Desordenes sexuales y del sueño en hombres con artritis reumatoide – la actividad alta de la enfermedad y la discapacidad funcional son factores asociados

Discussion

The association between RA and sexual and sleep disorders has been understudied in men, despite its impact on quality of life, and the comprehensive management of this chronic disease. This study, conducted at a specialized rheumatology center in Bogotá, Colombia, focuses on a population underrepresented in the scientific literature, highlighting clinical and sociodemographic factors associated with these conditions. Compared to other populations, the Colombian male RA cohort examined in this study reflects a distinct set of challenges highlighting the importance of considering differences in characteristics in the management of these disorders.

This study discovered that sexual disorders were found in a third of patients, most commonly premature ejaculation, and were associated with higher disease activity (median DAS28 of 3.55) and worse functional capacity (median HAQ of 0.375). These findings are in line with previous studies, but the prevalence rate observed here is lower than the 50-60% typically reported in the literature for male RA patients (29). Sleep disorders affected a third of patients, with similar associations to disease activity (median DAS28 of 3.79) and functional impairment (median HAQ of 0.37). These findings highlight the significant frequency of sexual and sleep disorders in RA male patients and underscore the need for an improved communication and a comprehensive management that includes attention to these aspects of patient health.

The relationship between the symptoms of RA and its impact on psychological aspects is clear, which implies an alteration in quality of life and social welfare (18). For this reason, identification of pathologies such as sexual and sleep disorders have become part of the comprehensive management when a patient with RA is approached, forcing treatment centers to structure interdisciplinary care programs, with the goal of attaining a global improvement for the patients and their disease. This is why these interventions have shown effectiveness independently of gender. We clarify that the analysis carried out in this study re-affirms the need for a comprehensive approach for all patients with RA, despite the fact that there is no difference between men and women, the male population represents a considerably smaller proportion and, therefore, the probability of consultation decreases. [11, 13]. According to the above, the approach begins with an adequate relationship between the patient and the health professional, which requires that spaces of confidence be given so that the patient can communicate this type of symptoms, or making experts in psychology available within the interdisciplinary team, under the cultural context, where the macho society hinders the communication of the male patient with the treating doctor [30]. This need is reflected in studies that report that only 36% of patientsmentioned other pathologies concomitant to their baseline RA and the remaining 64% did not trust their doctor, or the consultation was too short to talk about it [30].

Additionally, between 31% and 56% believe that these types of diseases are not relevant and are not associated with RA, as well as the presence of mental illnesses such as depression and anxiety that have been related to RA [31-34]. Due to the above, education, coping and acceptance of the disease, become tools to improve this communication and thus guarantee a global treatment for RA and its comorbidities.

Our results, report a lower frequency of sexual disorders, but it could be explained by the patient's lack of trust in the health professionals, given that the patients included in this study entered the comprehensive care program of the RA reference center. This argument is in agreement with those described in the literature, as early identification usually occurs in the second or third consultation, once the doctor-patient relationship has been established. [35]. Van Berlo points out that men tend to prioritize their physical appearance and body functionality, while women place greater emphasis on emotional, social, and cultural aspects. This contrast reflects how social expectations influence the perception of conditions associated with RA in both genders [37].

According to what was analyzed in this study, the  relationship between disease activity and patent functionality is clear, with the presence of sexual disorders (p = 0.004), because the patients without sexual alterations had better clinical measurements in the first evaluation. This reinforces the notion that disease activity, particularly its impact on functionality, is a key factor contributing to sexual dysfunction in male RA patients. This association is understood by the pathophysiology of RA, which involves stiffness, acute and chronic pain, and alteration in the hormonal mechanisms that are related to immunomodulation; this could also explain the association between autoimmune comorbidities and the presence of sexual disorders (p = 0.001) and sleep disorders (p <0.001). With regards to pain, joint compromise, specifically in the hip, knee and upper limbs, hinder activities related to intercourse, more in men than in women, which affects sexual activity, sexual desire, and masturbation [19, 29, 36]. This distinction between men and women in the way that joint compromise impacts sexual activity underscores the need for a gender-specific approach when addressing sexual dysfunction in RA patients.

Another relevant aspect that was associated with exual disorders was tobacco consumption, autoimmune comorbidities, depression-anxiety, and diabetes-hypertension, which are related to erectile dysfunction and which are explained by direct damage to the endothelium, alterations in the smooth muscle, and its direct consequence in vascular insufficiency [15, 19]. The complex interplay between these factors and sexual dysfunction highlights the need for an integrated approach to RA treatment that considers not only the RA symptoms but also the comorbidities that may exacerbate sexual health issues.

However, in this study no association was found between sexual disorders and sleep disorders, with depression and anxiety, despite the fact that some authors report significant relationships [6]. This relationship can be explained, because if there is a basic mental pathology, the other emotional components are affected, within these the sexual ones. In the same way, it is well known that this type of pathology is directly related to sleep disorders, either by the pathology per se or by concomitant pharmacological treatment. It is important to note that this relationship is also associated with age, as the older patients are more likely to have atherosclerotic vascular alterations, which reaffirms what was found in this study [36]. As such, age should be considered a significant factor when evaluating the risk of sexual dysfunction and sleep disorders in RA patients.

When compared with women's sexual disorders, the difference in symptoms is clear, since what most often affects men is premature ejaculation and orgasmic decrease, whereas in women it is dyspareunia and vaginal dryness. These problems could be improved if there is a treatment for RA and a psychological intervention with both the patient and his partner [38, 39]. Finally, no significant differences were found with the use of DMARDs (p = 0.85), and sexual dysfunction, although the literature suggests it, specifically with the use of methotrexate and leflunomide. This finding contrasts with some literature reports, but it could reflect differences in the study populations or treatment regimens. Once RA is diagnosed and drug treatment is started, with improving the disease activity, is expected a direct impact on the psychological and sexual aspects of the patient [6].

With respect to sleep disorders, there is an explanation regarding a pathological cycle that begins with the presence of chronic pain and ends with the alteration of proinflammatory mechanisms. Abad describes that sleep disturbances elevate TNF and IL- 6 which are present in autoimmune processes, and in patients with RA worsen and increase the activity of the disease, and that by not being controlled generate chronic pain, which in turn cause sleep alterations such as sleep quality, non-restful sleep, and multiple awakenings [18, 39]. Another pathology described in this type of disorders is obstructive sleep apnea/hypopnea syndrome (OSAHS), which is more frequent in men due to their muscle structure and is associated with the reduction of the mandibular opening due to joint involvement (temporomandibular), and in some cases arthritis in the cricoarytenoid joint is present, generating hypoxia and sleep deprivation, being more frequent in men than in women [18, 35].

Finally, in this study, it was possible to establish the association between age (p = < with sexual and sleep disorders, and work activity (p = 0.003) with sleep disorder, which could be explained as men are more active at work which improves their physical activity and therefore chronic pain [40]. Engaging in work and physical activity may help mitigate chronic pain and improve overall health. As such, RA treatment should incorporate lifestyle modifications alongside pharmacological interventions to optimize patient outcomes [40].

New pharmacological developments have allowed for better control of the disease. However, the costs and adverse effects that have not yet been described in detail require pharmacovigilance monitoring by the health professional. This must go under an integral structure where cultural and gender characteristics are considered. According to this,comprehensive treatment centers play a relevant role in RA management and personalized treatment, where “objectives by target” has become the path that shows better results. In this same way, once the patient is approached comprehensively, there can be comprehensive educational strategies as well as recreational activities that could improve quality of life, and that will directly impact the patient's disease activity and functionality.

It is important to highlight the relevance of generating spaces adapted to each patient, where the personal and cultural context play a significant role when comprehensively addressing the exclusive pathologies of men, forcing the construction and adaptation of strategies, to actively search for sexual and sleep disorders, and initiate timely treatment. All these actions would decrease the times of diagnosis and start of treatment, directly affecting the prognosis, both of the RA and of comorbidities [9, 41].

This study has important limitations, considering that specific scales were not used, only the DSM-V for the diagnosis of sexual and sleep disorders. However, the experience acquired, and the support of the interdisciplinary group, especially the psychological evaluation, bring us closer to the reality of these patients. Another weakness of the study is that, despite being an analytical cross-sectional study, it cannot establish a direct causal association due to its design. However, it does allow for the examination of variables of interest that may influence the outcomes described. Among the main biases present is selection bias, as the chosen population is highly specific to a reference center for rheumatoid arthritis, and the selection was made based on convenience.

To address these issues, future studies could incorporate more objective measures and consider broader, more diverse populations. Additionally, it would be valuable to routinely assess sexual function and sleep disorders during consultations for male patients with rheumatoid arthritis, to improve early detection and intervention, thereby enhancing the quality of life for these patients.

Conclusions

Our study reports a frequency of sexual and sleep disorders in one third of male patients with RA, which is likely to the descriptions reported in similar studies. We found that age, the presence of non-autoimmune and autoimmune comorbidities, disease activity, and the functionality of the patient was associated with sexual and sleep disorders. Finally, communication skills between patients and health professionals considering the characteristics of each patient and their social and cultural context, needs improvement. This strategy should be part of a comprehensive management scheme that involves different health specialties that offer not only a pharmacological treatment but a treatment that also prevents comorbidities. To improve clinical practice, it is crucial to integrate routine evaluations of sexual health and sleep quality into patient assessments for those with RA. This approach could lead to better management and outcomes for these patients, helping to identify and address issues that may impact their quality of life.helping to identify and address issues that may impact their quality of life.