ fear for dislocation has been emphasized (up to 80%) in previous literature [8]. In addition, the female patients in this study changed their preferred sexual positions after THA in non-recommended positions, mostly due to difficulties with the leg position [8]. Unknown is if this would lead to more dislocations of the prosthesis more easily. We had expected to find an association between the preferred technique and the surgeons’ advice concerning the waiting time before resuming intercourse, however, we did not. One third of the respondents indicated that resuming was permitted whenever the patient felt ready, and this was unrelated to the surgical technique. This seems in line with a recent review stating that “a more liberal lifestyle restrictions and precautions protocol will not lead to worse dislocation rates, but instead will lead to earlier and better resumption of activities and higher patient satisfaction” [24].

To the best of our knowledge there are no studies focused on dislocation caused by intercourse and positions. Compared to 20% (n = 254) of the USA surgeons [10], in our study a surprisingly low proportion of respondents reported being aware of at least one patient experiencing THA dislocation during sexual activity (7.4%). Only one study has determined –theoretically, based on MRI, 3D studies, and animations- which sexual positions pose the greatest risk for impingement and thus for dislocation of the prosthesis [25]. Notwithstanding this, we asked surgeons if they would inform the patient about the risk for dislocation during sexual activity in case they noted during surgery that the stability of the prosthesis was suboptimal. Previous literature suggests that, in the event of instability patients should be informed about which sexual positions to avoid [1]. However, more than two thirds of respondents stated they would not inform the patients, or only if patients were to ask about it. Obviously, the majority of respondents reported that they routinely provide their patients with general information on how to prevent dislocation; probably supposing their patients can translate this into knowledge about safe sexual positions themselves. Therefore, it remains uncertain if indirect information puts patients into risk. Although, in the twentieth century, communication about SF still is difficult (from the perspective of both surgeon and patient), surgeons should look for standardized ways to provide patient-information and tailor-made advice both, before and after surgery. In line with this, we believe that evaluating SF by means of PROMs could help to encourage surgeons to address SF, and will shed light on this under-recognized issue in orthopaedic practice.

Conclusions

Despite research, which suggests patients want more information and discussion with their surgeons about SF and hip replacement surgery, the majority of Dutch orthopaedic surgeons surveyed appear to not address this need. Our research did however show that addressing SF increases throughout a surgeon’s career. It was also clear that the age of both, the surgeon and patient influences this discussion. Surgeons’ views were divergent and there was no “common advice” about safe resumption of sexual activity. The results emphasize the need for further research and guidance for surgeons and their team in order to encourage addressing SF both, before and after THA.

HA, hip (osteo)arthritis; IQRs, interquartile ranges; PROMs, patient-reported outcome measures; SD, sexual dysfunction; SF, sexual function; SQoL, sexual quality of life; THA, total hip arthroplasty; VAS, visual analogue scale.