Letter: Sex After Neurosurgery—Is It Safe?

To the Editor: Many neurosurgical patients are young, fit, and lead active sexual lifestyles. Despite this, there is a paucity of evidence in the literature to suggest when or if sexual intercourse could be considered safe after neurosurgery. How often do we encounter complications from sex after neurosurgery? Do we have a safe "honey-moon period" for resuming sex? How soon or how late? Do patients question this prior to surgery? Our aim is to address the potential risk associated with sexual intercourse after neurosurgery and in doing so, attempt to offer guidance to patients and their treating team. We have categorized neurosurgical intervention into brain and spinal surgery for the sake of simplicity and to discuss the implications. BRAIN SURGERY: A PROBLEM OF PRESSURES? Post cranial surgery the concern is that sexual intercourse would raise the intracranial pressure, causing a reduction in cerebral perfusion. A drop in the cerebral perfusion pressure may potentially lead to stroke or seizure in the postoperative oxygen sensitive brain. There is also a possibility of cerebrospinal fluid (CSF) leak depending on the procedure performed. During exercise, and, deductively, during sexual intercourse, the mean arterial pressure is increased in order to adequately meet the oxygen demand. A study of 20 patients in the neurointensive care unit demonstrated that bed-side cycle exercises of 20-min duration had no effect on the patients' intracranial pressure despite raising the mean arterial pressure.1 In that case, can we equate exercise to sex? The mean arterial pressure is not the only pressure change that occurs during sexual intercourse. There is also an intra-abdominal pressure increase due to abdominal wall contractions as well due to the partner's weight being partially rested on the abdomen during face to face positions such as the "missionary" position. Increases in the intra-abdominal pressure result in increases in the intracranial pressure and therefore decreases in the cerebral perfusion pressure. Could this affect the oxygen delivery? This is a possibility; however, it is difficult to quantify. Another study looked at 65 patients undergoing exercise in the neurointensive care setting found that though exercise did not, in general, cause an increase in the intracranial pressure, certain movements that produced unconscious valsalva maneuvers might.2 Brief valsalva maneuvers are unavoidable during resistance exercise. It is possible that valsalva maneuvers occurring during intense sexual exertion or during orgasm could increase the intracranial pressure and again interfere with cerebral perfusion or predispose to CSF leak. SPINAL SURGERY: DISC PROLAPSE In spinal surgery, we take the example of lumbar disc prolapse and microdiscectomy. The concept can be carefully interpreted and applied to other spinal procedures. There is very little guidance for patients as to how long they should abstain from sex after spinal surgery. The guidance obviously will vary depending on the type of spinal surgery. In the context of lumbar microdiscectomy/laminectomy, one would be worried about a risk of recurrent disc prolapse and resuming sex sooner can, in theory, contribute to this complication. Sexual intercourse can potentiate pressure on the lumbar spine due to proximity to the pelvis. Having said that pelvic thrust or tilt exercises are commonly employed to improve lumbar stability as a treatment for back pain, and are even employed in rehabilitation following spinal surgery.3 Provided the motion is not overly forceful, the thrusting involved in sexual intercourse could provide a valuable benefit to the patients' physical therapy. One may agree to disagree. On the other hand, spinal fusion could restrict sexual activity due to pain or fear from the patient due to the implanted hardware. NEUROHORMONAL CHANGE Orgasm may cause a raise in intracranial pressure, albeit a double-edged sword…. A flood of catecholamines including dopamine during orgasm should provide analgesic benefit, working synergistically with opioids such as codeine, morphine, or oxycodone, which the patient may or may not be taking postoperatively. A corresponding reduction in opioid analgesic requirement could bring benefit to patient recovery, reducing harmful side effects such as constipation, nausea, and confusion. There is no study that we are aware at present that has looked at how orgasm affects intracranial pressure. For ethical reasons, it is difficult to perform a study in these cohorts to substantiate the findings from a neurosurgical perspective. CONCLUSION There is a lack of evidence to reliably conclude the safety of sexual intercourse after Neurosurgery. From a theoretical stand point alone, we recommend: High risk patients who have undergone major brain surgery should potentially avoid sexual intercourse for a short period following neurosurgery during which time the brain will be less adaptive and more sensitive to changes in perfusion. Patients who wish to engage in sexual intercourse despite the potential risk of seizures, stroke, or CSF leak, should be advised to avoid the valsalva maneuver, and be cautioned against any positions that involve straining, heavy lifting, or pressure on the abdomen. Patients post lumbar microdiscectomy should be cautioned about the risk of sex in the early postoperative period. Controlled and gentle pelvic thrusting should be encouraged as part of physical rehabilitation. As a common-sense rule, it stands to reason that if something is painful, then avoid it. Other than pain, there is no obvious contraindication to sex after most spinal surgery and the treating spinal neurosurgeon should be able to discuss this with the patient preoperatively. This applies to various spinal neurosurgical interventions. Both cranial and spinal postoperative patients may be rewarded with analgesic benefits from the endorphin response secondary to orgasm. The treating neurosurgical team should be aware of this aspect of the patient's life style and should be prepared to discuss this in the preoperative counseling period without any stigma attached. Patient information leaflets should include details regarding sex after neurosurgery. Last but more importantly, the fear pertaining to "sex after neurosurgery"' should not be dismissed and sex should be encouraged when the patient is up to it, with common sense approach. Disclosure The authors have no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article.