創傷後一年常發生性功能障礙


  October 14, 2008(加州舊金山) — 根據發表於第94屆美國外科醫學會(ACS)年度臨床研討會中的一篇報告,超過30%的創傷病患在中到重度創傷後一年,有某種程度的性功能障礙(SDF)。
  
  第一作者、華盛頓大學醫學院泌尿科的Matthew D. Sorensen醫師發表的這篇研究包括了14個州、69家醫院總共10,122名年紀在18至84的男性和女性;在他們創傷後3個月和12個月進行訪談,屬於「National Study on the Costs and Outcomes of Trauma (NSCOT) 」這個由國家健康研究中心贊助的多中心世代研究的一部份。
  
  在這12個月的評估期間,以功能涵容指數(Functional Capacity Index)這個在1970年代晚期到1980年代初期研發出來的問卷,來確認他們有無SDF與其嚴重程度如何;Sorensen醫師表示,所有的病患都被問到「你的生理健康,是否會限制你性關係的能力」,那些回答「是」的病患被要求描述他們的限制程度有多少;回答「一點點」的病患歸類為輕微性功能障礙,回答「許多」或「完全」的病患視為嚴重性功能障礙。
  
  該研究的目標是確認嚴重創傷後的性功能障礙風險因素與發生率;調查的10,122名對象中,30.5%報告有SDF (n = 3087) —嚴重性功能障礙者有1,773人、其他1,314人為輕微性功能障礙;分析個別因素以確認造成SDF的校正相關風險(aRR)。研究者校正種族、性別、婚姻狀態、生殖泌尿道損傷、創傷機制等,以確認SDF的預測因子。
  
  可明顯預測SDF的因子有;
  * 年紀(每增加一歲、aRR = 1.02 )
  * 家庭收入少(收入越低、風險越高,aRR = 1.12 - 1.60)
  * 個人健康狀態(健康越差、風險越高,aRR = 1.27 - 3.54)
  * 創傷前即有糖尿病(aRR = 1.34)
  * 創傷嚴重度分數增加(每增加一分、aRR = 1.02)
  * 骨盆骨折(aRR = 1.45)
  * 下肢骨折(aRR = 1.48)
  * 脊索損傷(aRR = 3.73)
  
  毫無意外地,損傷程度最嚴重的病患,性功能障礙風險最高。
  
  該研究試圖探究造成障礙的原因,因此讓病患完成另外一個問卷:慢性疼痛分類量表(Graded Chronic Pain Scale),結果顯示,疼痛指數越高的病患,性功能障礙的機會也增加。
  
  病患也完成美國流行病學研究中心之憂鬱量表(Center for Epidemiologic Studies Depression Scale,CES-D);嚴重性功能障礙者的憂鬱發生率幾乎是兩倍,輕微性功能障礙者也是如此;只有2.5%的憂鬱患者沒有性功能障礙。
  
  最後,該研究檢視SDF者的創傷後壓力症候群(PTSD),在沒有SDF的病患中,只有11%有PTSD症候群;近40%的輕微SDF病患有PTSD症候群,將近半數的嚴重SDF病患有PTSD症候群。
  
  Sorensen醫師在發表時指出,本研究的限制是沒有開始時的性功能資訊;此外,這些問卷是病患自行回答— 沒有和醫師碰面,也沒有身體檢查。
  
  擔任此研究的討論會主持人、東維吉尼亞醫學院泌尿科的Gerald Jordan醫師表示,這種報告實際引起我進一步探索與解釋後續情形的慾望。文獻中有提到與性功能障礙有關的其他關聯,其中一種為心臟手術;在發表的案例中,創傷嚴重分數或許有關,但也可能代表代謝受挫或者延長代謝不佳,之後需要探討荷爾蒙的問題。
  
  Jordan醫師為Medscape General Surgery闡述這些議題,我們是根據代謝傷害而探討荷爾蒙嗎?我們將細胞激素和autokine對創傷的反應視為一種內皮效果嗎?這是個迷人的領域。他形容這個議題是「二度收穫」。他觀察認為,發生性功能障礙影響重大,這個研究是有關「你對它的抱怨?」嗯!抱怨它和有它是兩回事。
  
  Sorensen醫師向Medscape General Surgery 表示,可以早期介入;他認為治療需依照所認定的原因,當然這些病患是在創傷後一年,所以,如果我們可以發現可以治療的共病症,例如憂鬱或疼痛,針對這些問題加以治療,或許他們的性功能會好一些。
  
  Sorensen醫師和Jordan醫師宣稱沒有相關資金上的往來。
  
  第94屆美國外科醫學會(ACS)年度臨床研討會:外科研討會SF04 — 泌尿與生殖手術。發表於2008年10月13日。

Sexual Dysfunction Common at 1 Year after Trauma

By Jacquelyn K. Beals, PhD
Medscape Medical News

October 14, 2008 (San Francisco, California) — More than 30% of trauma patients report some degree of sexual dysfunction (SDF) 1 year after they have suffered moderate to severe injuries, according to a study presented here at the 94th Annual Clinical Congress of the American College of Surgeons (ACS).

First author Matthew D. Sorensen, MD, from the Department of Urology at the University of Washington School of Medicine in Seattle, presented the study of trauma patients at 69 hospitals in 14 states. The 10,122 subjects were men and women and ranged in age from 18 to 84 years. They were interviewed 3 months and 12 months after their injury as part of the National Study on the Costs and Outcomes of Trauma (NSCOT), a multicenter cohort study funded by the National Institutes of Health.

During their 12-month assessment, patients were given the Functional Capacity Index, a validated questionnaire developed in the late 1970s or early 1980s, to determine the presence and severity of SDF. "All patients were asked if, as a result of their physical health, were you limited in your ability to have sexual relations?" Dr. Sorensen said. "Patients that answered 'yes' were asked to describe their limitation as a little, a lot, or a complete inability." The study classified patients answering "a little" as mild sexual dysfunction, and "a lot" or "complete inability" as severe sexual dysfunction.

The study's goal was to define the prevalence of and risk factors for sexual dysfunction after major trauma. Of the 10,122 subjects surveyed, 30.5% reported SDF (n = 3087) — a majority had severe dysfunction (n = 1773) while the remainder (n = 1314) had mild dysfunction. Analysis of individual factors identified the adjusted relative risk (aRR) that each contributed to SDF. The investigators adjusted for race, sex, marital status, genitourinary injury, and mechanism of injury to determine predictors of SDF.

Factors that significantly predicted SDF were:

  • age (aRR = 1.02 for each additional year of age);
  • decreasing household income (aRR = 1.12 - 1.60, increased risk associated with lower income);
  • self-reported health status (aRR = 1.27 - 3.54, increased risk associated with lower reported health);
  • preexisting diabetes (aRR = 1.34);
  • increasing Injury Severity Score (aRR = 1.02 for each 1-point increase);
  • pelvic fracture (aRR = 1.45);
  • lower extremity fracture (aRR = 1.48);
  • spinal cord injury (aRR = 3.73).

Not surprisingly, patients with the most severe injuries had the greatest risk for sexual dysfunction.

The study attempted to explore the source of the dysfunction. Patients completed another questionnaire, the Graded Chronic Pain Scale, which showed increased odds of sexual dysfunction in patients who had greater amounts of pain.

Patients also completed the Center for Epidemiologic Studies Depression Scale (CES-D). Depression was nearly twice as prevalent in the group with severe sexual dysfunction, as in those with mild dysfunction. Only 2.5% of patients with depressive symptoms had no sexual dysfunction.

Finally, the study examined the involvement of posttraumatic stress disorder (PTSD) in SDF. In patients with no SDF, only 11% had PTSD symptoms. Almost 40% of patients with mild SDF had PTSD symptoms, and nearly half of those with severe SDF had PTSD symptoms.

Dr. Sorensen noted in his presentation that a limitation of the study is not having baseline sexual function information. In addition, the responses to the questionnaires are self-reported — patients did not meet with a physician or have a physical examination.

Gerald Jordan, MD, from the Department of Urology at Eastern Virginia Medical School in Norfolk, Virginia, commented on the study as a discussant: "This is the kind of paper that actually whets my appetite to try and explain further what could be going on. There are some other associations in the literature with sexual dysfunction, and one is following cardiac surgery," he noted. In the present case, "the injury severity scores probably correlate with and could be a surrogate to metabolic insult or prolonged metabolic insufficiency, and then one would need to look at issues that are hormonal."

Dr. Jordan elaborated on these ideas for Medscape General Surgery: "Are we looking at hormonal things based on the metabolic insult? Are we looking at the cytokines and autokine response to the trauma as an endothelial effect? It's a fascinating area." He also raised the issue of "the secondary gain." Having sexual dysfunction "ups the award several thousand dollars," he observed. "This [study] was about 'Did you complain of it?' Well, complaining of it and having it are 2 different things."

Dr. Sorensen told Medscape General Surgery about the type of early interventions that might be possible. "I think the treatment would depend on what we think the cause is," he said. "Certainly these are patients that are a year out from their injury, so...if we can find other comorbidities that are treatable, like their depression or their pain, that if those are treated their sexual function might get better."

Dr. Sorensen and Dr. Jordan have disclosed no relevant financial relationships.

American College of Surgeons 94th Annual Clinical Congress: Surgical Forum SF04 — Urology and Reproductive Surgery. Presented October 13, 2008.

    
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