心臟移植病患性功能與相關因素之探討

Abstract

背景：性是人類的基本需求之一，其不僅有繁衍的生理功能，更能滿足愛、親密及歸屬感等心理需求，是影響生活品質的重要因素之ㄧ。然而，過去有研究結果指出，由於藥物副作用、心肺功能限制、共病現象、以及心理因素影響之下，心臟移植病患的性功能未能如預期般的在術後獲得改善，甚至有惡化的趨勢，發生性功能障礙比例更高達50%∼78%。究竟心臟移植病患的性功能在術後經歷了如何的轉變，以及日後影響性功能的相關因素為何，值得進一步探討。 目的：本研究目的包括：1.瞭解心臟移植病患術後性生活經驗、感受與想法、2.探討心臟移植病患性功能現況及檢視影響心臟移植病患性功能之相關因素。 研究方法：本研究為橫斷式研究，同時採用質性與量性研究設計，以問卷調查法、病歷回顧、及半結構式深度訪談法進行資料收集。自2012年4月至2013年5月止，於臺灣北部一所醫學中心心臟移植特別門診，以立意取樣方式收案，共119位（男性：95位；女性：24位）病患完成問卷填寫，及26位(皆為男性)病患接受訪談。研究工具包括：（1）量性研究部分：自擬基本屬性問卷、國際勃起功能指標量表（IIEF）、女性性功能指數量表（FSFI）、流行病學研究中心憂鬱量表（CES-D）；（2）質性研究部分：研究者本身、半結構式訪談指引、錄音筆。量性資料以SPSS 17.0統計軟體進行分析，訪談內容則參考現象學分析法。 研究結果：在質性研究部分，本研究從心臟移植病患所描述的術後性生活經驗中，歸納出四個主題，分別為一、經歷性能力的變化，二、保護心臟不願意它受到任何傷害，三、找回男性的自我，四、維繫與穩固夫妻關係。主題一「經歷性能力的變化」反映出心臟移植病患在術後所經歷到性慾與勃起功能改變的經驗與感受。主題二「保護心臟不願意它受到任何傷害」則是反映出心臟移植病患為了保護新心臟而對性活動出現擔心與害怕的情緒與認知反應。主題三「找回男性的自我」則反映出心臟移植病患由於術後性能力的改善而重新肯定自我男性角色的感受經驗。主題四「維繫與穩固夫妻關係」則是反映出對於病患而言，性在夫妻關係中所代表的意義與影響力。 在量性研究部分，本研究發現64.2%的病患有性功能障礙情形，包括女性性功能障礙盛行率為85.7%、以及男性勃起功能障礙盛行率為60.5%。多變項邏輯斯迴歸分析結果，發現年齡（OR=1.07, 95% CI=1.01-1.14, p=0.017）、血紅素值（OR=0.55, 95% CI=0.39-0.76, p=0.000）、服用降尿酸藥物（OR=6.06, 95% CI=1.55-23.69, p=0.010）、以及憂鬱（OR=5.31, 95% CI=1.22-16.56, p=0.012）等4個變項為預測性功能障礙之主要因子。 結論：從質性研究結果發現，心臟移植手術確實成功的改善部分男性病患的性慾以及勃起能力，幫助其找回身為男人以及擔任丈夫角色的自信。然而，由於受到年齡、生理功能、藥物、以及憂鬱等因素影響，性功能障礙問題在心臟移植病患族群當中相當普遍，而心臟移植病患及其配偶對於從事性活動的迷思與擔憂，也容易影響其恢復性生活的意願以及性生活行為。因此，建議醫護人員應將性生活諮詢納入術後常規衛教項目，邀請其配偶一同加入討論，透過主動評估心臟移植病患術後性功能恢復狀況、提供與疾病相關的性資訊、澄清病患對於性方面的疑惑與迷思，並在出現性功能障礙問題時轉介專科協助，以提升照護品質。

Background: Sex is considered as one of the basic human needs and plays an important role affecting one's quality of life. Through sexual activity, we can achieve primitive needs for survival and reproduction and, equally importantly, spiritual needs such as senses of belonging, happiness and security. However, according to previous studies, patient's sexual function, instead of getting better, is often continuously worsening after heart transplant surgery due to the side effects of medication, limited physical function, multiple comorbidities, and various psychological factors. And the prevalence of sexual dysfunction among heart transplant recipients is as high as 50~78%. Therefore, what are the changes of sexual function that patient experienced after heart transplant surgery? Moreover, are there any other existing factors that may lead to sexual dysfunction for heart transplant recipients? In order to fulfill this knowledge gap, this study was conducted. Aims: The aims of this study were: (1) to explore sexual life experience of heart transplant recipients and (2) to investigate the prevalence of sexual dysfunction and associated factors in heart transplant recipients. Methods: This study adopted a cross-sectional design and employed both quantitative and qualitative research methods. Data were collected by using questionnaires, chart review, and in-depth semi-structured interview. The purposive sampling method was used to recruit the subjects from a special heart transplant clinic of a medical center in the northern Taiwan from April 2012 to May 2013. Total of 119 subjects (95 men, 24 women) completed questionnaires, and 26 of them (male only) were interviewed. In quantitative study, the basic demographic questionnaire, the International Index of Erectile Function (IIEF), the Female Sexual Function Index (FSFI), and the Center for Epidemiologic Studies Depression Scale (CES-D) were distributed to each participants. SPSS 17.0 was used to process the descriptive and inferential analysis in quantitative study. In qualitative study, a face-to-face in-depth semi-structured interview was used to explore sexual life experience of heart transplant recipients. The interviews were recorded, transcribed verbatim, and analyzed using a phenomenology approach. Results: 1. Four themes essential to HTx’s sexual life experience were identified: experiencing changes in sexual function, protecting the new heart from getting hurt, regaining self-identity of being a man, reconnecting with partner and stabilizing relationship. 2. The prevalence of sexual dysfunction was 64.2%, with 60.5% of men and 85.7% of women affected. In multiple logistic regression analysis, age (OR=1.07, 95% CI= 1.01-1.14, p=0.017), hemoglobin (OR=0.55, 95% CI=0.39-0.76, p=0.000), taking anti-uric acid medication (OR=6.06, 95% CI=1.55-23.69, p=0.010), and depression (OR=5.31, 95% CI=1.22-16.56, p=0.012) were identified as associated factors with sexual dysfunction. Conclusions: In many cases, heart transplant surgery led to significantly improving male patient’s sexual desire and erectile function, thus helping them to regain confidence of being a man and husband. However, due to age, poor physical condition, medication, and depression, the problem of sexual dysfunction appears highly prevalent among heart transplant recipients. And for some patients, the fear of hurting the “new” heart restrained them and their spouses from resuming sexual activity, or felt compelled to alter their sexual behaviors. Hence, the findings of this research highlight the issues of sexual health in heart transplant recipients deserve closer attention. A holistic care for heart transplant recipients must include sexual counseling which patients’ spouses are strongly recommended to participate.Through assessing patient’s sexual function, offering disease-related sexual information, addressing patient's sexual problems or concerns, and referring to specialty for treatment of sexual dysfunction, health care profesionals may help heart transplant recipietns to achieve an optimum quality of life.