Pouch Surgery and Patient Comorbidities Are Associated with Male Sexual Dysfunction

Study underscores importance of patient education and clinical follow-up

Male inflammatory bowel disease patients who underwent ileo-anal pouch anastomosis (IPAA) after proctocolectomy were twice as likely to experience male sexual dysfunction (MSD) as patients who didn’t undergo the restorative procedure, new Cleveland Clinic research shows.

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Cardiometabolic risk factors, major depressive disorder and age appear to elevate the risk of MSD in post-IPAA patients. The study’s findings underscore the need for improved pre- and postsurgical patient education, the researchers conclude.

The need for research

Inflammatory bowel diseases, including ulcerative colitis and Crohn’s disease, are often complicated by symptoms such as diarrhea, stool frequency and fatigue that can result in MSD. Proctocolectomy with IPAA is the surgery of choice for uncontrolled ulcerative colitis and other colon-compromising conditions such as familial adenomatous polyposis.

Most patients do well following IPAA creation. However, IPAA is associated with MSD, possibly due to autonomic nerve damage during surgery. Research examining the relationship between IPAA and MSD is limited. Surveys have found a range of 2% to 10% of male IPAA patients experience MSD.

After hearing numerous patients report MSD following IPAA, gastroenterologist Taha Qazi, MD, who leads the Pouch Center in Cleveland Clinic’s Digestive Disease & Surgery Institute, initiated a major study of the epidemiology and risk factors for MSD in patients with IPAA. The results were presented at the Digestive Disease Week 2022 annual meeting, where the research was named best of DDW presentations.

“MSD is underreported,” says Dr. Qazi. “Doctors don’t often ask about it and patients don’t often want to talk about it. We wanted to get more definitive evidence of the number of IPAA patients with MSD and understand the risk factors for developing it.”

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Database and search criteria

The study surveyed a commercial database that aggregates electronic health record data from Cleveland Clinic and 25 other major integrated U.S. healthcare systems covering 25% of the U.S. population.

Patients with MSD and IPAA were identified using Systematized Nomenclature of Medicine-Clinical Terms (SNOMED-CT).  MSD was defined by the SNOMED terms “erectile dysfunction/impotence” or “ejaculatory disorder.” In addition, the study was the first to add prescriptions for phosphodiesterase-5 inhibitors to the MSD criteria.

IPAA was defined by the SNOMED terms “construction of pouch” or “reversal of Hartmann procedure” and included J-, S- and W-shaped pouches. Patients with precapillary pulmonary hypertension were excluded.

Incidence and risk factors

Among the 30,808,890 adult male patients (age 18 and older) whose records were included in the database from 1990 to 2022, a total of 41,830 cases involving IPAA were identified. All had been treated for IBD. MSD was documented in 1,940 IPAA cases, for a rate of 4.6%. This compares with an overall incidence of 551,700 MSD cases in men who did not undergo IPAA, or 1.79%.

The patients with MSD following IPAA were older (83.5% over age 45) than the non-IPAA cohort and had significant medical comorbidities: coronary artery disease (620, 31.9%), type 2 diabetes mellitus (680, 35.1%), primary hypertension (1,530, 78.9%), major depression​ (460, 23.7%) and substance abuse (660, 34.1%). Statistical analysis showed that cardiometabolic risk factors, major depressive disorder and age were the greatest risk factors for the development of MSD in IPAA patients.

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Raising awareness of MSD and IPAA

This study was the most comprehensive to date of MSD in the IPAA population, according to Dr. Qazi, and provides further evidence for the association of MSD with IPAA, particularly in older men with more severe disease and comorbidities.

“This study brings awareness to a condition that is often not discussed with patients and, more importantly, a condition that can be easily managed with prescriptions for phosphodiesterase-5 inhibitors as well as referrals to urology,” he says. “If there’s one thing this study makes clear, it is that physicians need to discuss MSD with their IPAA patients, before and after surgery, and proactively screen patients at risk.”

Further research

The Digestive Disease & Surgery Institute researchers are currently creating their own pouch registry, which will allow investigators to review IPAA patients’ postoperative history along with postoperative complications to determine if those factors are associated with higher rates of MSD.