Post-Stroke Sexual Disorders and Its Real-Life Experience within Couples in Brazzaville

Background: Post-stroke sequelae can have repercussions on the sexual life and relational life of patients and their partners. Objectives: To determine the frequencies of sexual disorders after a first stroke event; to identify the factors associated with sexual disorders; to explore the real-life experience of sexual disorders within couples. Methods: It was an analytical cross-sectional study, conducted on patients followed up for a first stroke and their partners. It was carried out at public and private hospitals in Brazzaville, Congo, during the period of patient follow-up, from May to September 2019 (5 months). The Female Sexual Function Index, International Index of Erectile Function 5 and interviews were used to describe sexual aspects. The real-life experience of couples was explored using standardized and pre-established questionnaires. Results: Of the 36 patients who had taken up again sexual intercourse after stroke, 29 (80.6%) were men. Among the post-stroke sexual disorders, erectile dysfunction (53.2%) and ejaculatory


Introduction
Strokes remain a public health problem throughout the world because of high mortality and sequel [1] [2] [3].
The management of stroke survivors aims to improve their quality of life. This improvement involves a prior assessment of residual disability that is either motor, cognitive or phasic [2] [3] [4] [5]. Among the disabilities, there are sexual disorders which affect 50% to 80% of stroke survivors [6].
Studies on the sexual aspects and relational factors in stroke survivors and their partners have been carried out in many countries [6] [7] [8] [9] [10]. In Congo, research into post-stroke sexual disorders has focused on erectile dysfunction [11]. In this study, erectile dysfunction after stroke was common (51.92%) with an impact on the lives of the couple.
Therefore, it seemed important to us to make a survey of all the sexual dysfunctions in patients after a first stroke event. The aim of this study is to improve the sex management of stroke survivors. Our objectives were to determine the frequencies of post-stroke sexual disorders, to identify the associated factors to sexual disorders and to explore the real-life experience of sexual disorders within couples.

Methods
This was an analytical cross-sectional study, approved by the Ethics Committee of Congo (number: 182; date: April 22, 2019) and conducted according to the Declaration of Helsinki. It carried out at public and private hospitals in Brazzaville, Congo, from May to September 2019 (5 months). It focused on stroke survivors with sexual disorders came back at follow-up visit and their partners. Patients and their declared partners have been exhaustively identified.
For stroke survivors, the inclusion criteria were: to be the victim of a first stroke event at least of six months and confirmed by brain imaging; to give informed consent to participate in the study; to be over 18 years old; to be unscathed from sexual disorders before the onset of stroke; to be devoid of phasic, major cognitive and chronic psychiatric pathologies.
For partners, the inclusion criteria were: to live with a wife or husband suffering from a stroke; to give informed consent to participate in the study.
The Female Sexual Function Index (FSFI) and International Index of Erectile Function 5 (IIEF-5) [12], as well as interviews, were used to describe the sexual aspects in stroke survivors. FSFI and IIEF-5 scores were determined according to the methods described in the documents related to these tests [12]. The exploration of the real-life experience of sexual disorders within couples was carried out using standardized and pre-established questionnaires.
The data collected were analyzed using the statistics software CSPro version 7.2. Qualitative variables were expressed in the form of frequency and percentage. For quantitative variables, mean and standard deviation were determined. The Pearson and Fisher chi-squared tests were used for comparison of qualitative variables. Comparison of quantitative variables was performed using the Student's t-test. Significance level was set at p < 0.05.

Results
Of the 103 stroke survivors came back at follow-up visit, 85 (82.5%) agreed to participate in the present study.
Among the 85 stroke survivors, 65 (76.5%) were included in the study. The characteristics of the population included in the study are regrouped together in The 7 female stroke survivors had a score of FSFI less than 26.5, indicating the existence of sexual functioning disorder. Their score of the domain related to sexual desire was equal to or less than 5, indicating the decrease of sexual desire. The other sexual functions, namely sexual awakening, vaginal lubrication, orgasm and sexual satisfaction, could not be identified.
Erectile dysfunction was the only sexual disorder significantly associated with the following factors: sleep disorder (p = 0.007) and mean duration of sleep per night (p = 0.01) ( Tables 2-4).
Among the 36 stroke survivors who had taken up again sexual intercourses, 28 (77.8%) did not communicate verbally or non-verbally with their partners about sexual problems and psychological effects following upon post-stroke sexual   13.3%).

Discussion
This study is about the epidemiology of post-stroke sexual disorders, factors associated with these disorders and real-life experience of these disorders within couples.
The predominance of male stroke survivors observed in our series (80.6%) has also been found in other studies [10] [13]- [18].  [33]. The overall frequency of our stroke survivors with decreased sexual desire (50%) falls in with this interval.
In the present study, and among ejaculation disorders, it is noted a higher rate of patients with premature ejaculation (79% of cases) compared with that of patients with delayed ejaculation (21%). Our data agree with those reported in other series [11] [31] [39]. Researchers have found a rate of stroke survivors with decreased ejaculation that is higher than that of stroke survivors with absent ejaculation [40]. This does not corroborate our data.
Literature data reveal that 20 to 78% of stroke survivors have an erectile dys-  [44].
The link between anxiety and post-stroke sexual disorders has been established in some studies [36]. In our series, no correlation is noted.

Strengths and Limitations
Our research in different centers and the exhaustive sampling made it possible to identify patients suffering from a first stroke and to present sexual disorders in all outpatient neurology consultations in Brazzaville. This allows us to extend the results obtained to the urban population of the city.
The use of different quiz to assess sexual disorders and experience is one approach encouraged for surveys of this kind [27]. These tests have been validated and used in most randomized trials [27] [28]. Trudel et al. [28] reported a very strong internal consistency (Cronbach's alpha) of IFSF, which was estimated to be 0.91.
The high participation rate (76.5%) reflected the desire of patients to come out of the shadows and find solutions to this problem; sexuality being an important element of the quality of life. The low participation rate of the partners (52.3%) therefore did not seem to have had any effect on this desire for a solution. Likewise, in various surveys on sexuality, the participation rate is often low. Chambon [5] in France reported a participation rate of 40%. Humphrey [21] in a much older study reported a much lower participation rate of 17%. This explains some of the difficulties encountered in our study such as obtaining the cooperation of certain partners, sexuality being a taboo and private subject. Likewise, our low recruitment can be explained by the fact that 6 months after a stroke, some patients are lost to follow-up and no longer want to return to the follow-up consultation.

Conclusion
Post-stroke sexual disorders are frequent in Brazzaville. Next to sleep disorder and mean sleep duration per night, psychological effects seem to be factors which have repercussions on the sexual life and relational life of stroke patients and their partners. It is important to implement sexual counseling in departments of neurology in order to improve the quality of life of couples.