Splenectomy is associated with sexual dysfunctions and decreased libido The removal of the spleen due to disease or trauma may be followed by disorders due to the asplenism, including immunodeficiency, hematological and metabolic diseases, mainly dyslipidemia, which can lead to sepsis, pulmonary embolism and early death. Although patients frequently report sexual disinterest after splenectomy, this feature has been experimentally studied only in a translational investigation performed by the same group of this work. To study libido and other sexual functions after the complete removal of the spleen in humans. This study was performed on 60 healthy adults, 30 men and 30 women, after more than 1 year of total splenectomy to treat isolated splenic trauma. The International Index of Erectile Function was applied to men and the Female Sexual Function Index to women. The analysis compared the responses obtained in the periods before and after the splenectomy. Laboratory tests with hematological and biochemical analyses, including sex hormones, were performed in all patients. The pre- and postoperative results were compared in each group using the paired t-test, with each patient being his or her own control and with significance to p < 0.05. A decrease in libido and an increase in sexual dysfunction was observed after splenectomy in all men and women, p < 0.001. All postoperative laboratory tests showed normal values in both genders. Asplenia is associated with a marked decrease in libido and intense sexual dysfunction in both men and women, with normal hematological and biochemical laboratory tests, including hormonal exams. During the Battle of Dettingen in England (1743), a soldier suffered abdominal trauma with externalization of the spleen, which was surgically removed. He recovered from the surgical procedure, but lost interest in sexual activity1. Shulz and Czermak, in the nineteenth century, observed a reduction in fertility in splenectomized animals. These two publications indicated the possibility that splenectomy could interfere in sexual activity1,2. In personal clinical experience with splenectomized patients, it was found that, after the removal of the spleen, many patients of both genders complained about the loss of sexual interest. The removal of the spleen due to disease or trauma may lead to adversities resulting from the asplenic state, including immune, hematological and metabolic disorders, mainly dyslipidemia, early death due to sepsis and pulmonary embolism3,4,5,6,7,8,9. The only published study that relates sexual activity to the spleen or splenectomy belongs to the authors of this study9. The previous work, carried out on couples of mice, started this translational investigation and found a reduction in the number of pregnancies after splenectomy. Another finding of that study was the reduction in the number of puppies from couples who had a pregnancy after splenectomy9. The purpose of this study was to verify changes in libido and other sexual functions after the complete removal of the spleen.This study belongs to a line of research and was carried out in accordance with the recommendations of the Declaration of Helsinki and was approved by the Research Ethics Committee of the Hospital Foundation of the State of Minas Gerais, logged under protocol number 068934/2016. All patients agreed to participate in the study, and signed the Free and Informed Consent.Medical records of patients of both genders, between 20 and 50 years of age, with no selection between men and women, who underwent a total splenectomy due exclusively to splenic blunt trauma, without other diseases, at the João XXIII Emergency Hospital in Belo Horizonte, Brazil, between 2010 and 2018, were collected, before the COVID-19 pandemic. All patients corresponding to these records were invited to a medical consultation, where this project was presented and explained to them. This study included only patients who agreed to participate in this research and who had an active sexual relationship before splenectomy, presenting no diseases, such as diabetes mellitus, vasculopathies, heart disease, malignant neoplasms, mental disorders, or addictions of smoking, alcoholism, the use of psychotropics, etc. Patients whose answers to the questionnaires were doubtful or incomplete, as well as those who did not perform all the complementary exams, were excluded from this study and replaced by other patients in similar conditions. At the end of this selection, 30 men and 30 women were studied with all the data collected reliably only by the authors of this work.Each patient underwent a careful anamnesis about their health, including immunological manifestations, current physical condition and complaints, as well as previous illnesses. Then all of them underwent a complete physical examination. After that, the questionnaires were answered in full by the 60 patients, who, at the time of their splenectomy, were between 20 and 44 (M = 30) years of age for men and between 19 and 47 (M = 34) years of age for women. Regarding marital status, in the male gender, eleven declared themselves to be single, eight, in a stable relationship, six married, and five, divorced. In the female sex, seven declared themselves to be single, nine, in a stable relationship, eight married, and six, divorced.Each patient was identified by age and post-splenectomy time. The International Index of Erectile Function (IIEF) was then applied to men and the Female Sexual Function Index (FSFI) to women10,11,12,13,14. For each question in the questionnaire, two responses were collected for the periods before and after the splenectomy. The postoperative study was conducted over a period of one to 9 (5 ± 3) years from the splenectomy.Patients underwent blood count on Sysmex XN-3000 hematology analyser (Sysmex America, IL-USA). The hematological tests included thrombocytes, erythrocyte characteristics, Howell Jolly, Heintz and Pappenheimer bodies. The leukocytes were classified by either their structure and by cell lineage, including B and T lymphocytes, separately studied. Creatinine, glucose, lipidogram, fractionated proteins, aminotransferases, luteinizing hormone (LH), follicle stimulating hormone (FSH), thyroid stimulating hormone (TSH), free thyroxine (T4), free testosterone, prolactin, estradiol, cortisol, adrenocorticotropic hormone (ACTH) and dehydroepiandrosterone were assessed using an Ortho VITROS® 5600 chemiluminescence immunoassay (CLIA) analyzer (Ortho Clinical Diagnostics, Skillman, NJ-USA) for detection of biochemical immunological and hormonal exams.The interpretation of the IIEF questionnaire for males followed the guidelines in Table 1. Each domain consisted of three to six objective questions, restricted to their specific aspects.Table 1 Classification of male sexual function through the domains of the international index of erectile function and values assigned to each domain by this index.The interpretation of the FSFI questionnaire for women followed the guidelines in Table 2. Each domain was made up of two to four objective questions, restricted to their specific aspects.Table 2 Classification of female sexual function through the domains of the Female Sexual Function Index and values assigned to each domain by this index.In addition to these questionnaires, each patient was asked about the number of children they had after splenectomy.The results were calculated for means and standard deviation of means (SDM), in addition to percentages, as measures to describe the parameter incidence. When comparing the measurements made on the same patient before and after splenectomy, the paired t-test was used to determine the difference between two measurements taken on the same patient. All results were considered significant for a probability of greater than 95%, corresponding to p < 0.05.All patients reported having had an active sex life until abdominal trauma, which only injured the spleen. All patients underwent laparotomy and removal of the spleen exclusively, with no need for further surgical procedures. The patients had no postoperative complications or other conditions related to splenectomy, no disease was found, and no patient was using medication or psychotropic drugs. No patient presented any symptom related to immunological deficiency after splenectomy, including pneumonia, urinary or genital infection, sepsis, meningitis and frequent influenza episodes.In males, the mean erectile function score decreased after splenectomy, indicating a worsening libido and the appearance of sexual dysfunctions. There was a reduction in all studied domains, with a greater worsening of sexual desire (Table 3).Table 3 Comparative analysis of male sexual function scores (mean ± standard deviation of mean) of the international index of erectile function domains.When asked about erectile function, 100% of patients reported having been normal in the preoperative period and that erectile dysfunction occurred only after undergoing the splenectomy, which was reported by 80% of the patients. Ejaculatory and orgasm dysfunction also appeared in 80% of the patients after undergoing the splenectomy. Preoperatively, only four (13.3%) patients reported having moderate orgasm and ejaculation dysfunction.Sexual desire was totally lost by 70% of the men after undergoing the splenectomy, and only one patient reported maintaining normal, unchanged erectile function after the procedure. Before the splenectomy, 86.7% of the patients reported having a normal sexual desire, only 13.3% of the patients had sexual dysfunction, which, according to their reports, was not intense. In the preoperative period, sexual intercourse was reported to be satisfactory for all patients; however, there was a decrease in sexual satisfaction after undergoing a splenectomy in 40% of them. When asked about general satisfaction regarding preoperative sexual function, only one (3.3%) patient reported moderate complaints, but after having undergone the splenectomy, the patient reported moderate and severe dissatisfaction in sexual activity in 96.7% of the patients.In females, a reduction was found in the score of all studied domains, when the periods before and after splenectomy were compared (Table 4). Satisfaction in sexual activity was the domain with the highest drop in scores, followed by reductions in orgasm and sexual desire. In the preoperative period, the domain that had the lowest average score was the natural vaginal lubrication, which was reported as reduced and unsatisfactory, while in the postoperative period, the lowest average score was the decrease in sexual desire. Reduction or loss of sexual desire occurred in all patients after undergoing the splenectomy, whereas in the preoperative period, this disorder was present in 43.4% of them.Table 4 Comparative analysis of female sexual function scores (mean ± standard deviation of mean) of the Female Sexual Function Index domains, before and after splenectomy.Asked about arousal for sexual intercourse, 56.6% of the patients revealed severe dysfunction after undergoing a splenectomy, while in only 6% of them this function was unchanged. Most patients (93.3%) felt a decline in the natural vaginal lubrication, and 100% sexual dissatisfaction after undergoing a splenectomy. There was an increase in complaints of pain related to sexual intercourse from 13.3% before surgery to 86.7% after the splenectomy.None of the 60 patients had children after the splenectomy. However, it should be considered that 12 (40%) men, and 8 (26.6%) women underwent splenectomy less than three years before this study and about half of the patients were not married or in a stable relationship.All laboratory test results were within normal reference values. No abnormal event was found in the hematological study, all elements were normal and no atypical cytopathological body was found. Only free testosterone values were close to the lower limit of normal in 90% of the men. However, the averages of the sexual function domains of patients who had normal testosterone and those with low values did not differ (Table 5).Table 5 Comparative analysis of female and male hormone levels (mean ± standard deviation of mean) after splenectomy.Both male and female sexual functions are associated with multiple organic and psychosocial factors. To reduce the intervening factors, this series was restricted to healthy patients, of reproductive age, and with active sexual activity, without the illegal use of drugs or psychotropic drugs, smoking, or alcoholism1,3,4,5,6. Surgical trauma was restricted to the spleen, which was the only injured organ in all cases and must be fully removed. Thus, sexual dysfunctions that arose after splenectomy could be associated with asplenic status. The assessment of the sexual functions used internationally accepted accurate questionnaires10,11,12,13,14. According to the literature, sexual dysfunctions are more frequent in women (43%) than in men (31%)15. In females, hypoactive sexual desire is the most common dysfunction (27%), followed by dyspareunia (23%) and the absence of a satisfactory orgasm (21%)16. In this study, the dysfunction most reported by patients in the preoperative period was low sexual excitement (53.3%), followed by hypoactive sexual desire (43%), and little vaginal lubrication (30%). In the postoperative period, all patients had more than one manifestation of sexual dysfunction (Table 4). Despite the extensive literature review, no other surgical procedure was found that resulted in sexual dysfunction in all patients.Salto et al. found delayed ovulation and a higher incidence of pseudopregnancy in asplenic rats. These disorders were normalized after the injection of splenocytes, indicating an association of splenic tissue with ovarian functions17. Okely et al. studied the dynamics of ovulation associated with mediators of acute inflammation and observed fewer leukocytes in the ovaries of splenectomized rats, indicating
https://www.nature.com/articles/s41598-021-01371-7
Splenectomy is associated with sexual dysfunctions and decreased libido
