Sexual Activity in Patients with Femoroacetabular Impingement: Narrative Review of the Literature

Abstract

Introduction Femoroacetabular impingement (FAI) is a common cause of hip pain in young patients, affecting deep flexion and rotation movements, including sexual activity (SA). This study aimed to synthesize the evidence on SR in patients with FAI.

Methods A narrative review of the literature was performed in the Pubmed, Scielo, PEDro, and Epistemonikos databases. Primary studies on sexual relations in patients with FAI were included.

Results Seven papers published between 2014-2024 on SR in patients with FAI were found. In the published studies, difficulties in SR associated with FAI have been described in 61-91% of patients, with the main causes being pain and stiffness, which began one to two months after symptoms. Post-surgical improvements have been described in 29-89% of patients, with a resumption of sexual activity between 29-48 days. No evidence was found regarding traumatologists' assessment of sexual activity in patients with AFP in clinical practice (e.g., frequency, difficulty, pain, etc.). Finally, there is little evidence regarding specialists' education of patients about sexual relations.

Conclusion FAI significantly impacts sexual activity, with improvements reported after arthroscopy in a group of patients. SR is a topic rarely addressed by surgeons, both in the evaluation of patients and in their education.

Level of evidence: V

Keywords

Femoroacetabular impingement - Sexual Activity - Sexual Behavior - Sexual Function

Introduction

Femoroacetabular impingement (FAI) is one of the main reasons for consultation for hip pain in young patients,[1] whose treatment in cases where conservative treatment has failed is hip preservation surgery.[2] [3] [4] [5] Its reported prevalence is highly variable, depending on the methodology used, ranging from 3% in the white, non-athletic population to 60.7% in asymptomatic women with radiographic abnormalities.[6] [7]

FAI originates from a combination of abnormalities in both the femoral head and the acetabulum, posing a risk of soft tissue injury such as labral damage or chondral tears, and an increased risk of developing osteoarthritis in the long term.[1] [6] FAI is classified into cam, pincer, or mixed types. The cam-type results from flattening or convexity at the femoral head-neck junction, whereas the pincer type is caused by focal or global overcoverage of the femoral head by the acetabulum. The mixed type combines both morphological abnormalities.[1] In symptomatic patients, most present with at least one imaging finding compatible with FAI.[7]

Patients with FAI have alterations in hip muscle strength, range of motion (ROM), and gait biomechanics.[8] [9] Its main symptom is hip-groin pain,[6] [10] which may occur during activities of daily living, sports, or any movement involving deep flexion and rotation, including sexual intercourse.[11] [12] [13]

Studies show that chronic pain in people with hip-related pathologies, such as osteoarthritis and rheumatoid arthritis, affects sexual function, describing improvements in activity, performance, and sexual satisfaction after hip arthroplasty.[14] [15] [16] [17] [18] However, there is little evidence in patients with FAI. This is relevant because, unlike patients with hip osteoarthritis, these patients are predominantly young and sexually active.[19] [20] [21] [22] In this context, the objective of this study was to synthesize the available evidence on sexual activity in patients with femoroacetabular impingement.

Methodology

Narrative literature review. A search was conducted in the databases PubMed, Scielo, PEDro, and Epistemonikos.

The keywords used were "Femoroacetabular impingement"; "Sexual Activity"; "Sexual Behavior"; "Sexual Function." Articles published in English, Spanish, or Portuguese were included.

The inclusion criteria for the review were studies on the prevalence, etiology, natural history, assessment, education, and/or treatment of sexual activity in patients with FAI. Primary studies of any design and methodological quality were included. Reference lists of all the articles retrieved were also searched in full, as were papers presented at conferences in the field. Reviews and editorial letters were excluded.

Results

A total of seven studies published between 2014 and 2024 were found ([Fig. 1]). Of these, five had the primary objective of evaluating sexual intercourse in patients with FAI before and after surgery,[12] [23] [24] [25] [26] while two of them evaluated the safety of sexual positions using computed tomography[11] and magnetic resonance imaging.[27]

Fig. 1 Primary studies included in the narrative review on sexual activity in patients with femoroacetabular impingement.

The published information was organized into five subtopics ([Fig. 2]).

Fig. 2 Subtopics published in the literature related to sexual activity in patients with FAI.

• 1. Difficulties in sexual relations associated with femoroacetabular impingement

Of the published studies, five evaluated the prevalence of sexual difficulties in patients with FAI. Between 61 and 94% of patients presented some type of sexual difficulty,[12] [23] [24] [25] [26] caused by pain, stiffness, and/or loss of interest[12] [26] [27] and with onset between one and two months after the onset of symptoms, with no significant differences according to sex and age.[12]

Regarding the prevalence of SR difficulties by sex, there are differences in the literature. Of the total number of studies, only three compared RS by sex, yielding different results. Lee et al. found no differences, Smith observed worse outcomes in women, and Alkan found worse outcomes in men.[12] [25] [24]

Of the other two studies that evaluated difficulties in return to sport, Raut et al. evaluated only women who underwent arthroscopic surgical treatment for FAI due to labral tear symptoms.[23] 88% of the patients reported being sexually active and of these, 94% described hip pain during sexual intercourse.[23] In the most recent cohort, Rynecki et al. assessed difficulties in SR according to the individual's role within the SR (penetrative or receptive). In this study, patients who engaged in receptive intercourse were five times more likely to experience preoperative hip pain interfering with intercourse than patients who exclusively engaged in penetrative intercourse (95% CI, OR, 2–15; p = < 0.001).[26] In addition, 15% of patients indicated that their sex life caused great tension and/or unhappiness in their relationship, and 39% indicated that it caused some or no tension and/or unhappiness. 32% indicated that these difficulties contributed to their decision to have surgery. 68% of patients reported feeling some degree of anxiety related to the worsening of their hip condition and its impact on sexual relations.[26]

• 2. Changes in sexual relations after arthroscopy in patients with FAI

Improvements in sexual relations have been observed in 29 to 89% of patients with FAI following hip arthroscopy.[12] [23] [24] [25] [26] Smith et al evaluated a total of 2613 patients who completed the iHOT-12 questionnaire pre- and post-arthroscopy.[25] A median of 30 points (IQR 19-45) was described before surgery, 60 points (IQR 35-81) 6 months after arthroscopy, and 61 points (IQR 35-84) at one year of follow-up, presenting fewer difficulties in sexual activity after surgery (p-value <0.001).[25] Although both men and women improved significantly, the increase was greater in women [median 27 at 6 months postoperatively (IQR 17-40) and 58 (IQR 33-80), p-value <0.001]. Finally, a moderate correlation was found at 6 and 12 months between quality-of-life scores and sexual difficulties score (iHOT-12).[25]

Raut et al described similar results, where 89% of patients showed an improvement in symptoms during sexual intercourse post-surgery.[23] On the other hand, Lee et al. observed difficulties in 10.8% of patients, and 74.8% indicated that they strongly agreed or agreed that they enjoyed their sexual activity after the intervention. Despite this, 13.7% reported feeling unhappy in their relationships due to sexual difficulties caused by hip pain.[12] In the cohort published by Rynecki et al., 52% of patients who identified as participating in the penetrative role during intercourse experienced no postoperative pain, and 10% reported experiencing severe pain. However, fewer than 10% of individuals with FAI who participated in the receptive role reported no pain, and 17% reported severe pain during intercourse.[26]

Finally, Alka et al described improvements in sexual relations post-surgery in 29% of patients, while 49% did not experience improvements post-surgery.[24] This study reports a prevalence of pudendal nerve injury in 31% of the patients evaluated, which is a risk factor for worse outcomes in postoperative sexual activity.[24]

Resumption of sexual activity averaged 29.2 ± 20.1 days after hip arthroscopic surgery, and patients reported minimal pain during sexual intercourse at 48.8 ± 40.6 days postoperatively.[12] Differences in the resumption of sexual activity were observed according to sex and age. Women resumed sexual activity later than men (women: 34.8 ± 23.2 days; men: 21.0 ± 10.7 days; p < 0.001). Younger patients resumed sexual activity on average after 26.3 ± 21.7 days, while older patients resumed sexual activity after 35.7 ± 13.5 days (p = 0.017). No differences in the resumption of sexual relations were observed between patients who were penetrative versus those who were receptive.[26] In the study by Rynecki et al, 15% of patients had not resumed sexual relations at 6 weeks post-surgery, and only 5% had not resumed at 14 weeks post-surgery.[26]

Regarding the frequency of sexual activity, between 48 and 51% of patients reported no changes after surgery, between 13 and 35% indicated an increase, and between 17 and 30% indicated a decrease.[12] [26] Men reported a higher prevalence of increased frequency of sexual activity (men: 61.9%; women: 38.1%; p-value < 0.0001).[12]

• 3. Sexual positions in patients with clamping

Sexual positions may be affected by hip pain and range of motion in patients with FAI.[11] [12] [23] [27] In the study by Lee et al., 29% of patients reported changes to their sexual positions, with this proportion being higher in women (82.3% versus 17.7%, p <0.001). In the study by Raut et al., 20 of 92 sexually active women reported that discomfort during sexual intercourse was associated with positions where the hip was flexed or abducted, which often resulted in them being unable to continue.[23]

Of the articles found, two evaluated the safety of sexual positions. Sochacki et al. used CT simulations to evaluate the safety of sexual positions in patients with cam-type FAI before and after surgery. They defined safe positions as those in which less than 20% of the models indicated impingement, i.e., those with a low risk of impingement.[11] In a later study, Morehouse et al described safe sexual positions in patients with FAI following hip arthroscopy.[27] They assessed the risk of impingement for 12 traditional positions in a man and a woman who had motion markers applied to the skin surface. A safe position was defined as one with a motion value not exceeding 0° for hip extension, 30° for external rotation, 30° for abduction, 90° for hip flexion, 10° for internal rotation, or 10° for adduction.[27]

In the study by Rynecki et al., they described the presence of pre- and postoperative pain during sexual intercourse. In patients who played the receptive role, they observed a significant decrease in pain in positions 1, 2, 4, 5, 6, 9, and 11 ([Fig. 3]), while in those who played the penetrative role, no differences were observed.[26] Safe sexual positions, as well as those with reduced pain, are summarized in [Table 1].

Fig. 3 Sexual positions adapted from the article by Rynecki et al.[26] by María Jesús Lira. A person shaded in pink represents the passive role.

Table 1

	Article	Sochacki et al [11]				Morehouse et al [27]		Rynecki et al [26]
	Variable result	Safety of sexual position				Safety of sexual position		Pain
	Sex/Role	Woman	Man	Man	Man	Woman	Man	Receptive role
Position	Time	Pre- surgery	Post- surgery	Pre- surgery	Post- surgery	Post- surgery	Post- surgery	Post-surgery
1		−	−	Safe	Safe	−	−	Reduction
2		−	Safe	Safe	Safe	−	−	Reduction
3		−	Safe		Safe	−	Safe (left side)	−
4		−	Safe	Safe	Safe	−	−	Reduction
5		−	−	−	Safe	−	−	Reduction
6		Safe	−	−	Safe	−	−	Reduction
7		Safe	−	Safe	Safe	Safe	−	−
8		Safe (left side)	−	Safe (left side)	Safe	Safe	−	−
9		Safe (right side)	−	−	Safe	−	−	Reduction
10		−	Safe	Safe	Safe	Safe	Safe	−
11		−	−	Safe	Safe	−	Safe	Reduction
12		−	Safe	Safe	Safe	−	Safe	−

• 4. Measurement of sexual relations in patients with AFP inclinical practice

In patients with PFA, no evidence was found regarding whether specialists, in their clinical practice, assess aspects of sexual relationships such as frequency, difficulties, pain, among others. Despite this, it has been described as important for the treating physician to directly ask the patient if their sexual relations have been affected by FAI.[23]

With the approach of patient-centered medicine, a series of specific questionnaires have been developed to evaluate quality of life and functionality.[28] Among the self-reported questionnaires that assess functionality in patients with hip problems, the only one that could be a useful tool to evaluate sexual relations is the iHOT-33 (original version)[29] and its abbreviated version, iHOT-12.[30] This questionnaire includes a question about difficulties during sexual intercourse and is validated in Spanish (Spain); however, there is no cross-cultural validation for Chilean patients. The overall score ranges from 0 to 100 points. Each question is scored on the same scale. For the question "Do you have difficulties during sexual activity because of your hip?", the score ranges from 0 to 100. Those scoring 100 have no difficulties at all, while those scoring 0 have extreme difficulties during sexual activity.[29] [31]

• 5. Educational needs of patients with FAI associated with sexual relations

There is little evidence regarding educational needs associated with sexual intercourse in patients with FAI. In the only study that described the educational needs of patients with FAI, they were asked directly about this topic. Only 28.1% of patients reported having received information about sexual activity before and/or after hip arthroscopic surgery.[12] In order of preference, patients preferred education to be delivered by the surgeon through a conversation (77.4%), through a brochure (67.4%), through a conversation with a family physician (36.6%), through a conversation with a nurse (17.2%), and finally through a conversation with a social worker (6.3%). A greater percentage of women preferred their partners to be present during the conversation (p-value = 0.02) and to receive an educational brochure (p-value = 0.01).[12]

Discussion

The objective of this narrative review was to synthesize the available evidence on sexual activity in patients with femoroacetabular impingement. Five subtopics addressed in studies published between 2015 and 2024 were identified: difficulties in sexual intercourse associated with femoroacetabular impingement, changes in sexual intercourse after hip arthroscopy, safe sexual positions, assessment of sexual intercourse in clinical practice, and educational needs associated with sexual intercourse in patients with femoroacetabular impingement.

Of the seven articles analyzed, it is evident that sexual activity is an emerging topic of study in patients with FAI. The published studies suggest that sexual activity may be negatively affected in patients with FAI.[12] [23] [24] [25] [26] Prevalences of difficulties in sexual relations have been described between 61 and 94% of patients, associated with pain, stiffness, and/or loss of interest.[12] [26] [32]

Regarding sexual relations after hip arthroscopy, improvements have been observed in patients, although improvements have been described in between 29 and 89% of patients, there is a significant percentage who do not experience changes post-arthroscopy.[12] [23] [24] [25] [26] The patients who benefited most from surgery were men or people who perform penetration and younger patients.[12] [24] [25] [26] [32] On the other hand, pudendal nerve injury has been described as a risk factor for post-surgical sexual dysfunction, with a prevalence of 31% of patients.[24]

On the other hand, pudendal nerve injury has been described as a risk factor for post-surgical sexual dysfunction, with a prevalence of 31% of patients.[12] [26] Considering the high percentage of patients who continue to have difficulties post-surgery, there is a question as to whether resuming sexual relations too soon contributes to persistent hip pain during intercourse after hip arthroscopy.[26] There is currently no consensus on how long patients should wait to resume sexual relations after surgery, and this information may be relevant to the education of these patients.

Regarding sexual positions, those involving greater degrees of hip flexion and abduction were associated with greater preoperative pain,[11] [26] [27] with a percentage of patients continuing to experience discomfort postoperatively. It is unclear why this residual hip pain persists in such cases. Therefore, future research should aim to investigate other possible etiologies of persistent postoperative hip pain during sexual intercourse, including stress after labral or capsule repair or extra-articular impingement.[26]

In clinical practice, assessment of sexual relations was infrequent,[12] despite being recognized as an important aspect to evaluate.[12] [32] This is consistent with what has been published in the literature, where studies suggest that orthopedic surgeons rarely discuss sexual activity with their patients despite its importance and possible improvements after surgery.[14] [33] [34] [35] In a study of orthopedic surgeons, more than 80% stated that they rarely or never discuss sexual relations with patients after hip replacement surgery. Of the 20% who did discuss sexual relations with their patients, 96% spent 5 minutes or less.[36]

While the educational needs of patients with FAI are a relevant aspect,[23] [32] there is only one published study indicating that 28% of patients received some type of information on this topic.[12] In a qualitative study published in 2024 by Bell et al, patients with FAI reported wanting to be educated about exercise, surgical treatment, and the cost of surgery.[37] Sexual relations were not mentioned among the needs of these patients. Studies on educational content for patients with FAI available on YouTube and the Internet also do not mention sexual relations among the contents addressed in such education.[38] [39]

The results summarized in this review should be interpreted with caution, as it has limitations. Among the included studies, the level of evidence is type III (cohort studies). Furthermore, the published studies were conducted in countries such as the United States, Turkey, and England, and there may be cultural variations between countries.

Conclusion

FAI significantly impacts sexual activity, with improvements reported after arthroscopy in many patients. Sexual relations are a topic rarely addressed by surgeons within the physician-patient relationship. Future studies should analyze prognostic factors for post-arthroscopy success, as well as educational needs in this patient group.

Conflictos de Interés

Ninguno.

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Eingereicht: 27. September 2024

Angenommen: 21. März 2025

Artikel online veröffentlicht:
20. Mai 2025