Hyposexuality is defined as diminished sexual drive or libido. There has been little research into the sexuality in patients with obstructive sleep apnea (OSA). We investigated the prevalence and relating factors for hyposexuality in OSA men.
Consecutive 182 male (mean age 48.3 y) were enrolled who were newly diagnosed with OSA through polysomnography. All completed Symptom checklist-90-Revised (SCL-90-R), Epworth Sleepiness Scale (ESS), Beck Depression Inventory (BDI), and Beck Anxiety Inventory (BAI). Subjects were divided into non-hyposexuality (score 0) and hyposexuality (score ≥1) groups according to the question “Loss of sexual interest or pleasure” in SCL-90-R.
110 of 182 subjects (60.4%) answered hyposexuality (score ≥1). Significant correlations were found between hyposexuality and following factors; age (rho=0.248), BDI (rho=0.450), BAI (rho=0.410), ESS (rho=0.221), and percentage of non-REM stage 3 (N3%) (rho=-0.184). Apnea-hypopnea index was significantly correlated with nocturia (rho=0.320), ESS (r=0.230), N1% (r=0.596), N2% (r=-0.540), N3% (r=-0.195), and lowest oxygen saturation (r=-0.641). Comparing two groups, hyposexuality group showed significantly lowered total sleep time (380.2 min vs. 359.1 min), and sleep efficiency (83% vs. 76%). The severity of hyposexuality was correlated with BDI (rho=0.330), BAI (rho=0.253), and N3% (rho=-0.215) in subjects with hyposexuality. After controlling for age, polysomnographic parameters were not correlated with hyposexuality.
About half of untreated OSA male subjects reported diminished libido. Age, daytime sleepiness, mood disorders, and decreased sleep quality were associated with hyposexuality. Of these, aging process was the most important factor for hyposexuality.
Obstructive sleep apnea syndrome (OSA) is a common sleep disorder affecting 4 to 9% of adult males and makes repetitive upper airway obstruction occurring hundreds of times in a night [
Hyposexuality is defined as diminished sexual drive or libido, and may or may not be accompanied by erectile or orgasmic dysfunction [
To date, there has been no large population-based study of association between OSA and hyposexuality in South Korea. The present study is to investigate the prevalence of hyposexuality in OSA male and to explore the related factors for hyposexuality in those subjects.
Patients who visited to the sleep clinic of Samsung Medical Center, Seoul, Korea from January 2014 to October 2014 were consecutively enrolled. All the patients were male between 18 and 81-year-old with history of sleep apnea and daytime sleepiness. They completed overnight polysomnography (PSG) and questionnaires. We defined OSA as 5 or more of apnea-hypopnea index (AHI) and presence of daytime sleepiness. Of total 206 patients, 8 patients were excluded because AHI was lower than 5. 16 patients who had uncontrolled metabolic disorders [hypertension (HTN), diabetes mellitus (DM), chronic renal disease], psychiatric disorders, critical illness, or other sleep disorders were also excluded.
All subjects were performed overnight PSG. PSG parameters were defined according to the American Academy of Sleep Medicine [
We used a question number 5 of Symptom checklist-90-Revised (SCL-90-R) to assess degree of hyposexuality [
Continuous data are presented as mean±standard deviation or median and interquartile range, as appropriate. We compared clinical data, questionnaires, and PSG parameters between patients with hyposexuality and without hyposexuality using Student t test, Mann-Whitney U test. Pearson correlation analysis, Spearman correlation analysis, and Partial correlation anaylsis were used to analyze associations among hyposexuality, clinical data, and PSG parameters. Analysis was conducted using SPSS version 18.0 software (SPSS Inc., Chicago, IL, USA), and a
Over the half of the patients had a complaint of hyposexuality, 110 of 182 (60.4%). Hyposexuality group was older (49.9±11.4 vs. 44.3±13.4;
The data of PSG parameters are depicted in
In a whole patients analysis, the severity of hyposexuality showed positive correlation with BDI (rho=0.450;
In comparison of AHI with PSG parameters and questionnaires, a frequency of nocturia (r=0.363;
This retrospective study focuses on hyposexuality in male with untreated OSA. First of all, we excluded patients with metabolic syndrome which are related to OSA. Because uncontrolled HTN and DM are known causes to make hyposexuality. Hypertension related atherosclerotic process damage to vascular and perivascular genital tissues [
We demonstrated that untreated OSA leads to hyposexuality in over half of male patients (60.4%) and poor sleep quality was correlated with decreased libido. TST and percentage of sleep efficiency (SE%) were decreased in hyposexuality group. In some previous studies, apneic patients tend to have lower TST, which was related to less SE% and higher daytime sleepiness. Because OSA related recurrent flow-limited breathing and episodic oxygen desaturation that is terminated with arousals [
We also found that the less slow wave sleep including N3, the more severe hyposexuality were presented. This pattern is similar in both whole OSA patients and hyposexuality group analysis. There were no significant difference of WASO and arousal index between two groups in our study. However, the mean values were much higher than normal range. These are related to visible or non-visible arousal and produce sleep fragmentation [
In some previous studies, the reduced amounts of LH and testosterone level is associated with OSA related sleep fragmentation and sexual dysfunction [
When we control the age factor, BDI, BAI, and ESS were remained significant positive correlation with the severity of hyposexuality. On the other hand, PSG parameters were not correlated with the hyposexuality. These results could be come from some reasons. First of all, age is a core factor that leads to hyposexuality. In previous studies, age of patients affect negatively to sexual drive. Laumann et al. reported that increasing age for men is positively associated with erection problems and decreased sexual drive [
In respect of AHI, it had positive correlation with nocturia. Nocturia was defined as two or more voids per night. In other studies, nocturia was found in about 40% of OSA patients and the AHI was higher in patients with nocturia than in those without it, even in less than 50 years of age [
Depression and anxiety are causes for sexual dysfunction. Depression is presented with loss of interest, reduction in energy, and inability to experience pleasure. These symptoms are expected to produce difficult sexual relationships. Hyposexuality was reported by over 70% of patients with depression and anxiety [
There is a limitation in this study. We used only one questionnaire, the question number 5 of SCL-90, to evaluate the severity of hyposexuality. However, in previous studies, loss of sexual drive was measured by question number 5 of SCL-90-R. Karp et al. showed that both loss-of-libido items of Hamilton Rating Scale for Depression-16 and SCL-90 presented similar correlation result to assess hyposexuality [
In conclusion, decreased sleep quality significantly reduce sexual drive in untreated OSA male. The most important factor that associated with hyposexuality is aging process. Further investigations will be required to identify an improvement of hyposexuality in treated OSA patients and what are additional tests or questionnaires to confirm their sexual problems.
This research was supported by Basic Science Research Program through the National Research Foundation of Korea (NRF) funded by the Ministry of Science, ICT & Future Planning, Republic of Korea (No. 2014R1A1A3049510) and by Samsung Biomedical Research Institute grant (#OTX0002111).
Correlation analysis between hyposexuality and clinical/polysomnography parameters in all patients. Severity of hyposexuality was positively correlated with BDI, BAI, and ESS scores (A-C). However, N3% showed negative correlation to hyposexuality (D). BDI: Beck Depression Inventory, BAI: Beck Anxiety Inventory, ESS: Epworth Sleepiness Scale, N3%: percentage of non-REM stage 3, SCL-90: Symptom checklist-90.
Correlation analysis between hyposexuality and clinical/polysomnography parameters in hyposexuality group. Hyposexuality group presented positive correlation of severity of hyposexuality to BDI, BAI (A, B). ESS showed no significant correlation with hyposexuality (C). Decreased N3% is correlated with hyposexuality (D). BDI: Beck Depression Inventory, BAI: Beck Anxiety Inventory, ESS: Epworth Sleepiness Scale, N3%: percentage of non-REM stage 3, SCL-90: Symptom checklist-90.
Clinical characteristic of patients
Non-hyposexuality (n=72) | Hyposexuality (n=110) | ||
---|---|---|---|
Age (years) | 44.3±13.4 | 49.9±11.4 | 0.005 |
Body mass index | 25.9±3.8 | 25.5±2.8 | 0.478 |
Epworth sleepiness scale | 8.5±3.7 | 10.4±5.0 | 0.013 |
Beck depression index | 5.7±4.6 | 10.0±5.9 | <0.001 |
Beck anxiety index | 5.6±5.5 | 11.1±8.7 | <0.001 |
Nocturia, n | 1.0 [0–1.3] | 1.0 [0–1.5] | 0.954 |
Values are expressed as mean±standard deviation or IQR [interquartile range]. n: numbers
Polysomnography parameters
Non-hyposexuality (n=72) | Hyposexuality (n=110) | ||
---|---|---|---|
TIB (min) | 444.4±33.4 | 436.2±64.2 | 0.705 |
Total sleep time, min | 381.5±52.1 | 359.0±69.5 | 0.023 |
Sleep latency | 8.6±8.4 | 8.2±7.0 | 0.692 |
REM latency | 108.4±88.9 | 100.9±54.1 | 0.902 |
Sleep efficiency % | 86.6±9.6 | 79.8±12.6 | 0.031 |
Arousal index | 29.0±15.5 | 30.1±16.8 | 0.722 |
N1% | 22.9±12.2 | 24.0±12.2 | 0.535 |
N2% | 53.0±10.1 | 53.7±11.7 | 0.616 |
N3% | 4.1±5.4 | 2.5±4.7 | 0.100 |
REM % | 20.1±5.7 | 19.6±6.6 | 0.416 |
WASO, min | 60.8±48.6 | 65.3±45.4 | 0.225 |
AHI | 34.4±21.4 | 30.5±21.5 | 0.149 |
RDI | 36.6±20.9 | 33.4±20.6 | 0.295 |
REM RDI | 35.6±22.8 | 35.2±20.7 | 0.796 |
REM arousal index | 23.4±16.0 | 24.9±17.0 | 0.560 |
PLMD index | 7.6±13.3 | 7.5±17.0 | 0.757 |
Movement arousal index | 0.7±1.5 | 0.8±1.5 | 0.932 |
Lowest O2 sat % | 82.2±6.9 | 83.5±6.5 | 0.138 |
Values are expressed as mean±standard deviation. TIB: time in bed, REM: rapid eye movement, N1: non-REM stage 1, N2: non-REM stage 2, N3: non-REM stage 3, WASO: wake after sleep onset, AHI: apnea-hypopnea index (number of apnea and hypopnea/h of sleep), RDI: respiratory disturbance index, PLMD: periodic limb movement disorder
Correlation between hyposexuality and clinical/polysomnography parameters in all patients after controlling for age
Severity of hyposexuality |
||
---|---|---|
r-value | ||
BDI | 0.439 | 0.001 |
BAI | 0.350 | 0.010 |
ESS | 0.292 | 0.034 |
N3% | -0.065 | 0.393 |
All statistical test were performed using Partial correlation controlled for age,
The question number 5 in SCL-90-R “Loss of sexual interest or pleasure” from 0 (not at all) to 4 (extremely). BAI: Beck Anxiety Inventory, BDI: Beck Depression Inventory, ESS: Epworth Sleepiness Scale, N3%: percentage of non-REM stage 3, SCL-90-R: Symptom checklist-90-Revised
Correlation between AHI and sleep parameters
AHI/h |
||
---|---|---|
r-value | ||
Nocturia |
0.363 | <0.001 |
ESS | 0.230 | 0.001 |
N1% | 0.596 | <0.001 |
N2% | -0.540 | <0.001 |
N3% | -0.195 | 0.006 |
Lowest O2 saturation | -0.641 | <0.001 |
All statistical test were performed using Pearson correlation except nocturia,
Spearman correlation was used. AHI: apnea-hypopnea index, N1: non-REM stage 1, N2: non-REM stage 2, N3: non-REM stage 3, ESS: Epworth Sleepiness Scale