Handbook of Clinical Neurology, Vol.

130 (3rd series)

Neurology of Sexual and Bladder Disorders
D.B. Vodušek and F. Boller, Editors
© 2015 Elsevier B.V. All rights reserved

Chapter 16

Sexual function after strokes

FRANÇOIS BOLLER*, KUNAL AGRAWAL, AND ALISSA ROMANO
Department of Neurology, George Washington University Medical School, Washington, DC, USA

Strokes represent the second leading cause of death and
the third leading cause of disability-adjusted life years
(DALYs), accounting for over 44 million DALYs lost
in adults worldwide (Mukherjee, 2011; Hankey, 2013).
Thanks in part to better and more available diagnosis,
treatment, and rehabilitation, the vast majority of stroke
patients tend to survive strokes, particularly in the indus-
trialized world. It is estimated that close to 65 million
people have survived a stroke and may need assistance
in activities of daily living. The burden of both ischemic
and hemorrhagic strokes has significantly increased
between 1990 and 2010, including absolute number of
strokes (37% ischemic, 47% hemorrhagic), mortality
(21% ischemic, 20% hemorrhagic), and DALYs lost
(18% ischemic, 14% hemorrhagic) (Krishnamurthi
et al., 2013). Both the incidence and the prevalence of
strokes are expected to continue to increase markedly
within the next two decades as the global population
and life expectancy continue to grow (Truelsen and
Bonita, 2009).
Motor disability and cognitive changes such as apha-
sia and visuospatial disorders are most often considered
among the major contributors to stroke burden. How-
ever, lower urinary tract dysfunctions and disorders of
sexual functions are also frequent sequelae of stroke.
Sexual dysfunctions after strokes deserve to be empha-
sized and discussed in detail because they may contrib-
ute significantly to lower quality of life and also
because their study may improve our understanding of
brain physiology and neuropsychology. This chapter dis-
cusses the psychologic, psychosocial, and physical
changes surrounding sexual dysfunction after stroke
and also presents geographic and cultural peculiarities
particular to sexual dysfunction. While most strokes
cause hyposexuality, this chapter will also address hyper-
sexuality as a sequela to stroke, as well as the role of
medications in sexual dysfunctions.
As mentioned in Chapter 1, the new DSM-5, released
in 2013 (American Psychiatric Association, 2013), creates
a paradigm shift compared to DSM-IV (American
Psychiatric Association, 1994), and recommends that
we keep in mind that sexuality may be experienced dif-
ferently according to gender and therefore should be
classified and managed accordingly (Sungur and
Gunduz, 2014). This chapter will take this point into
account and present the few available data concerning
differences between men and women.
PHYSICAL, PSYCHOLOGIC,
PSYCHOSOCIAL, AND ANATOMIC
FACTORS AS DETERMINANTS OF
POSTSTROKE SEXUAL FUNCTIONING
Strokes induce physical and psychosocial barriers to sex-
ual activity and both aspects of the problem need to be
addressed. Physically, mobility restrictions such as hemi-
plegia or hemiparesis may affect comfort and position-
ing and therefore play a significant role in sex after
stroke. Most studies show a direct association of
decreased sexual activity and level of motor disability.
A British study suggests that the level of independence
in activities of daily living can be used as a predictor of
sexual activity after stroke (Rosenbaum et al., 2014).
However, a study by Cheung (2002) demonstrated that
even patients with mild or no physical disability
reported significantly decreased sexual activity and
difficulty resuming sexual activity after stroke, under-
scoring the multifactorial nature of poststroke sexual
dysfunction.
Depression and anxiety, which are common after
stroke, are strongly correlated with sexual dysfunction
(Rosenbaum et al., 2014). An often-quoted study by
Korpelainen et al. (1999) assessed sexual functioning
of stroke patients (n ¼ 192) and their spouses (n ¼ 94).

*Correspondence to: François Boller, MD, PhD, Department of Neurology, George Washington University Medical School, 2150
Pennsylvania Avenue NW, Suite 9-400, Washington DC 20037, USA. Tel: +1-202-677-6282, E-mail: fboller@mfa.gwu.edu
290 F. BOLLER ET AL.
Etiologies included brain infarction and intracerebral
hemorrhage; in addition, 12 subjects had a subarachnoid
hemorrhage. The main intent of the study was to assess
the associations of clinical and psychosocial factors with
poststroke changes in sexual functions. The authors
reported a marked decline in most measures of sexual
function, including libido, coital frequency, erectile dys- that a decrease in libido was greater following left-
function (ED) in men, and disorders of lubrication in
women, as well as a general decline in sexual satisfac-
tion. A large majority of the interviewed patients
(79%) and spouses (84%) considered that they had a nor-
mal prestroke sexual life. Forty-five percent of patients
and 48% of spouses complained of a marked decrease in
sexual life following a stroke. Almost one-third of
patients and spouses said they no longer had sexual inter-
course. A decrease in libido was reported by 57% of par-
ticipating subjects. According to Korpelainen et al.
(1999), psychologic, social, and relationship factors were
mainly responsible for this decrease. The most important
explanatory variables were a general attitude toward
sexuality, which was felt to be “unimportant” by a great
majority of subjects with decreased libido. In the
Korpelainen et al. (1999) study, 24% of patients ceased
sexual activity entirely due to fear of causing a new
stroke. Furthermore, 14% of male patients also feared
impotence. Depression and drugs such as antihyperten-
sion medications were also found to be contributing fac-
tors. No relationship was found between sexual function
after stroke and gender, marital status of the patients, or loss of identity, shift in gender roles, and inadequate
etiology of stroke. The authors also concluded that the
location of the lesion bore no relation to sexual function
changes. Such conclusions, however, are not built on
solid ground, since very little information other than
the presence of right or left hemiparesis is available on
these patients. It is obviously questionable to compare
a patient with an intracerebral infarct with one who
has suffered a subarachnoid hemorrhage.
Some other studies have attempted to identify a cor-
relation between psychosocial factors, sexual activity,
and location of the stroke lesion. Giaquinto et al.
(2003) studied sexual changes in 68 patients 1 year after
stroke. Sexual decline was common, mainly related to
age and physical disability. Further analysis led the
authors to conclude that psychologic rather than medical
causes are responsible for a decline or discontinuity of
sexual activity in stroke survivors. Giaquinto et al.
(2003) also stated that their statistical analysis showed
no relation between decreased sexual activity and the
hemisphere in which the lesion was located, thus failing
to support the hypothesis of a critical anatomic location
responsible for sexual activity. A selection bias may have
been involved, since the authors’ exclusion of patients
with pronounced aphasia probably excluded those
patients with the most severe left-hemisphere lesions.
Lesion location apparently played a role in a small group
of patients with hypersexuality (see below).
On the other hand, some data suggest that the side
and location of the hemispheric lesion make a differ-
ence, but here again, there are some apparent contradic-
tions. In an older study, Kalliomaki et al. (1961) found
hemisphere lesions (37.8%) compared to right-
hemisphere lesions (16.7%). Several other studies have
also found loss of libido and depression more often asso-
ciated with left-hemisphere lesions (Renshaw, 1975;
Goddess et al., 1979; Kauhanen, 1999). However, oppo-
site results were found in a study focused on changes in
sexual functions after strokes in males (Coslett and
Heilman, 1986). This study found that the prevalence
of major sexual dysfunction (mainly reduced libido
and sexual potency) was significantly greater after
right- than after left-hemisphere stroke. It is reasonable
to conclude that lesions of either hemisphere can affect
sexual activities, but for different reasons: aphasia and
depression after left-hemisphere lesions, a deficit in
arousal and perhaps visuospatial disorders after right-
hemisphere lesions. Furthermore, the temporal lobes
seem to play a special role in sexual behavior, as shown
by patients with the Kl€ uver–Bucy syndrome (see
Chapter 6).
Psychosocial factors can also influence poststroke
sexual functioning. These factors include a perceived
communication with physicians. In a study by Schmitz
and Finkelstein (2010), 29 patients were given semistruc-
tured interviews and provided information about sexual
issues and their perspectives. The study shows that par-
ticipants often felt discomfort in talking about sex with
their partner. Nearly all participants suggested that the
stroke resulted in a shift in their respective relationships,
often disrupting defined gender roles and interactions.
In some, the new role as “caregiver” conflicted with their
sexual needs. In one interview, a husband explained, “it’s
hard to get rid of that role [caregiver] and be a husband
again. I still help her get up, help her move. When she
takes a shower, I help her transfer from the tub seat,
and help her dry. These are things I don’t mind doing.
Is that as the husband or the caregiver? I would like to
be a husband again” (Schmitz and Finkelstein, 2010).
The loss of identity and dependency have significant
impacts on the self and, as a result, on sexual
functioning.
Participants in the Schmitz and Finkelstein (2010)
study also noted that they were uncomfortable talking
about sex not just with their partner but also in discus-
sions with their physicians. One stroke survivor com-
mented, “well I think they’re ashamed. . .you don’t ask
about your penis or anything like that because that’s
 SEXUAL FUNCTION AFTER STROKES
bad.” Furthermore, this study also indicated that only
one physician discussed sexuality as part of the acute
rehabilitation experience, and many patients felt that
physicians are uncomfortable discussing sensitive sexual
issues. For instance, one of the patients interviewed
stated, “[Physicians] haven’t been educated enough
about being open. They might be a little inhibited
themselves” (Schmitz and Finkelstein, 2010).
Does age play a role in the burden of poststroke sex-
ual dysfunctions? A recent paper by Bugnicourt et al.
(2014) studied specifically the occurrence of impaired
sexual activity in young (less than 60 years old) ischemic
stroke patients. They found that one-third of these rela-
tively young persons are affected. In addition, they
found that, in some cases, impaired sexual activity
occurs even after ischemic events with limited sequelae
such as transient ischemic attacks. The main factors
associated with sexual impairment were depression
and medications. One would expect that stroke-related
sexual impairment might affect younger subjects more
severely because they and their spouse expect a higher
level of sexual activity. For some subjects still of repro-
ductive age, there may also be repercussions for family
planning. The literature, including the Bugnicourt et al.
(2014) study, does not address these aspects.
THE IMPACT OF POSTSTROKE
MEDICATIONS ON SEXUAL
DYSFUNCTION
Aside from physical and psychosocial obstacles causing
sexual dysfunction, medications which are commonly
prescribed after stroke can also have significant effects
on sexual functioning. Depression is an important factor
influencing sexual dysfunction, and affects 30–50% of
poststroke patients in the first year alone (Dafer et al.,
2008). While antidepressant effects on sexual dysfunc-
tion are detailed in Chapter 27, it is worth reiterating that icant beneficial effects on sexual function and can be
many of the medications prescribed to attenuate depres-
sion tend to substantially impact sexual functioning,
including tricyclic antidepressants, monoamine oxidase
inhibitors, and selective serotonin reuptake inhibitors
(SSRIs). In fact, SSRIs have been shown to induce sexual
dysfunction with delayed orgasm, diminished sexual
desire, and ED in a greater proportion (30–60%) of trea-
ted patients than those in other classes (Gregorian et al.,
2002). However, not all antidepressants have been shown
to cause hyposexuality. Korpelainen et al. (1998)
described a case series where two stroke patients and
one patient with Parkinson’s disease were treated with
the monoamine oxidase inhibitor moclobemide, which
resulted in hypersexuality. It is important for physicians
and patients to recognize that both depression and anti-
depressant medications can lead to sexual dysfunction.
291
In addition to antidepressants, it is certainly worth
mentioning that drugs commonly prescribed after a
stroke, such as antihypertensive and lipid-lowering med-
ications, also have sexual side-effects. Some of these
medications are sexually enhancing, while others cause
sexual dysfunction. In a recent review, Nicolai et al.
(2014) reviewed cardiovascular drugs and sexual func-
tions. Beta-blockers have been shown to cause serious
side-effects of ED and loss of libido in about 21.6% of
patients (Nicolai et al., 2014). It is thought that beta-
blockers inhibit the sympathetic nervous system, which
controls erection, emission, and ejaculation, as well as
luteinizing hormone and testosterone release. This is
particularly true of first- and second-generation beta-
blockers. However, nebivolol, a newer third-generation
beta-blocker, appears to have a very low risk of sexual
side-effects and in one study and was seen to signifi-
cantly improve erectile function due to possible nitric
oxide modulation.
Angiotensin-converting enzyme (ACE) inhibitors,
particularly captopril, have been shown to improve sex-
ual function. However, in the Treatment of Mild Hyper-
tension Study (THOMS), enalapril was associated with a
significant decrease in sexual activity when compared to
placebo. It is believed that ACE inhibitors prolong the
half-life of nitric oxide, and limit degradation of brady-
kinin, which can lead to improved erectile function.
Interestingly, the ACE inhibitor lisinopril has been
shown to only temporarily decrease sexual activity
(Nicolai et al., 2014). Furthermore, angiotensin II recep-
tor antagonists have a positive effect on sexual function.
A study comparing valsartan with atenolol reported an
increase in sexual intercourse in patients treated with val-
sartan (Nicolai et al., 2014). Valsartan also has been asso-
ciated with improved libido and an increase in sexual
fantasies as compared to atenolol (Nicolai et al., 2014).
Overall, angiotensin II receptor antagonists show signif-
initiated in patients with sexual side-effects.
Early studies with calcium channel blockers indicated
a negative association with ejaculation difficulties as
well as gynecomastia. However, the THOMS study
demonstrated that amlodipine did not cause sexual dys-
function. This suggests that calcium channel blockers,
based on their ability to increase dilation of blood vessels
by reducing calcium in smooth muscles, do not have a
detrimental effect on sexual function. Statins and
lipid-lowering medications have also been reported to
improve erectile function in patients who had no cardio-
vascular risks other than ED. However, in patients
with cardiovascular risk factors such as smoking or
diabetes, it was suggested that ED was more likely to
occur after statin initiation (Nicolai et al., 2014). It is
thought that statins may provide sexual benefit due to
292 F. BOLLER ET AL.
antioxidant effects. Overall, the Nicolai review
proposes that beta-blockers, cardiac glycosides, and
diuretics have a negative effect on sexual function, while
alpha-blockers, ACE inhibitors, and calcium channel
blockers have no effect, and angiotensin receptor
blockers and statins may have a positive effect on sexual
function.
THE PREVALENCE AND IMPACT OF
POSTSTROKE SEXUAL DYSFUNCTION
AROUND THE WORLD
Sexual dysfunction following strokes is fairly frequent
and, not surprisingly, is prevalent throughout the world,
as shown by studies in Europe (Calabrò et al., 2011), in
the USA (Coslett and Heilman, 1986), in Africa
(Akinpelu et al., 2013), China (Cheung, 2002), and in
the Middle East (Bener et al., 2008; Tamam et al.,
2008). In southwestern Nigeria, Akinpelu et al. (2013)
aimed to determine the influence of clinical and psycho-
logic factors on sexual dysfunction in poststroke survi-
vors (n ¼ 77; 60 males, 17 females). Approximately 95%
of participants reported dysfunction in at least one sex-
ual activity (libido, coital frequency, vaginal lubrication,
erection, ejaculation, orgasm, or satisfaction with sexual
life) after stroke. The participants’ sexual function was
not affected by the side of hemiparesis; however changes
in psychologic factors such as willingness to have sex,
general attitudes about sex, and the ability to express
sexual feelings were reported to have a negative influ-
ence on sexual functioning. These findings indicate that
psychologic factors are important in determining sexual
function in Nigerian stroke survivors. This study also
suggests that a decline in sexual functioning is common
amongst Nigerian poststroke patients.
A similar study was conducted in China, where
Cheung (2002) attempted to determine the impact of
stroke on sexual functioning in patients with minimal
or no poststroke disability (n ¼ 106; 63 males,
43 females). Approximately 55% of all patients in the
study reported a decline in sexual libido after stroke,
and coitus became less frequent or absent after stroke
in about half of all patients compared to coital frequency
before stroke. In addition, almost 53% of males reported
either diminished or absent ejaculation after stroke and
approximately 75% of females experienced decreased or
absent poststroke vaginal lubrication. Regarding sexual
satisfaction, only 25% of patients reported adequate sex-
ual satisfaction after stroke. Cheung (2002) mentions
that the psychosocial factors likely contributing to post-
stroke sexual dysfunction include an unwillingness for
sexual activity as well as the inability to discuss sexuality faction scores. In China, Cheung (2002) reported that
with one’s partner. This study highlights that psychoso-
cial factors play an important role in libido, sexual
activity, and sexual satisfaction. This is in agreement
with current western literature regarding poststroke sex-
ual dysfunction.
The prevalence of poststroke sexual dysfunction in
different parts of the world is further documented by
studies from the Middle East. Bener et al. (2008) con-
ducted a study in Qatar with the goal of investigating
the prevalence and risk factors of poststroke ED
amongst male patients (n ¼ 605). Approximately 48%
of participants reported some degree of ED, with 36%
reporting severe, 33% moderate, and 31% mild ED.
Advancing age (60–75 years), diabetes, hypertension,
and hypercholesterolemia were significantly higher in
stroke patients with ED compared to stroke patients
without ED. The higher prevalence of ED was clearly
associated with decreased sexual performance. Accord-
ing to Bener et al. (2008), recent changes in socioeco-
nomic status and lifestyle, such as increased smoking,
unfavorable eating habits, and decreased daily physical
activities, increased the incidence of stroke and subse-
quent prevalence of SD in Qatar, leading to more prob-
lems with sexual functioning in men.
Another study conducted by Tamam et al. (2008)
assessed sexual function in 103 Turkish stroke patients
(63 male, 40 female) with no or mild disability.
Approximately 6% of participants reported a post-
stroke coital frequency greater than twice per week
compared to approximately 26% of participants report-
ing the same coital frequency prestroke. In addition,
female patients had a significant decline in vaginal
lubrication (46% prestroke, 12% poststroke) and
orgasm (35% prestroke, 12% poststroke), while male
patients were affected in regard to erection (77% pre-
stroke, 37% poststroke) and ejaculation (80% pre-
stroke, 35% poststroke). These results illustrate the
importance and prevalence of sexual dysfunction in
Turkish stroke survivors.
Given that poststroke sexual dysfunction is preva-
lent around the world, it is interesting to note that
the interpretation of sexual satisfaction after stroke
can be influenced by cultural bias amongst different
countries. For example, in the Nigerian study con-
ducted by Akinpelu et al. (2013), only 30 participants
(40%) reported a dissatisfaction with sexual life despite
an overwhelming majority of enrolled patients report-
ing dysfunction in at least one sexual activity. Accord-
ing to Akinpelu et al. (2013), in the Nigerian cultural
context, the ability to have children is perceived as a
major determinant of satisfaction with sexual life
and this cultural perception may have influenced the
participants’ responses, resulting in low sexual dissatis-
only six female participants (14%) felt sexuality was
important compared to 36 male participants (57%)
 SEXUAL FUNCTION AFTER STROKES
who felt the same way. This gender discrepancy in sex-
ual importance may lead to an unwillingness for sexual
activity that subsequently contributes to sexual dissat-
isfaction in the Chinese population.
A third example of cultural influences on sexual sat-
isfaction is mentioned within the Middle Eastern study
conducted in Turkey (Tamam et al., 2008). In this study,
Tamam et al. (2008) reported a less prominent post-
stroke decline in sexual satisfaction (despite an overall
decrease in sexual functioning) due to a cultural bias
of living in a predominantly Muslim population, in which
masculinity is equated with virility and femininity is
equated with submissiveness and virtue. In light of this
concept, nine male patients (14%) and 11 female patients
(27.5%) reported prestroke sexual dissatisfaction com-
pared to 29 male (41%) and only 10 female (25%) partic-
ipants reporting sexual dissatisfaction after stroke
(Tamam et al., 2008). Regardless of cultural influences
on sexual satisfaction, the overall results from different
parts of the world are consistent with the current litera-
ture in poststroke sexual dysfunction, confirming that
different cultures and ethnicities across the world may
influence the reported prevalence of sexual dysfunction
in stroke survivors.
HYPERSEXUALITYAFTER STROKE
Are poststroke sexual activities always decreased? An
interesting finding of the Korpelainen et al. (1999) study
is that about 10% of patients (but none of the spouses)
reported increased libido after the stroke without rela-
tion to the side and location of the lesion. Those patients, during sexual intercourse, may result in right-to-left
however, were significantly younger than the others.
Giaquinto et al. (2003) found increased sexual activity
in two of their 68 patients, both of whom had a lesion
of the right temporal lobe.
Braun et al. (2003) specifically addressed the question to-left shunting that occurs with the Valsalva maneuver
of hypersexuality after stroke. Their study concluded
that there are “opposed left and right hemisphere contri-
butions to sexual drive.” Their study consisted of a
review of previously published case reports of patients
with frank hypo- or hypersexuality. Hyposexual patients
(seven cases) tended to have left-hemisphere lesions, pri-
marily of the temporal lobe, while hypersexual patients
(11 cases) mostly had right-hemisphere lesions, again pri-
marily of the temporal lobe. Libido, they state, seems to
be organized in the brain in a doubly dissociated manner.
The normal right hemisphere probably inhibits libido and
the normal left hemisphere enhances it. Assuming that
there is a link between libido and affect, these data are
compatible with a number of studies showing a greater
incidence of depression in patients with left-hemisphere
lesions (Paradiso et al., 2013; Jiang et al., 2014).
293
CORRELATION BETWEEN STROKE AND
SEXUAL INTERCOURSE
In addition to whether stroke can cause hypersexual
activity, another interesting question is whether stroke
can happen as a result of sexual intercourse. Currently,
stroke during sexual intercourse is thought to be quite
unusual; however, a few case studies have proposed
some underlying pathology that may help establish a
relationship between cerebral ischemia and coitus. One
of the reported predisposing risk factors to stroke during
sexual intercourse is the existence of a patent foramen
ovale (PFO). According to current literature, a PFO is
present in approximately 35% of the population between
the ages of 1 and 29 years, 25% between the ages of
30 and 79 years, and in 20% between the ages of
80 and 99 years (Velicu et al., 2008). It is thought that
having a PFO, especially in young patients, can lead to
a paradoxic embolus and subsequently cause infarcts
in a cardioembolic distribution. However, only a few
reports have described stroke in the setting of a PFO dur-
ing sexual intercourse.
Velicu et al. (2008) published a case report of a young
woman on oral contraceptives with a complex atrial sep-
tal abnormality, large PFO, and right lower-extremity
deep-vein thrombosis who had a striatocapsular ischemic
infarct during sexual intercourse. According to Velicu
et al. (2008), a paradoxic embolism through a PFO
may likely result from the physiologic changes during
coitus that are believed to be similar to the Valsalva
maneuver. The intrathoracic, central venous, and right
atrial pressures that occur during Valsalva, and possibly
shunting through a PFO if the pressure of the right
atrium exceeds the pressure of the left atrium. Interest-
ingly, the patient described by Velicu et al. (2008) had a
stroke while at rest, suggesting that an increase in right-
may be less important than shunting through a PFO
at rest.
A similar phenomenon of right-to-left shunting at rest
causing subsequent paradoxic embolism is described by
Becker et al. (2004). In their case series, Becker et al.
(2004) reported anterior and posterior circulation
strokes in four young female patients (ages 23–38 years),
all with a PFO. Some of these patients also had additional
risk factors of either cigarette smoking or using oral con-
traceptives. Becker et al. (2004) suggest that, while heart
rate and blood pressure increase significantly during coi-
tus, the intrathoracic pressure and direction of flow
through interatrial defects during sexual intercourse
and orgasm are unknown. This might indicate that, as
mentioned above, an increase in intrathoracic pressure
is not required to precipitate paradoxic embolization
294 F. BOLLER ET AL.
when right-to-left shunting occurs at rest (Becker et al.,
2004). Despite the above case reports proposing a mech-
anism for stroke in the setting of a PFO, it is important to
note that the existence of a PFO, either alone or together
with an atrial septal abnormality, is not enough to consti-
tute an increased stroke risk (DiTullio et al., 2007).
Postcoital headache is another predisposing factor
that may provide insight into the underlying relationship
between sexual intercourse and stroke. Headaches have
served as an indicator of acute stroke immediately after
intercourse, but have typically been attributed to either
intracerebral hemorrhage or subarachnoid hemorrhage
(Yeh et al., 2010). Few cases exist in which postcoital
headaches lead to acute ischemic strokes. Calabrò
et al. (2013) describe a young female patient, aged
23 years, on oral contraceptives who suffered from a
right ischemic striatal stroke after suddenly experiencing
an “explosive” headache during orgasm. According to
Calabrò et al. (2013), hyperventilation during the normal
human sexual response may lead to reduced cerebral
blood flow by up to 50% of baseline and cause subse-
quent headaches due to cerebral artery narrowing shortly
after orgasm. Segmental cerebral artery vasospasm may
be a presumed pathogenesis for acute strokes as a com-
plication of these postcoital headaches (Calabrò
et al., 2013).
These case reports highlight that sexual intercourse
could be a possible, though unusual, trigger for stroke.
Even though there is proposed underlying pathology that
may explain a mechanism between coitus and cerebral
ischemia, the relationship between stroke and sexual
intercourse is still largely unknown.
CONCLUSION
A few points should be raised in conclusion. DSM-5
(American Psychiatric Association, 2013) urges us to
be aware of possible differences between men and
women in terms of sexual dysfunction. None of the post-
stroke studies reviewed in this chapter addresses this
question directly. Kalliomaki et al. (1961) and
Kauhanen (1999) found that gender was not related to
development of depression or loss of libido. The few
data available from other studies suggest that, if differ-
ences exist, they are mainly related to psychosocial and
cultural factors.
We have stated that sexual dysfunctions after a stroke
are frequent. This is also because strokes often occur
within a background of other sexual dysfunction risk
factors, such as generalized atherosclerosis or diabetes.
It needs to be stressed, however, that in some cases they
do not occur or are temporary. To quote an autobio-
graphic report by a physician who suffered a left-
hemisphere stroke:
I had heard it said that following a stroke, sex is
finished. I want to clear up that misapprehension
now. It is true of course that certain physical dif-
ficulties, such as hand or leg paralysis might alter
athletics, but physical difficulties do not alter
orgasmic potential (Dahlberg and Jaffe, 1977).
On the other hand, when they occur, sexual dysfunc-
tions are clearly multifactorial. A better understanding
of the psychosocial and physiologic mechanisms under-
lying sexual functioning can provide insight into improv-
ing sexual activity and therefore quality of life in
patients affected by strokes and other brain lesions.
ACKNOWLEDGMENT
We wish to thank Margaret Forbes for her judicious
advice on an earlier version of this chapter.
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