Association between depressive symptoms and sexual dysfunction in men with traumatic spinal cord injury

RESUMO Introdução: A lesão medular acarreta em perda da independência funcional, autonomia e status social. Essa enorme mudança contribui para o aparecimento dos sintomas depressivos nessa população. Objetivo: Avaliar os sintomas depressivos e disfunção sexual em homens com lesão medular traumática, analisando a associação entre eles. Métodos: Estudo observacional, realizado com 44 homens com lesão medular traumática, idade entre 18 e 60 anos, tempo de lesão superior a um ano e vida sexual ativa. O grau de comprometimento neurológico foi avaliado através da versão revisada em 2011 da ASIA Impairment Scale, os sintomas depressivos através do Inventário de Depressão de Beck e a função sexual através do Índice Internacional de Função Erétil. Foram aplicadas técnicas de estatística descritiva e análise bivariada para verificar associação, utilizando um nível de significância de 0,05. Resultados: Os voluntários possuíam média de idade de 34,1 anos, e tempo médio de lesão de 7,7 anos. Todos os indivíduos da amostra tinham nível de lesão acima do segmento medular L2, sendo as incompletas as mais frequentes (68,2%). O tempo médio da última relação sexual foi de 56,5 dias e a frequência semanal de relação sexual foi a mais relatada (65,9%). Da amostra, apenas 17,6% tinham sintomas depressivos, sendo 6,8% com disforia e 6,8% apresentando sintomas leves a moderados. Não foi encontrada associação entre sintomas depressivos e disfunção sexual, exceto para o domínio da disfunção de satisfação geral (p=0,02). Conclusão: Não existe associação entre sintomas depressivos e disfunção sexual em homens com lesão medular crônica.


INTRODUCTION
Sexual function is a very affected aspect after spinal cord injury, ranging from changes in sexual desire to erection, ejaculation and orgasm dysfunction, but severity depends on the level and complexity of the lesion 1,2 . This factor could seem minor when compared to loss of motor function and autonomy [3][4][5][6][7] . However, the recovery of sexual function is one of the patient's top priorities during the rehabilitation process 8 .
Several studies in these individuals show the association of sexual function and quality of life [9][10][11][12] . As an important component in health and well-being, sexuality deserves special attention during the rehabilitation process, since the population affected after traumatic injury is predominantly male of reproductive and productive age 3 .
The loss of functional independence, social status, along with numerous other factors resulting from the injury, contribute to psychological consequences, leading to severe impairment in relation to any form of treatment, making it difficult for these patients to recover 11 .
After traumatic spinal cord injury there is a high prevalence of depressive episode when compared to the general population, about 10 to 30% 12,13 . Depressive behavior is considered one of the top ten causes of disability worldwide, and in patients with spinal cord injury, it has been associated with length of hospital stay, reduced functionality and performance during rehabilitation, and increased morbidity and mortality 14 .
Against this scenario, it is important to assess whether there is a relationship between sexual function and depressive symptoms in individuals with traumatic spinal cord injury, as there are studies that evaluate depressive symptoms after spinal cord injury, but there is a shortage when associated with sexuality 15,16 .
The aim of this study was to evaluate sexual dysfunction and depressive symptoms in men with chronic traumatic spinal cord injury and to analyze its association.  18 . This determines the degree of neurological disability and its level of injury, assessing the sensory level and motor level in each hemibody separately.

METHODS
The evaluation of segment S4-S5 determines the complexity of the lesion, whether complete or incomplete 16,18  showed depressive symptoms present in only 13.6%, ranging from disability (6.8%) to mild to moderate symptoms (6.8%) ( Table 1).
When analyzing the degree of injury and the severity of depressive symptoms, no statistically significant association was observed between both groups, complete injury and incomplete injury (p=0.21) ( Table 2).
When examining the IIFE domains separately, it was found that the highest prevalence of sexual dysfunction was in patients with no depressive symptoms, with no statistical association, except for the general satisfaction domain (p=0.02) ( Table 3). Still related to the domains, the orgasmic function, followed by the erectile function, presented the largest and most severe dysfunction (  (Table 4).

DISCUSSION
The present study found that spinal cord injury negatively inter- It is suggested that a longer injury time may be considered a facilitating agent for a more satisfactory sexual relationship, since with the chronicity of the lesion, there is usually a recovery of  However, although studies show that the presence of a steady partner can positively influence the maintenance of sexual practice after injury, rehabilitation and recovery of sexual function 25,26 , in the sample studied, less than 40% had a fixed partner, which did not affect the frequency of sexual activity. A small portion made use of 5-phosphodiesterase inhibitor drugs. For improving the erectile function of man, it can lead to a more satisfying sex life and fewer agents inhibiting pleasure and satisfaction, contributing positively to the patient's self-esteem,   Ferro JKO, Silva CP, Oliveira DA being a factor in the onset of depressive symptoms related to sexual aspect 27 . However, other studies show that despite the effects relevant to erection, the use of the medication mentioned above did not result in satisfaction with sex life 11,28,29 .
On the other hand, the presence of sexual dysfunction is considered as predictors of sexual satisfaction, either due to the inability to reach an orgasm, as well as reduced erection function and quality by overriding the restriction of mobility or type of disability 29 .
This fact could be observed in this study, in which the orgasmic function was the domain that presented the largest and most severe dysfunction. Dalberg et al. 9 , concludes that inability to reach orgasm among spinal cord injury patients is present in 35% of them, which may be explained by physiological effects and loss of sensory elements in male genital organs.
From the collected data, it was observed that a small part of the sample (17.6%) presented depressive symptoms, corroborating previous findings of low prevalence in patients with chronic spinal cord injury 30,31 . This finding could be related to the longer time after the injury, since there is evidence that the longer this time, greater knowledge of the injured body, in which the adaptation phase was passed and men begin to accept its trauma condition, learning to live with it as best as possible 32,33 .
However, other authors defend the opinion that the existence of depressive symptoms would be more related to the characteristics inherent to each individual, and the spinal cord injury itself is not the determining factor in the manifestation of depressive symptoms 33 . However, psychological distress and depression have the greatest impact on health condition and quality of life 34 .
Based on unscientific observations it is known that the worse the life of an individual with physical limitations, the higher the risk of developing high rates of depression, anxiety and hopelessness 33 .
And all these factors are related to sexual dysfunction as well as sexual satisfaction after the injury 31 .
When assessing the association between sexual function and depressive symptoms, no statistical difference was observed in most domains of IIFE, except that related to overall satisfaction. This fact could be explained by the predominance of the type of injury, difference in age and the duration of the participants injuries, which could have provided a good adaptation during this time after the injury.
Our findings on general satisfaction dysfunction show a direct relationship between depressive symptoms and dissatisfaction, noting that the worse the dysfunction, the worse the depressive symptoms presented. Therefore we can relate the magnitude of psychic suffering to the extent of physical harm.
The limitations of the study may be related to the relatively small sample size, the non-inclusion of patients with acute spinal cord injury, as well as the level of injury found. In addition, the research does not consist of objective tests, only questionnaires, relying on the patient's subjective report. Although this association was not found in most domains, the study was important because of the shortage of research about sexuality after spinal cord lesion, regarding the patient and the partner. It is important that healthcare professionals providing care to this audience are prepared to evaluate, treat and guide beyond the physical aspects, important issues for quality of life in order to improve attention during the rehabilitation process, with sexuality and the presence of depressive symptoms being a constant target of evaluation and treatment in this process.
In conclusion, the present study found no association between depressive symptoms and sexual dysfunction in men with chronic pain, except for the domain of general satisfaction.