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CE credit is no longer available for this article. (Expired January 2005)
Originally posted January 2003
New meaning for safe sex
DORI ROGERS, RN, MSN, CCRN
DORI ROGERS is the education coordinator at Hall-Brooke Behavioral Health Services, Westport, Conn. She was working in the ED of a Waterbury, Conn., hospital when the incident in the opening scenario occurred.
KEY WORDS: dislocation, hip prosthesis, total hip replacement (THR), "ENIGMA" Model
Safe sex for patients with total hip replacements means knowing when they can resume sexual relations and how they can do so without injuring themselves. Unfortunately, few patients get the information they need.
Barbara arrived by ambulance at our ED at 8 a.m. one Sunday morning. She was moaning in pain and wrapped in bed linens. Trailing behind the paramedic was an embarrassed, red-faced gentleman. When Barbara (not her real name) was asked what happened, she exclaimed in horror, "Oh no! Do I have to tell that story again?"
X-rays confirmed what we suspected. Barbara had dislocated her hip prosthesis during sexual intercourse.
An orthopedic surgeon arrived to manipulate Barbara's hip prosthesis back in place while she was under moderate sedation. She was able to return home three hours later. Her discharge instructions included information about safe sexual positions for total hip replacement (THR) patients to help prevent another dislocation.
Barbara was never given such information at her post-THR discharge several months earlier from another facility. Although she had been cautioned then not to bend her hips more than 90 degrees in everyday activities, the subject of sexual activity had never come up.
That's not surprising. Few healthcare professionals have received professional training in addressing issues surrounding sexuality.1 A 1991 study of hip replacement patients, apparently the only study of its kind, found that 81% of the patients surveyed said they were not told when they could safely resume sexual intercourse.2 Yet, nearly 90% of them said they would have liked such information.2
Recognizing sex as a quality of life issue
The number of people age 65 and older—the prime hip fracture population—is expected to double by 2030.3 In addition, because of the development of longer lasting prostheses, younger patients are also more likely to receive hip replacement surgery for a variety of conditions such as osteoarthritis or rheumatoid arthritis.4
Given the expected increase in hip replacement patients, the term "safe sex" takes on new meaning: how to enjoy sex without dislocating the new hip.
As a nurse, you can help THR patients feel more comfortable asking for guidance about resuming sexual activity. Not only can this help prevent patients from suffering a painful dislocation, as Barbara had, but it can also restore or enhance their quality of life.
Bringing up the topic of sexuality may be a challenge on several levels, though, since the issues are not simply a matter of technique, but of how the patient feels about her body. Tact and sensitivity are essential, since for some patients sex may be the last thing they want to talk about.
Ways to broach a sensitive subject
The goal of rehabilitation after THR is to sustain and, if possible, increase patients' ability to function, and that includes sexual function.5 Addressing issues about sexual activity should therefore be made a part of the standard instructions given to THR patients on how to protect their new hip.
Whether you're giving instructions at discharge or during a follow-up visit, it's important to remember that THR patients are at risk for developing a negative body image because of scars or the use of adaptive equipment. This can damage their self-esteem if they—or their partners—begin to view themselves as less desirable, less valuable, or less masculine or feminine. They may also worry about their ability to perform sexually.5
Following the steps outlined in the "ENIGMA Model of Assessment and Recommendation for Sexual Satisfaction" can help.5 The steps go like this:
Engage the patient in dialogue. You don't need to specifically address sexual issues at this point. But you can give the patient an opening to talk. For instance, as you review standard precautions after THR, you might say something like: "Many patients don't realize that once the hip has healed, it's perfectly safe to have sex again, as long as you follow a few simple guidelines. If you like, we can talk about any questions or concerns you have either now or later."
Or, you could say something like, "I often get questions about when it's safe to resume sexual activity. The answer is, usually four to eight weeks."6 You might also point out that many patients' sex lives improve after THR because the joint, when it heals, is usually free of the pain and stiffness that might have made previous sexual activity uncomfortable.
Another approach is to tell anecdotes. Robert D. Small, MD, chief of orthopaedic surgery at the Orthopaedic Institute in White Plains, N.Y., likes to tell patients about a woman who, at 55, had bilateral hip replacement. She told the doctor that now that she could move her hips, her sex life had greatly improved. She also proudly announced that she had a new boyfriend.
Normalize the topic of sexual activity by using a nonjudgmental, matter of fact attitude. Talk about sex the same way you would discuss any other aspect of the patient's recovery, such as his diet or the need for light exercise.7 If you sense the patient is embarrassed, acknowledge that such a reaction is normal and that "many of us" feel the same way when discussing sex.6 But add that it's healthy to raise questions and have them answered.
Inform the patient about sexual functioning after THR to clear up potential misunderstandings or misconceptions on the part of the patient or partner. Explain that it's perfectly normal to have a low desire for sex right after major surgery.6 But reinforce the fact that sex is possible and much more comfortable after THR. Emphasize the importance of avoiding certain sexual positions, to protect the new hip. Show diagrams of positions that are less likely to cause accidental dislocations. (See the patient handout.) Refer the patient to sources of educational materials on hip replacement and sex after hip replacement, such as those in the "Patient resources" box.
Guide patients by using language that the patient and partner will understand. Avoid medical jargon. Adapt your terminology to theirs. For example, some patients may not quite understand the term orgasm. You may need to use another word instead.5
Maximize patients' ability to solve sexual concerns by communicating with their partners. The patient may still feel some temporary pain and stiffness after surgery that would make sex uncomfortable and difficult to enjoy. Or the partner may fear injuring the patient. Explore those fears with them and encourage each to communicate their concerns with each other. Also remind patients that sexual expression is not limited to intercourse, but that holding hands, touching, kissing, and hugging are all important forms of sexual intimacy.6
Assess on an ongoing basis. The patient may not feel comfortable discussing sexual concerns right away, but may have a question the next time you see her. In fact, she may wait for you to bring up the topic again.5
Medications may impair sexual function
As part of your patient education, be sure your THR patient is aware that some medications may interfere with sexual function. For example, central nervous system depression caused by analgesics such as oxycodone terephthalate (Percodan, Endodan) may decrease libido and the ability to perform sexually.8 Sleeping medications such as zolpidem tartrate (Ambien) act as hypnotics.9 Both analgesics and sleeping pills tend to take effect quickly. Percodan's onset is 10 – 15 minutes, peaking at 30 – 60 minutes.8 Zolpidem causes sleepiness in 7 – 27 minutes.9
As a result, patients should take their medication schedule into account when thinking about having sex. For example, patients on sleeping medications should plan on having sexual intercourse before they take the medication.
Remind patients, however, not to stop or postpone taking medications without consulting their healthcare provider. If they believe that a medication is having an adverse effect on their sexual function, encourage them to ask about alternative treatments.
When a referral is needed
While hip replacement can lessen sexual problems caused by joint-related pain and disability, other sexual problems may remain. For example, the aging process itself can slow down reactions to sexual stimulation or decrease the strength of orgasm.10 Patients having difficulties adjusting to such circumstances may benefit from counseling by a psychologist or social worker who specializes in sexual problems.
Other candidates for sexual counseling include patients who show signs of:1
• sexual dysfunction that predates the hip disability and surgery,
• conflict with their partner as a result of the disability,
• sexual dysfunction because of problems coping with the disability, or
• a negative sexual self-image following surgery.
As members of the healthcare team, we have a responsibility to advise THR patients that they could injure themselves during sex if not careful, while being mindful not to "push" information on them.5 By following the assessment and teaching steps described here, you'll be able to achieve that delicate balance and ensure that patients can enjoy sexual intimacy without hurting their new hip.
REFERENCES
1. De Lisa, J. A., & Gans, B. M. (Eds.). (1998). Rehabilitation medicine: Principles and practice (3rd ed.). Philadelphia: Lippincott-Raven.
2. Stern, S. H., Fuchs, M. D., et al. (1991, Aug.). Sexual function after total hip arthroplasty. Clin Orthop, (269), 228.
3. American Academy of Orthopaedic Surgeons. "Live it safe—prevent broken hips." 2001. http://orthoinfo.aaos.org/brochure/thr_report.cfm?Thread_ID=25&topcategory=Hip (9 Oct. 2002).
4. Brown, S. R., Davies, W. A., et al. (2002, Sept.). Long-term survival of McKee-Farrar total hip prostheses. Clin Orthop, (402), 157.
5. Braddom, R. L. (2000). Physical medicine and rehabilitation (2nd ed.). Philadelphia: W. B. Saunders.
6. Whittington, F. W., Mansour, S., & Sloan, S. L. (2001). Sex after total joint replacement. Atlanta: Media Partners.
7. Mayo Clinic Jacksonville. "Discharge instructions following total hip replacement." 2001. www.mayo.edu/mcj/ortho/discharge.html (9 Oct. 2002).
8. Hodgson, B. B., & Kizior, R. J. (2003). Saunders nursing drug handbook. Philadelphia: W. B. Saunders.
9. Wilson, B. A., Shannon, M. T., & Stang, C. L. (2002). Nurse's drug guide: 2002. Upper Saddle River, NJ: Prentice Hall.
10. Pedretti, L. W. (1996). Occupational therapy: Practice skills for physical dysfunction (4th ed.). St. Louis: Mosby.
Patient resources
For more information on sexual activity following hip replacement surgery, direct your patients to these publications and Web sites:
A patient's guide to artificial hip replacement. (1999). Media Partners, Inc., Atlanta. May be purchased for $1.35 at http://mediapartnersinc.com/media_partners/catalog/ .
Sex after total joint replacement: A guide for you and your partner. (2001). Media Partners, Inc., Atlanta. May be purchased for $1.55 at http://mediapartnersinc.com/media_partners/catalog/ .
"Sexual function after a total hip replacement." 2001. Available at the University of Virginia Health System's Web site: www.healthsystem.virginia.edu/internet/orthopaedics/sexfunc.cfm .
Patient Information
Safe sexual positions for hip surgery patients
If you've had total hip replacement surgery, you need to follow some basic advice about how to protect your hip joint. The following information will help you identify sexual positions that are comfortable and that can reduce your risk of injury.
General guidelines
• Don't bend the affected leg more than 90 degrees at the hip.
• When lying on your back, don't turn or roll your affected leg toward the other leg.
• Don't turn the toes of the affected leg inward.
• When lying on your side, keep both legs separated with pillows between them. Don't let your knees touch and don't let the toes of your affected leg turn downward.
Recommended sexual positions
Bottom position for the male or female patient
Click here to view full-size graphic
Place one or two pillows under your affected thigh for support and comfort and to reduce friction on your skin, which may still be healing. Keep the toes of your affected leg pointed upward and slightly outward—but never inward.
Top position for male patients only
Click here to view full-size graphic
Don't bend your affected hip more than 90 degrees while getting into position. Keep your affected leg out to the side with your toes pointed slightly outward. (Female patients: Don't assume this position because it will require that you bend more than 90 degrees at the hip.)
Side-lying position for the male patient
Click here to view full-size graphic
Lie on your unaffected side. Both you and your partner should face the same direction. You should be behind your partner in a "spooning" position. Your partner should place at least two pillows between her legs and your affected leg should rest on top of hers during intercourse. Don't bend your affected leg more than 90 degrees, and don't let the toes of your affected leg dangle or turn downward.
Side-lying position for the female patient
Click here to view full-size graphic
Lie on your unaffected side and place enough pillows between your legs to support the affected leg. Make sure the affected leg doesn't drop off the pillows during intercourse. Your partner should assume the spooning position behind you. Don't bend your affected hip more than 90 degrees, and don't let the toes of your affected leg turn downward.
Caution: If you dislocate your hip during sexual intercourse, you will experience pain, your affected leg will appear shorter, and your foot will turn inward. Lie down, don't move, and tell your partner to call an ambulance.
Source: Whittington, F. W., Mansour, S., & Sloan, S. L. (2001). Sex after total joint replacement. Atlanta: Media Partners.
Emil Vernarec, ed. Dori Rogers. New meaning for safe sex. RN 2003;1:38.
Published in RN Magazine
