Stroke is the leading causes of death and disability throughout the world. Although physical and cognitive impairments after stroke have been well studied, little information is known about one of the crucial aspect of the quality of life of stroke patients, namely sexual functioning and satisfaction. Post-stroke sexual dysfunctions seem to be very common; in men affected by stroke, a decline in libido and poor or tailed erection and ejaculation are frequently observed.

Sexual disorders after stroke are thought to be due to multiple etiologies, including both organic (i.e lesion localization, premorbid medical conditions, medications) and psychosocial (i.e fear of recurrences, loss of self-esteem, role changes, anxiety and depression). Thus, exploration in sexual dysfunctions and sexual counselling by trained professionals should be part of stroke rehabilitation.

Stroke, also known as cerebrovascular accident or “brain attack”, is a syndrome caused by a focal disruption in the cerebral blood flow due to occlusion of a blood vessel (ischemic stroke) or rupture of a blood vessel (hemorrhagic stroke). The interruption in blood flow deprives the brain of nutrients and oxygen, resulting in injury to cells in the affected vascular territory of the brain. Ischemic strokes are more common than hemorrhagic ones (80% vs 20%).

When brain cells die, function of the body parts they control is impaired or lost, causing paralysis, speech and sensory problems, memory and reasoning deficits, coma, and possibly death.

Classification and etiopathogenesis of both ischemic and hemorrhagic stroke are shown in tables Etiopathogenesis of ischemic stroke and Etiopathogenesis of Hemorrhagic stroke.

Table Etiopathogenesis of ischemic stroke

Causes
Common Atherosclerosis
Small vessels diseases
Cardioembolism/transcardial embolism
Uncommon Emathological disorders
Migraine stroke
Oral contraceptive/estrogen
Non estro-progestinic drugs
Unusual Primary vasculitis
Giant cells arteritis
Takayasu‘s arteritis
Systemic Lupus Erythematosus
Sneddon syndrome
Systemic necrotizing arteritis
Nodal Osteoarthritis
Churg-Strauss Syndrome
Wegener syndrome
Rheumatoid Arthritis
Sjögren Syndrome
Behçet diseas
Relapsing polychondritis
Sclerodermia
Sarcoidosis
Bürger‘s Diseases
Central Nervous System arteritis
Secondary vasculitis
Infection (Viral, bacterial)
Drugs
Beam radiation
Celiachia‘s disease
Chronic inflammatory bowel diseases
Inborn malformation
Fibromuscular dysplasia
Carotid Kinking and coiling
Basilar artery ectasia
Emotional incontinencehers-Danlos syndrome
Emotional incontinenceastic Pseudoxantoma
Marfan‘s Syndrome
Artero-venous malformation
Injured vasculopathies such as carotid dissection
Other cause
Snake poison
Fatty/gas embolia
Cerebral autosomal Dominant Arteriopathy with Subcortical
Infarcts and Leucoencephalopathy (CADASIL)
Fabry‘s disease

Table Etiopathogenesis of Hemorrhagic stroke

Side

Causes

Intraparenchymal Hemorrage Hypertension
Diabetes Mellitus

 

Brain trauma

 

Internal Carotid artery dissection
Eclampsia
Reperfusion injury
Rupture of aneurysm or artero-venous malformation

 

Arteriopathies such as Moya-Moya, Takayasu‘s Syndrome and Fibromuscular Dysplasia

 

Altered hemostasis (thrombolysis, anticoagulation)

 

Hemorrhagic necrosis (tumor)
Venous outflow obstruction (cerebral sinus venous thrombosis)

 

Extraparenchymal Hemorrage

 

Subarachnoid hemorrahage
Brain trauma
Rupture of aneurysm
Rupture of artero-venous malformation
Artery dissection
Extradural hemorrhage
Brain trauma
Artery dissection
Dural artero-venous fistulas

Epidemiology of Stroke

Stroke could soon be the most common cause of death worldwide. Indeed, it is currently the second leading cause of death in the Western world, ranking after heart disease and before cancer, and causes 10% of deaths worldwide. Geographic disparities in stroke incidence have been observed, including the existence of a “stroke belt” in the southeastern United States, but causes of these disparities have not been explained. The incidence of stroke increases exponentially from 30 years of age, and etiology varies by age. Advanced age is one of the most significant stroke risk factors. Ninety-five percent of strokes occur in people age 45 and older, and two-thirds of strokes occur in those over the age of 65. However, stroke can occur at any age, including in fetuses.

Quality of Life in Stroke Survivors

The most difficult aspect of having a stroke is living with the disability caused by this condition. Stroke is associated with high morbidity rates, meaning that many patients experience both physical and mental disability following the event. In fact, stroke morbidity is the leading cause of decreased independence and lowered quality of life among adults. Interestingly, coping strategies are powerful determinant of quality of life, but only more than 5 months after discharge; before this time quality of life is mainly determined by general functioning. Despite the enormous personal and societal impact of stroke, the best method for measuring stroke outcome is not clear, even if assessment of stroke impact has been standardized. The National Institute of Health Stroke Scale (NIHSS) contains 13 items and measures severity of impairment in consciousness, orientation, gaze, motor function, sensation, language, speech and inattention, while the modified Rankin scale measures handicap or death on a scale of 1-6.

Nevertheless, some commonly used stroke outcome measures, such as the Barthel Index, a measure of disability in 10 functional items, and the Short Form 36 (SF-36), for example, have no assessment of language. Consequently, patients with severe aphasia may have a normal score on these measures and therefore be classified as having “good” outcome for purposes of analysis of drug efficacy. Other domains often neglected in stroke outcome assessments are cognitive, psychological, and social function.

Sexuality is an integrant and important part of quality of life and patient affected by neurological disability, especially if young, should also be investigated and treated for sexual disorders. Indeed, it is common knowledge that the impact of sexual dysfunctions on patients with recent stroke is great; however even though they suffer from sexual impairment, patients usually do not ask for counselling, and, moreover, they are not commonly investigated for this issue by physicians.

Aim of this chapter is to evaluate the burden of stroke on sexual function taking into account the complex interaction between neurological, psychological and relational factors.

Erectile Dysfunction after Stroke

Conclusion

Since the number of people who survive stroke and live with its consequences is increasing, there is a need for a better management of stroke related problems, including sexual dysfunction, providing the patients and their caregivers’ information useful to achieve a better quality of life.

Discussing and treating sexual problems in stroke survivors enters the framework of a holistic approach. Prevention should dispel stereotypes, myths, and misperceptions, not only in stroke survivors and their partners but also in rehabilitation staff members who may be unprepared for this goal.

Levitra

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