Sex after Neurosurgery–Limitations, Recommendations, and the Impact on Patient’s Well-being

The aspects that affect the well-being of patients after neurosurgery are diverse.


Introduction
The aspects that affect the well-being of patients after neurosurgery are diverse.While most contemporary research argues that well-being is multidimensional and related to how individuals, communities, and societies feel when they are successful, there is no single agreed-upon de inition [1].Well-being is de ined in the Oxford Dictionary as the state of feeling healthy and happy (Cambridge Dictionary).Well-being is a term used synonymously with a wide range of concepts including self-esteem, self-ef icacy, self-determination, resilience, quality of life, improved mood, positive mental health, life satisfaction, and value [2].
A patient after neurosurgery experiences a hospitalization that can affect his well-being and he eventually returns to the community from which he came.A community is a small, local group of people who share common interests and values [3].When patients return after neurosurgery to a society that should help them reintegrate while dealing with new physical and mental disabilities, this requires cooperation and can re lect the level of social cohesion, which may be affected by the resilience of the community.
No agreement has yet been reached on an accepted and agreed-upon de inition of "community resilience".In a systematic literature review, 80 articles were identi ied in which "community resilience" remains an amorphous concept that is understood and applied differently by different research groups.However, despite the differences in concept and implementation, there are well-understood elements that are widely suggested as important for a resilient community.Focusing on these individual elements may be more productive than trying to de ine and study community resilience as a distinct concept [4].
A resilient community is a community that can help its members withstand and recover from general or personal adversity and crises, respond to individuals in times of crisis, and provide them with strong social networks.The strength of each individual in society ultimately contributes to the strength of society as a whole.If so, the aspects that affect people's well-being are many, and one of them is a stable and strong community [4].We will try to understand in this report the patients' well-being after neurosurgery and how we can ensure that they become a signi icant part of society again and not a burden.This report will deal with a speci ic aspect that may contribute to their well-being at different levels and that is sex.The goal is to systematically review the literature investigating sexual relations after neurosurgery and offer recommendations for dealing with patients after neurosurgery since there is not much literature on the subject but there is a great need for essential information on this subject, both on the part of the therapists and the patients.

Literature review
Emotional intimacy, sexual satisfaction, and relationship satisfaction are closely intertwined for couples and can play a signi icant role in the dynamics of their relationship [5].A study that explored the relationship between sex and personal well-being found that abstinence was particularly related to maintaining relationships over time.Perceptions of a partner's motivations for sex were also related to wellbeing [6].
When the relationship between well-being and selfsatisfaction with sexual function in women was investigated, a group of 349 women aged 18 to 65 were recruited from the community.Women who identify themselves as having sexual dissatisfaction have a lower general psychological well-being.These indings reinforce the importance of addressing sexual health and sexual well-being in women as an essential component of their health care [7].
In the English Longitudinal Study of Aging (ELSA) a total of 6,201 core participants aged 50 to >90 completed a comprehensive questionnaire.While the likelihood of reporting sexual health concerns tended to decrease with age in women, the opposite was seen in men.Poor sexual function and disagreements with a partner about initiating and/or feeling obligated to have sex were associated with general sex life dissatisfaction in men.Sexually active men reported higher levels of concern for their sexual health and well-being than women of all ages.The conclusion is that sexual health must be managed not only in the context of age, gender, and general health but also within the framework of the existing sexual relationship between partners due to the impact on their well-being [8].
Little is known about the relationship between sex and the risk of complications after neurosurgical intervention.In a study aimed at determining the relationship between sex and morbidity after neurosurgery, the percentage of patients who experienced complications within 30 days of surgery was 20.3% for men and 11.3% for women.The indings indicate that the male gender is a predictor of the risk of postoperative complications and an increase in hospitalization after neurosurgical intervention.This inding may be used clinically to help identify patients at increased risk for complicated recovery [9].
Patients facing the prospect of a potentially life-changing procedure with an uncertain outcome demonstrate high levels of concern and need for information.Many of them are not satis ied with the amount of information received from the doctors.There are many ways physicians can improve the delivery of information to patients, including providing written information and overcoming barriers to effective communication [10].
The physical demands of intercourse were reviewed in original studies published in PubMed, Scopus, and Web of Science through April 2020.18 studies analyzed physical demands during intercourse.It was found that sexual intercourse can induce an energy expenditure of ~100 kcal and an average heart rate between ~90 and ~130 beats per minute.However, the physical demands may vary depending on the health status, position, duration of the activity, stage of the relationship, and differences between the sexes [11].
Intercourse may elicit moderate physical demands, but the demands vary according to contextual variables.Also, not only studies that combine physiological and kinematic analyses are necessary, but also quality studies should be published to better understand the physical demands of sexual intercourse, thus increasing the ability to guide patients after medical procedures when they return to their homes [11].
The impact of different types of neurosurgeries on sexual health and activity after surgery is a common question among patients and healthcare professionals.There are recommendations from neurosurgeons, but there is no clear answer to this question in scienti ic literature and there is no blanket clinical agreement.Sexuality is an essential aspect of quality of life.However, intercourse is physically challenging and leads to obvious changes in blood pressure, heart rate, and breathing rate that can lead to vital complications [12].

Discussion
Many neurosurgical patients are young, it, and lead sexually active lifestyles.Moreover, some of them suffered a cerebral hemorrhage while having sex and many questions arise regarding the return to routine after weeks and months of hospitalization and rehabilitation.There is a paucity of evidence in the literature to suggest when or if intercourse can be considered safe after neurosurgery.How often do we encounter sexual complications after neurosurgery?Do we have a safe "honeymoon period" for resuming sex?How soon after hospitalization is it safe to have sex?Do the patients doubt this possibility and fear it [13]?This report will attempt to answer these important questions.The goal is to offer guidance to patients and their primary caregivers.To simplify things, we will classify the patients in neurosurgery into four groups: those who underwent brain surgery, those who underwent spinal surgery, those who suffered from subarachnoid hemorrhage, and those who underwent traumatic brain injury.

Brain surgery
After brain surgery, the fear is that having sex will raise the Intracranial Pressure (ICP), causing a reduction in brain perfusion.Such a drop can lead to a stroke, seizure, or even a Cerebrospinal Fluid (CSF) leak.During intercourse, mean arterial pressure increases to adequately meet the brain's demand for oxygen.A study that examined the increased ICP in patients who performed exercises for 20 minutes, showed that there was no effect on patients' ICP.Can we equate physical activity with sex [14]?
Besides the arterial pressure in the brain, there is an increase in intra-abdominal pressure due to the contractions of the abdominal wall and due to the weight of the partner in the "missionary" position.This increase leads to an increase in intracranial pressure and therefore to a decrease in cerebral perfusion pressure.In a study that assessed the safety of physical therapy by investigating its effect on Intracranial Pressure (ICP) and cerebral perfusion pressure, 65 patients were examined in a neurosurgical intensive care Most participants (83%) were male; the average age was 42.4 years.The average experience in neurosurgical practice was 9 years.The respondents assumed that in 34% of their patients, sexual health was compromised due to spinal disease.Most of the respondents (64%) stated that the responsibility for discussing sexual health lies (partially) with the neurosurgeon; however, 73% indicated (almost) never doing so.The main reasons for not discussing sexual health were the patients' age (42%), lack of knowledge (38%), and patients' lack of initiative to raise the issue (36%).26% cited lack of time as a reason.There was no evidence of physician gender or age mismatch as an important barrier.50% of participants wanted to gain more knowledge about discussing sexual health with patients [19].
Additional training in sexual health counseling at the beginning of the residency program seems critical.Neurosurgeons have the potential to identify sexual dysfunction and make appropriate referrals when needed, thereby improving the overall well-being of their patients as they return to the community they left and take their steps back to normalcy [19].
As part of the rehabilitation treatment after spinal surgeries, pushing or tilting exercises of the pelvis are performed which are usually used to improve lumbar stability.The thrust involved in intercourse may provide a valuable bene it to the patient's physical therapy provided the movement is not too forceful [20].

Subarachnoid hemorrhage
Sexual intercourse may also be a trigger for subarachnoid hemorrhage, bleeding in the space between the brain and the surrounding membrane, with a fatal outcome, as shown in a case report of a 22-year-old woman who suffered subarachnoid hemorrhage after intercourse.The patient was immediately transported to the hospital by emergency medical services but died within 24 hours.After postcoital headaches, subarachnoid hemorrhage is the second most common cause of neurological complications of intercourse.Nevertheless, more studies are needed to prove a direct link between sexual contact and cerebral aneurysm rupture [12].
To assess the consequences of aneurysmal subarachnoid hemorrhage (aSAH) on sexual pleasure in patients, anonymous, standardized questionnaires concerning sexual function were administered, including the International Index of Erectile Function (IIEF), the Female Sexual Function Index (FSFI), and a statement of subjective change in sexual pleasure.After aSAH.33 patients participated in the study, all of whom had positive neurological outcomes (score 4 or 5 on the Glasgow Outcome Scale).The results showed that 10 patients (31.3%) reported subjective worsening of sexual pleasure after aSAH.Sexual dysfunction affected 9 of the 19 patients (47.4%).All 19 women suffered from hypoactive sexual desire disorder.Erectile dysfunction was present in 7 of the 14 male patients -50% [21].
unit.The researchers concluded that physical therapy can be used safely in patients with normal or elevated ICP provided that Valsalva-like maneuvers are avoided [15].
Orgasm as a result of returning to sexual activity may indeed cause an increase in ICP, although a lood of catecholamines including dopamine during orgasm should provide an analgesic bene it, working synergistically with pain relievers that the patient may be taking after surgery.A reduction in the requirement for opioid analgesics can bene it the patient's recovery, and reduce opioid side effects such as constipation, nausea, and confusion.No research has been found to date that has examined how orgasm affects ICP.
For ethical reasons, it may be dif icult to conduct research in these groups to substantiate the indings [16].

Spine surgery
In spine surgery, there are different types of surgery, but most of them have the same restrictions.The guidance of course varies depending on the type of surgery, but there is very little guidance for patients regarding how long they should abstain from sex after spine surgery.An example of lumbar disc prolapses and microdiscectomy is used.In the context of a microdiscectomy/lumbar laminectomy, a patient discharged after surgery will be concerned about resuming intercourse for several reasons.There is a risk of recurrent disc prolapse because intercourse can increase the pressure on the lumbar spine due to the proximity to the pelvis, having intercourse too early may accelerate complications such as delay in spinal fusion or displacement of an implant.All these together, and the fear of pain limit the resumption of sexual activity [17].
In a survey that included 50 spine surgeons: 47 men and 3 women with an average age of 45.7 years, the participants were asked questions about the number of weeks it is recommended to abstain before returning to sexual activity after minor, medium, and major spinal surgeries.It was found that there were no statistically signi icant correlations between the ages or years of the participants.Some answers differed signi icantly between participants.The results also showed a trend for spine surgeons to recommend longer intervals for returning to sexual activity after more involved surgical procedures.The results of the survey demonstrate the complete lack of doctor's agreement regarding recommendations for returning to sexual activity after surgery and the need for further research [18].
Despite the high prevalence of sexual dysfunction in spine patients, counseling about sexual health is not often done in neurosurgical care.Members of the Dutch Association for Neurosurgery were sent a questionnaire regarding their attitudes, knowledge, and practice patterns regarding sexual health discussion to identify the knowledge, attitude, and practice patterns of neurosurgeons who advise their patients about sexual health because it is not known to what extent neurosurgeons discuss this topic with their patients [19].
Since this study is the irst known evaluation of sexual health following aSAH with positive neurologic outcomes, and it con irms that sexual dysfunction is common in this population, it is recommended to investigate sexual health during follow-up with these patients [21].

Traumatic brain injury
Another group we will refer to in this report is a group of patients with traumatic brain injury (TBI).A study aimed at investigating the impact of TBI on sexual ability, activity, and satisfaction and linking the indings to neurological status, functioning, and well-being included 92 TBI individuals (65 men, 27 women).Their age ranges from 20 years -70 years.The median age at the time of injury was 32 years.The time since the injury ranges from 1-20 years (median 9 years).The participants were tested according to a procedure that includes a neurological examination, self-assessment of general health status and functioning, and mood and data collection on social situations.53 of the participants had a stable relationship with a partner at the time of the investigation [22].
This study showed that TBI generally alters sexual function and desire.Many of the respondents reported a decrease in the ability to achieve an erection, a decrease in the ability to experience orgasm, a decrease in sexual desire, and a decrease in the frequency of intercourse.A high level of physical independence and preserved sexual ability were the most important predictors of sexual adjustment [22].

Recommendations
From a theoretical point of view and considering the literature review above, the recommendations are: • The attending neurosurgical team should be aware of this aspect of the patient's lifestyle and should be prepared to discuss it during the preoperative consultation period without any stigma in recognition of the impact of sexual intercourse on the patient's well-being.Patient information lea lets should include details about sex after neurosurgery.
• High-risk patients who have undergone major brain surgery may avoid intercourse in the postneurosurgery period.Patients who wish to have sex despite the potential risk of seizures, stroke, or CSF leak should be advised to avoid the Valsalva maneuver and be warned against any positions that involve effort, heavy lifting, or pressure on the abdomen.
• Patients should be warned after microdiscectomy about the risk of intercourse in the early postoperative period.Controlled and gentle pelvic thrusting should be encouraged as part of physical rehabilitation.As a rule, if pain appears, it is recommended to avoid it.Apart from pain, there is no clear contraindication to sex after most spine surgeries and the spine neurosurgeon should be able to discuss this with the patient before surgery.This applies to various neurosurgical interventions on the spine.
• Post-cranial and spinal surgery patients may be rewarded with analgesic bene its from the endorphin response secondary to orgasm.Staff should be aware of that.
• Since it has been shown that sexual dysfunction is common in the aSAH population, it is recommended to investigate sexual health during follow-up with these patients and guide them accordingly.
• Given that many TBI individuals report physiological sexual disturbances and decreased sexual ability, it is important to inform patients about the options to optimize their sexual ability.Organized sex education programs should be an integral component of TBI rehabilitation.
• The fear regarding "sex after neurosurgery" should not be eliminated and sex should be encouraged when the patient agrees to it, with a commonsense approach [20][21][22].

Conclusion
The aspects that affect the well-being of many people, among them a stable and strong community that can help its members withstand general or personal dif iculties and crises and recover, respond to individuals in times of crisis, and provide them with strong social networks.The strength of everyone in society ultimately contributes to the strength of society until, in the end, the strength of the whole exceeds the sum of its parts.
The well-being of patients after neurosurgery is important for them to become a signi icant part of society again.This report dealt with a speci ic aspect that may contribute to their well-being at different levels and that is sex.An investigation of intercourse after neurosurgery in the literature reveals a lack of evidence to reliably conclude the safety of intercourse after neurosurgery.Moreover, both doctors and patients lack information about the possibility of intercourse after neurosurgery, rehabilitation, and return to the community.
It is advisable to use the recommendations from the literature for the treatment of patients after neurosurgery.
The recommendations presented in this report may ill in the gaps regarding concerns after neurosurgery and overcome the limited information available regarding intercourse after neurosurgery.More research is needed on this important topic that has a direct relationship to the well-being of patients after neurosurgery and for some in the community to which they return after hospitalization.