Effectiveness of physical exercise to decrease sexual dysfunction in adults with cardiovascular disease: a systematic review protocol

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Abstract

Review question/objective

This systematic review aims to identify, appraise and synthesize the best available evidence on the effectiveness of physical exercise interventions on sexual function in adult patients with cardiovascular disease and sexual dysfunction.

Review question/objective

More specifically, the review question is:

Background

Sexuality is an important part of people's physical and mentalhealth.1,2 There is an increased prevalence of sexual dysfunction inpatients with cardiovascular disease3-5 due to physical and mental changes associated with cardiovascular disease, and also from side effects of medication.6,7 Sexual dysfunction has a negative impact on quality of life and well-being in persons with cardiovascular disease, and sexual dysfunction is associated with an increase in anxiety anddepression.8-11 There is some evidence to suggest that physical activity may potentially improve sexual function in individuals with chronic heart failure.12

Background

Sexual dysfunction and its relation to cardiovascular disease

Background

Male sexual dysfunction is often associated with erectile dysfunction, defined as the persistent inability to obtain or maintain an erection which enables satisfying sexual activity.13 Erectile dysfunction is associated with age, but can also be triggered by both physical and psychogenic conditions and is often related to vascular disease such as diabetes, hypertension and heart disease.14 In addition, factors such as smoking and obesity are also associated with a higher incidence of erectile dysfunction.3-5 Sexual dysfunction in women is divided into physical and psychological causes including:7,15

Background

The most common dysfunction in women is a lack of sexual interest or desire.7

Background

A number of medications which have favorable prognostic effect in patients with cardiovascular disease also increase the risk of developing sexual dysfunction in both men and women.6 Drugs used to treat erectile dysfunction may also adversely interact with drugs used to treat cardiovascular disease.6 As such, alternative treatments for sexual dysfunction are worth investigating.

Background

Instruments for measuring sexual dysfunction

Background

When investigating sexual dysfunction in clinical research, various instruments are used including self-reported questionnaires and interview-based questionnaires. Self-reported questionnaires are the most frequently used tool to measure sexual dysfunction in clinical research. A number of questionnaires for example the International Index of Erectile Function (IIEF)16 and the Brief Male Sexual Function Inventory for urology (BFSI)17have been tested for validity and reliability which are considered to be fundamental characteristics of good measurement.18

Background

Prevalence and incidence of sexual dysfunction

Background

Sexual dysfunction has been investigated in both men and women with established cardiovascular disease and found to be highly prevalent in this population. The prevalence of sexual dysfunction in both male and female patients with chronic heart failure has been studied in several populations and found to be between 75% and 89%.19-22

Background

The majority of research investigating sexual dysfunction, however, has been conducted on men and focuses on erectile dysfunction. In studies investigating males with ischemic heart disease, the prevalence of erectile dysfunction ranged from 39% to 74%.23-26 Data from the Massachusetts Male Aging Follow up Study (MMAS) including 1709 males showed that 35% of men aged 40 to 70 had moderate to complete erectile dysfunction and showed that age and cardiovascular disease were the most common variables associated with erectile dysfunction.3,4 Data from the Health Professionals Follow up Study (HPFS) including 31,742 males examining the impact of obesity, physical activity, alcohol use and smoking on the development of erectile dysfunction found that physical activity was significantly inversely associated with erectile function.

Background

Men who expended physical activity equivalent to running nearly 1.5 hours per week or doing rigorous outdoor work for three hours per week had a 0.8 relative risk (95% CI 0.7-0.9) of erectile dysfunction compared to men performing limited physical activity.5

Background

Furthermore, emotional components such as depression and impaired quality of life, which are highly common in patients with cardiovascular disease, are also associated with sexual dysfunction,27, 28 and one study showed that men with untreated depression were nearly twice as likely to develop erectile dysfunction as those without depression.29

Background

Current treatment strategies

Background

Despite the fact that several sets of international guidelines recommend health professionals address the topic of sexuality with cardiovascular patients,30,31 this is rarely done in practice.32,33 Health professionals express that it is difficult to talk about sexuality with patients and do not feel they have the required knowledge assume that patients are embarrassed or anxious.33

Background

In general there is no consensus or practice on how or where patients with cardiovascular disease and sexual dysfunction should be treated. Some patients are treated with phosphodiesterase-5(PDE-5) inhibitors for example sildenafil and tadalafil, and a few are referred to sexological clinics. Treatment with PDE-5 inhibitors is effective for about 50% to 80% of those treated (36) but is directed primarily towards men and towards those with sexual dysfunction of a physical etiology. In cardiovascular patients that do not respond to the drug, where its use is contraindicated because of treatment with nitrates, and also in women, there is no consensus on what alternative treatment should be offered.

Background

Alternative treatment strategies

Background

There is evidence that suggests that physical activity may prevent and also improve erectile dysfunction in men who have not already developed cardiovascular disease.5, 34 Whether this is the case in patients with already established cardiovascular disease has yet to be determined, but it is plausible to believe and a number of studies pointing in that direction.12, 35 A trial studying the effect of four weeks of supervised physical training, including home exercise for patients, who have had a myocardial infarction, found that patients more often return to sexual activity if they have exercised.35 Another trial indicates that eight weeks of physical training show improvement in male heart failure patients' sexuality.12 This study measured three parameters: partner relationship, the quality of penile erection and personal wellness. There was a significant improvement in all parameters in relation to the control group. Conversely there is literature where physical interventions have shown no effect on heart patients' sexuality.36

Background

Physical exercise is generally perceived as health promotion and is a regular part of many rehabilitation programs for chronically ill patients. Whether a physical intervention targeting sexual dysfunction should be an alternative or adjunct to conventional treatment is an interesting thought. Due to these conflicting results there is a need for a detailed study of the literature in order to investigate the real effect of a physical intervention on sexual dysfunction in patients with cardiovascular disease.

Background

An initial search in the data bases CINAHL, JBI COnNECT+, PubMed and Cochrane Library shows that no systematic review on this topic exists, or is currently underway.

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