Sex After Hip Surgery: Advice That Patients May Not Receive

Neil Chesanow


November 30, 2015

A Discomfiting Subject for Many Doctors

As a recent Medscape article ironically pointed out: "It seems that everyone is talking about sex these days, except where it may really matter most—inside the doctor's office. Even though sex is an integral part of life, studies show that all too often doctors aren't having 'the talk' with their patients.[5] Instead, the topic is frequently glossed over or pushed by the wayside, even though it means missing an important component of the patient's overall state of health."

Scales used to evaluate function and quality of life in patients before or after THR often leave something to be desired in this regard.[2] The Western Ontario and McMaster University Questionnaire, Hip Disability and Osteoarthritis Outcome Score, Harris Hip Score, Merle d'Aubigné Hip Score, and Short Form Health Survey (SF-36), among others, do not include specific questions about sexual activity and therefore cannot be said to evaluate all aspects of quality of life.

Patients may not feel free to initiate discussions of their sexual activity with their surgeons, even though they may want to. One study found that nearly one third (32%) of those planning to undergo THR reported concerns about difficulties in sexual activity.[6,7]

"I don't think orthopedic surgeons are reticent about having this discussion," says Hue Luu, MD, associate professor of orthopaedic surgery at the University of Chicago, who performs THR using Stryker Mako Robotic Arm-Assisted Technology, which received Food and Drug Administration (FDA) approval last March. "Our schedules are so busy, and we're so focused on a patient's function and getting their strength and activity back to normal, that we sometimes forget to talk about the sexual part of a healthy relationship between patients and their spouses or significant others."

Such an oversight, perhaps understandable for a busy surgeon, may nevertheless lead to a lawsuit. As it is, orthopedics is among the most-sued surgical specialties. In July, The Doctors Company, a large medical liability insurer, published an analysis of 1895 malpractice allegations against orthopedists.[8]

"A significant factor in these orthopedic claims was whether a patient who suffered an injury understood the cause of the outcome," the authors write.[8] "When a patient alleged improper performance of a surgical procedure, it was often due to a complication disclosed prior to surgery. This finding underlines the importance of helping patients understand the information provided during the informed consent process. It also highlights the importance of engaging the patient and family when a complication occurs to show empathy and to explain what caused the undesirable result."

After THR, dislocation of the prosthesis is a frequent cause of implant failure that occurs because of impingement, which can result from premature sexual activity or the use of sexual positions not recommended after the procedure.[2] Of course, if the positions were not recommended because they were never discussed, the groundwork for a potential liability suit may be established. That a surgeon was too busy to have this discussion is a weak defense, the study investigators note.

This is not a problem unique to orthopedists. "The research suggests that many clinicians feel it's appropriate to discuss sexual issues with their patients, but time constraints and a lack of training on how to manage sexual problems are important barriers," Andrea Bradford, PhD, an assistant professor in the Department of Gynecologic Oncology and Reproductive Medicine at the University of Texas MD Anderson Cancer Center in Houston, told Medscape.[5] She added that although some physicians are personally uncomfortable with questions about sexuality, "I think most are open to the discussion if the circumstances are conducive to it."

But for one reason or another, the circumstances often aren't conducive. In one study, only about 15% of patients reported receiving counseling for sexual activity after an acute myocardial attack, and among the patients who did, most stated that they, not their doctors, initiated the discussion.[9] In another study seeking to identify and quantify barriers that physicians encounter in discussing sexually transmitted diseases with patients, fewer than one half of primary care doctors (44.3%) provided some form of counseling--for example, asking about sexual history or offering advice about safe sex--on a regular basis.[10]