The Effects of Fibromyalgia Syndrome on Female Sexuality: A Controlled Study

Unraveling the Complex Web of Fibromyalgia: A Narrative Review

Fibromyalgia is a complex and often misunderstood chronic pain disorder. It is characterized by widespread musculoskeletal pain, fatigue, and heightened sensitivity, and has evolved in diagnostic criteria and understanding over the years. Initially met with skepticism, fibromyalgia is now recognized as a global health concern affecting millions of people, with a prevalence transcending demographic boundaries. The clinical features and diagnosis of fibromyalgia encompass a range of symptoms beyond pain, including sleep disturbances and cognitive difficulties. This study emphasizes the importance of a comprehensive evaluation for accurate diagnosis, considering the shift from tender point reliance to a more holistic approach. Etiology and pathophysiology involve genetic predisposition, neurotransmitter dysregulation, central sensitization, and immune system involvement. Risk factors such as gender, age, family history, and comorbid conditions contribute to susceptibility. The impact on quality of life is profound, affecting physical and social aspects, often accompanied by mood disorders. Management approaches include pharmacological interventions, non-pharmacological therapies, lifestyle modifications, and alternative treatments. This study also delves into emerging research, exploring advances in neurobiological understanding, brain imaging, genetic markers, glutamate modulation, cannabinoids, gut microbiome, and digital health tools for fibromyalgia management. Overall, this study provides a nuanced and up-to-date overview of the complexities surrounding fibromyalgia, aiming to enhance understanding and support for individuals grappling with this challenging condition.

Influence of socio-affective factors on quality of life in women diagnosed with fibromyalgia

Introduction

Fibromyalgia is a disease that involves chronic pain, with high prevalence in the female population and great impact on the bio-psycho-social sphere of people affected by it. However, few studies have analyzed the possible influence of socio-affective factors on the quality of life of people who suffer from this disease.

Objective

The aim of this study was to determine the relationships between the impact of this disease on the lives of people with fibromyalgia and these variables. Specifically, we analyzed the quality of partner relationship, perceived loneliness, life satisfaction, and perceived socio-family situation.

Method

A descriptive-correlational cross-sectional design was used. The sample consisted of 69 women diagnosed with fibromyalgia. The participants completed different questionnaires that measured their happiness, satisfaction with life, perceived loneliness, quality of partner relationship, socio-family valuation, and the impact of fibromyalgia.

Results

The quality of partner relationship, perceived loneliness and socio-family valuation seem to be good predictors of subjective happiness, life satisfaction, and the impact that fibromyalgia has on people's lives, in the sense that the more positive the valuation of the couple relationship and of the socio-family situation, and the lower the perceived loneliness, people feel happier, more satisfied with their lives and the lower the impact that fibromyalgia has on their lives.

Conclusion

The 50% of satisfaction with life can be explained from the scores obtained in perceived loneliness and the quality of partner relationship. In this sense, perceived loneliness was a good predictor of the impact of fibromyalgia on the lives of these patients.

Evaluation of sexual dysfunction in females with neck and upper back myofascial pain syndrome: a cross-sectional study

Myofascial pain syndrome (MPS) is a prevalent chronic musculoskeletal pain disorder that is frequently encountered in clinical practice and can cause sexual dysfunction in women. While there have been studies examining sexual function in various painful rheumatic conditions, particularly fibromyalgia, no studies have been conducted specifically on primary MPS. In this context, we aimed to investigate the frequency of sexual intercourse and the factors associated with it in women diagnosed with MPS. The study was designed as a cross-sectional study at a tertiary rehabilitation center between May 2022 and April 2023. Forty-five consecutive sexually active women (mean age: 38.1 ± 6.8 years) diagnosed with primary MPS were included in the study. They were compared to 45 healthy women of similar ages. The participants were interviewed regarding their weekly frequency of sexual intercourse and the importance of sexual life. Also, the Beck Depression Inventory (BDI) and the Visual Analog Scale (VAS) were assessed. The importance of sexual life score (p = 0.008), BDI (p < 0.001), VAS pain (p < 0.001), and VAS fatigue (p < 0.001) values were found to be lower in the patient group compared to the control group. The frequency of sexual intercourse was lower in the patient group, although this difference did not reach statistical significance (p = 0.083). In patients with a higher BDI score (≥ 17), the number of sexual intercourse was lower (p = 0.044), and the severity of fatigue was higher (p = 0.013). Significant associations were observed in MPS patients between the weekly frequency of sexual intercourse and VAS pain, VAS fatigue, BDI, and the importance of the sexual life score. A positive correlation was observed between the number of weekly sexual intercourses and the importance of the sexual life score (r = 0.577, p < 0.001), and negative correlations were found between BDI (r = - 0.478, p < 0.001), VAS pain (r = - 0.409, p < 0.001), and VAS fatigue (r = - 0.439, p < 0.001). Patients with MPS should be assessed for depressive mood and fatigue, as these factors may contribute to sexual dysfunction. These results may also emphasize the importance of adopting a multidisciplinary approach in the management of MPS patients with concurrent sexual dysfunction. Clinicaltrials.gov identifier: NCT05727566.

Evaluation of sexual function and depression in female patients with fibromyalgia

OBJECTIVE

Fibromyalgia is one of the most important problems, especially for women. Studies point to disorders in the sexual functions of fibromyalgia patients that reduce their quality of life. The aim of this study was to investigate sexual dysfunction and its relationship with disease severity and depression in women with fibromyalgia.

METHODS

This study included 98 female patients diagnosed with fibromyalgia and 54 healthy women. The Female Sexual Function Index was used to assess sexual dysfunction. Fibromyalgia disease severity was measured with the Fibromyalgia Impact Questionnaire. Hamilton Depression Scale was filled in to evaluate the depression status of the patients.

RESULTS

According to the female sexual function index data, female sexual dysfunction was found in 78 (79.6%) patients with fibromyalgia and only in 12 (22.2%) controls. When the female sexual function index scores of fibromyalgia patients with and without depression were compared, patients with additional depression had lower female sexual function index scores, and this difference was statistically significant (p=0.002). In the correlation analysis, the female sexual function index score showed a significant negative correlation with the hamilton depression scale (rho=-0.235, p=0.020) and fibromyalgia impact questionnaire (rho=-0.215, p=0.033) scores.

CONCLUSION

This study highlights the high prevalence of sexual dysfunction in female fibromyalgia patients and the significant correlation between sexual dysfunction and both disease severity and depression.

Impact of Fibromyalgia Syndrome on Female Sexual Function: A Systematic Review With Meta-analysis

OBJECTIVE

The aim of this study was to examine sexual dysfuntion in women diagnosed with FMS compared with healthy controls.

METHODS

A systematic review with meta-analysis was performed. The literature search was conducted using PubMed Medline, Scopus, Web of Science, CINAHL, SciELO, and PsycINFO PROQUEST until February 2021. Observational studies with 2 groups (women with FMS and healthy controls) that assessed sexual function were included. Pooled effect was calculated using Cohen standardized mean difference (SMD) and its 95% confidence interval (CI) in a random-effects model.

RESULTS

Twelve studies were included comprising 1367 women (766 diagnosed with FMS and 601 healthy controls). The methodological quality of the included studies was moderate, according to the Newcastle-Ottawa Scale. Our findings showed a significant sexual dysfunction in women diagnosed with FMS (SMD = 1.72; 95% CI, 1.18-2.26; p < 0.001). In addition, the secondary outcomes more affected in women with FMS were sexual satisfaction (SMD = -2.09; 95% CI, -2.83 to -1.36; p < 0.001) and the pain during sexual relations (SMD = -1.97; 95% CI, -2.81 to -1.12; p < 0.001).

CONCLUSIONS

Women with FMS showed a significant sexual dysfunction and other related sexual difficulties, such as increase in sexual pain and a decreased sexual desire or sexual satisfaction, compared with healthy women.

Development and Validation of a Scale for Assessing the Interference of Chronic Primary Pain Conditions in Sexual Functioning: The Sex-Pain Questionnaire

Chronic pain represents one of the main health public problems worldwide and significantly affects the sexual life of patients. However, no specific instruments of evaluation have been found that address this population. This study presents the SEX-PAIN Questionnaire, developed for identifying chronic pain's interference with sexual functioning among people with chronic pain. Methods. The validation has been carried out with a sample of 303 Spanish non-hospitalized patients with chronic pain diagnosis aged between 20 and 71 years old (Mage = 49.49; SD = 10.7). Exploratory Factor Analysis (EFA) yielded 2-factor structure: Sexual and Relationship Dissatisfaction, and Chronic Pain Impact on Sexual Life. This structure was later verified through Confirmatory Factor Analysis (CFA). Internal consistency (Omega) of each factor was .72 and .96, respectively. This study presents the psychometric properties of a new measure addressed to patients with chronic pain. This 17-items self-administered instrument can be a useful measure of the chronic pain's interference with sexual functioning among chronic pain patients. It represents the first original questionnaire known in Spanish language to date. This measure could potentially help researchers and clinicians to obtain key information to design appropriate healthcare interventions.Supplemental data for this article is available online at https://doi.org/10.1080/0092623X.2022.2039336 .

Chronic primary or secondary non-inflammatory musculoskeletal pain is associated with disrupted sexual function and relationships: a systematic review

OBJECTIVE

Evidence points to the impact of chronic musculoskeletal pain conditions on sexual function, yet there is little systematic appraisal and synthesis of evidence examining these associations across non-inflammatory conditions. We aimed to systematically review evidence surrounding the association between chronic primary and secondary musculoskeletal pain with intimate relationships and sexual function.

METHODS

Four electronic databases were searched from 1^st January 1990 to 5^th September 2019 for cross-sectional or prospective epidemiologic and qualitative studies among cohorts with chronic primary or secondary non-inflammatory musculoskeletal pain, defined by ICD-11 classification criteria.

RESULTS

Fifty-one eligible studies were included (46 quantitative, 3 qualitative, 2 mixed-methods designs). Sample sizes ranged from 13 to 12,377 and mean age from 32.6 to 69.2 years. Cross-sectional controlled cohort studies consistently reported poorer sexual function outcomes among cohorts with pain relative to comparison groups. Of 15 studies reporting outcomes for the Female Sexual Function Index, 14 demonstrated mean scores ≤26.55 for the pain group, indicating sexual dysfunction. In four studies reporting the International Index of Erectile Function, the pain cohorts demonstrated consistently lower mean subscale scores and the erectile function subscale scores were ≤25.0, indicating erectile dysfunction. Three key themes emerged from a meta-synthesis of qualitative studies: impaired sexual function; compromised intimate relationships; and impacts of pain on sexual identity, body image and self-worth.

CONCLUSION

Sexual dysfunction and negative impacts on intimate relationships are highly prevalent among people with chronic non-inflammatory musculoskeletal pain. Consideration of these associations is relevant to the delivery of holistic, person-centred musculoskeletal pain care.

Alexithymia and Psychological Distress in Patients With Fibromyalgia and Rheumatic Disease

BACKGROUND

Fibromyalgia syndrome (FMS) is a chronic rheumatologic disease characterized by widespread musculoskeletal pain and other psychopathological symptoms which have a negative impact on patients' quality of life. FMS is frequently associated with alexithymia, a multidimensional construct characterized by difficulty in identifying feelings (DIF) and verbally communicating them difficulty describing feelings (DDF) and an externally oriented cognitive thinking style (EOT). The aim of the present study was to investigate the relationship between alexithymia, anxious and depressive symptoms and pain perception, in patients with FMS and other rheumatic diseases (RD).

METHODS

The sample consisted of 127 participants (M = 25, F = 102; mean age: 51.97; SD: 11.14), of which 48 with FMS, 41 with RD and 38 healthy control group (HC). All groups underwent to a test battery investigating anxiety and depressive symptoms (HADS), pain (VAS; QUID-S/-A) and alexithymia (TAS-20).

RESULTS

A high prevalence of alexithymia (TAS ≥ 61) was found in FMS (47.9%) and RD (41.5%) patients, compared to the HC group (2.6%). FMS patients showed significant higher scores than HC on DIF, DDF, EOT, anxiety and depression. The clinical sample, FMS and RD groups combined (n = 89), alexithymic patients (AL, n = 40) exhibited higher scores in pain and psychological distress compared to non-alexithymic patients (N-AL, n = 34). Regression analysis found no relationship between alexithymia and pain in AL, meanwhile pain intensity was predicted by anxiety in N-AL.

CONCLUSION

While increasing clinical symptoms (pain intensity and experience, alexithymia, anxiety, and depression) in patients with fibromyalgia or rheumatic diseases, correlations were found on the one side, between alexithymia and psychological distress, on the other side, between pain experience and intensity. Meanwhile, when symptoms of psychological distress and alexithymia were subthreshold, correlations with pain experience and intensity became stronger.

Prevalence of Pelvic Floor Disorders in the Fibromyalgia Population: A Systematic Review

This study aimed to review the literature to establish the prevalence of pelvic floor disorders in the fibromyalgia population. A systematic literature search through computerized databases including PubMed and EMBASE was completed using medical subject heading (MeSH) terms from January 1, 1990 to November 1, 2017. Articles were included if the focus was prevalence of pelvic floor disorders in the population of persons with fibromyalgia. To provide consistency of diagnosis, use of the American College of Rheumatology 1990 or 2010 criteria was required. Evidence was graded according to Canadian Task Force on Preventive Health Care and Newcastle-Ottawa quality assessment scales. A total of 11 studies were deemed eligible for inclusion from 1024 articles initially identified. Only one study used the most recent 2010 American College of Rheumatology diagnostic criteria. There was significant heterogeneity in the reporting of fibromyalgia populations. Outcomes reported were variable and not consistent across studies; thus, data could not be pooled. There appears to be a high prevalence of gastrointestinal, genitourinary, and gynaecological dysfunction. In case-control studies, these dysfunctions appeared to be more prevalent in the fibromyalgia group than in the control populations. However, this difference could not be quantified more specifically. In conclusion, the small number of eligible studies and the variety of pelvic floor outcomes reported limited formation of conclusive prevalence of pelvic floor disorders in the fibromyalgia population. From the small number of studied patients, there may be a higher prevalence of gastrointestinal, genitourinary, and gynaecological concerns in women with fibromyalgia.

Psychological impact of fibromyalgia: current perspectives

Fibromyalgia syndrome (FMS) is a chronic disorder characterized by widespread and persistent musculoskeletal pain and other frequent symptoms such as fatigue, insomnia, morning stiffness, cognitive impairment, depression, and anxiety. FMS is also accompanied by different comorbidities like irritable bowel syndrome and chronic fatigue syndrome. Although some factors like negative events, stressful environments, or physical/emotional traumas may act as predisposing conditions, the etiology of FMS remains unknown. There is evidence of a high prevalence of psychiatric comorbidities in FMS (especially depression, anxiety, borderline personality, obsessive-compulsive personality, and post-traumatic stress disorder), which are associated with a worse clinical profile. There is also evidence of high levels of negative affect, neuroticism, perfectionism, stress, anger, and alexithymia in FMS patients. High harm avoidance together with high self-transcendence, low cooperativeness, and low self-directedness have been reported as temperament and character features in FMS patients, respectively. Additionally, FMS patients tend to have a negative self-image and body image perception, as well as low self-esteem and perceived self-efficacy. FMS reduces functioning in physical, psychological, and social spheres, and also has a negative impact on cognitive performance, personal relationships (including sexuality and parenting), work, and activities of daily life. In some cases, FMS patients show suicidal ideation, suicide attempts, and consummated suicide. FMS patients perceive the illness as a stigmatized and invisible disorder, and this negative perception hinders their ability to adapt to the disease. Psychological interventions may constitute a beneficial complement to pharmacological treatments in order to improve clinical symptoms and reduce the impact of FMS on health-related quality of life.

The association between fibromyalgia and female sexual dysfunction: a systematic review and meta-analysis of observational studies

Female sexuality in patients with fibromyalgia has received little attention in the literature, and published data have mainly relied upon a small sample size with evident heterogeneity. Our aim was to pool the observational studies on the association between fibromyalgia and sexual dysfunction in female patients to reach a more comprehensive and reliable result. The literature search comprised of Pubmed-Medline, Cochrane, and Embase databases. The relevant studies that met the inclusion criteria were gathered and the pooled effect size was calculated. The standard mean difference of the global sexual function score as well as the sub-items scores were calculated using the random-effect size model. Sensitivity analysis was conducted. Publication bias was assessed using Funnel plots and Begg and Mazumdar rank correlation tests. The meta-analysis was conducted in accordance with the MOOSE guideline. The six selected studies contained 919 participants (ranging from 51 to 362). Of those, 578 were patients with fibromyalgia, and 341 were the controls. While four studies evaluated the sexual function using the female sexual function index (FSFI) questionnaire, two used changes in the sexual functioning questionnaire (CSFQ). Patients with fibromyalgia had a decreased total sexual function score [(-5.02 (-7.58 to -2.46), p < 0.0001; Q = 664.28; p-value for heterogeneity = p < 0.0001; I² = 99.24%)]. All sexual response cycle domains including desire, arousal, orgasm, pain, lubrication, and satisfaction were found detrimental in patients with fibromyalgia compared with the healthy controls. For the sensitivity analysis, omitting any one of the six studies did not produce a significant difference in the original pooled summary effect size. Our meta-analysis provided a clear association between female sexual dysfunction and fibromyalgia, suggesting patients with fibromyalgia should be assessed regarding sexual health, although further, well designed longitudinal studies are needed to establish the causality between fibromyalgia and female sexual dysfunction.

Psychiatric comorbidity and childhood trauma in fibromyalgia syndrome

Objectives

In this study, we aimed to compare patients with fibromyalgia syndrome (FMS) and those with myofascial pain syndrome (MPS) and healthy women and to investigate the prevalence of childhood traumatic experiences (CTEs) in relation to comorbid mood and anxiety disorders.

Patients and methods

Between February 2014 and May 2014, a total of 136 women including 52 with FMS, 35 with MPS, and 49 healthy controls were included in the study. The Sociodemographic Data Form, Mood and Anxiety Disorders Modules of Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) Axis I Disorders (SCID-I), Fibromyalgia- related Symptom Scale (FSS), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), and Childhood Trauma Questionnaire-28 (CTQ-28) were applied to participants.

Results

As a result of the semi-structured clinical interview conducted by a psychiatrist experienced in psychological trauma, the prevalence of any mood or anxiety disorder were found to be significantly more common in the FMS group. Childhood traumatic experiences, not only in general, but also with all subtypes, were also reported to be significantly more in FMS patients. Besides, only in patients with FMS, a significant relationship was found between the psychiatric diagnoses and the presence of CTEs. Furthermore, the CTQ-28 scores were correlated positively with the FSS scores as well as HDRS and HARS. Among the symptoms screened by the FSS, only crying and over-reacting to incidents were significantly associated with CTEs in FMS group.

Conclusion

Based on our study results, CTEs may play a critical role in the development of fibromyalgia and may be related with comorbid mood and anxiety disorders in FMS patients. Associating psychological symptoms such as crying or over-reacting to incidents in FMS patients should be, therefore, alerting for psychiatric consultation.

Sexual dysfunction, mood, anxiety, and personality disorders in female patients with fibromyalgia

BACKGROUND

We aimed to investigate the current prevalence of sexual dysfunction (SD), mood, anxiety, and personality disorders in female patients with fibromyalgia (FM).

METHODS

This case-control study involved 96 patients with FM and 94 healthy women. The SD diagnosis was based on a psychiatric interview in accordance with the Diagnostic and Statistical Manual of Mental Disorders, fourth edition criteria. Mood and anxiety disorders were diagnosed using the Structured Clinical Interview. Personality disorders were diagnosed according to the Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders.

RESULTS

Fifty of the 96 patients (52.1%) suffered from SD. The most common SD was lack of sexual desire (n=36, 37.5%) and arousal disorder (n=10, 10.4%). Of the 96 patients, 45 (46.9%) had a mood or anxiety disorder and 13 (13.5%) had a personality disorder. The most common mood, anxiety, and personality disorders were major depression (26%), generalized anxiety disorder (8.3%), and histrionic personality disorder (10.4%).

CONCLUSION

SD, mood, and anxiety disorders are frequently observed in female patients with FM. Pain plays a greater role in the development of SD in female patients with FM.

Evaluation of Sexual Dysfunction in Females With Ankylosing Spondylitis

Objectives

This study aims to evaluate sexual function in females with ankylosing spondylitis (AS), compare them with healthy controls, and demonstrate the effects of AS on female sexual functions.

Patients and methods

Fifty-four AS patients (mean age 39.33±8.57 years; range 20 to 55 years) and 56 similar aged healthy controls were included in the study. Depression levels and sexual functions of all participants were evaluated by the Beck Depression Inventory and Female Sexual Function Index (FSFI), respectively. Other assessment methods included the visual analog scale for pain, fatigue, and importance of sexual life; Bath Ankylosing Spondylitis Disease Activity Index for disease activity, Bath Ankylosing Spondylitis Functional Index for functionality, Bath Ankylosing Spondylitis Metrology Index for spinal mobility, and Short Form-36 (SF-36) for quality of life.

Results

Total FSFI and all FSFI subscale scores and number of weekly sexual intercourse were significantly lower while Beck Depression Inventory score was significantly higher in females with AS when compared to controls. In AS patients with depression, total FSFI score and FSFI subscales scores of desire and arousal were significantly lower than those without depression. In females with AS, there were negative correlations between total FSFI score and duration of complaint, Beck Depression Inventory score, Bath Ankylosing Spondylitis Metrology Index score, visual analog scale score, age, and duration of marriage while positive correlations existed between total FSFI score and visual analog scale importance of sexual life score and number of weekly sexual intercourse, SF-36 fatigue, SF-36 social function, SF-36 pain, and SF-36 mental component scores.

Conclusion

Sexual dysfunction was more common in female AS patients without marked impairment in body image and hip involvement when compared to normal population. Sexual problems which are generally neglected should be handled regardless of disease activity when evaluating patients with AS and establishing a treatment plan.

Effects of low sleep quality on sexual function, in women with fibromyalgia

Sexual dysfunction is a common experience in women with fibromyalgia. However, the physiopathology of this association is unclear. We aimed to evaluate whether sleep disturbance has an influence on sexual function in women with fibromyalgia. Fifty-four sexually active premenopausal women with fibromyalgia were enrolled in the study. The following questionnaires were used: the Female Sexual Function Index (FSFI), the Pittsburgh Sleep Quality Index (PSQI), the Fibromyalgia Impact Questionnaire (FIQ) and the Beck Depression Inventory (BDI). Appropriate statistical analyses were used by using SPSS 18. The mean FSFI score was 25.344 ± 6.52 and showed no correlation with age, body mass index, BDI or duration of fibromyalgia. However, a positive correlation between sexual dysfunction and low sleep quality was found (r=0.43; P=0.001). In addition, the median FSFI score was 29.2 (27.2-32.4) in patients with higher sleep quality (PSQI⩽5), whereas it was 21.4 (18.9-25.3) in patients with lower sleep quality (PSQI>5) (P<0.001). There was a positive correlation between sexual dysfunction and symptoms of fibromyalgia as indicated by a higher FIQ score (r=0.37; P=0.006). Sexual dysfunction in female patients with fibromyalgia may be due to low sleep quality. Treatment of the sleep disorder may improve female sexual function.

Sexual Dysfunctions in Men and Women with Inflammatory Bowel Disease: The Influence of IBD-Related Clinical Factors and Depression on Sexual Function

INTRODUCTION

Inflammatory bowel disease (IBD) is likely to have an impact on sexual function because of its symptoms, like diarrhea, fatigue, and abdominal pain. Depression is commonly reported in IBD and is also related to impaired sexual function. This study aimed to evaluate sexual function and its association with depression among patients with IBD compared with controls.

METHODS

IBD patients registered at two hospitals participated. The control group consisted of a general practitioner practice population. The web-based questionnaire included the Female Sexual Function Index (FSFI) for women and the International Index of Erectile Function (IIEF) for men. Other variables evaluated were depression, disease activity, IBD-related quality of life, body image, and fatigue.

RESULTS

In total, 168 female and 119 male patients were available for analysis (response rate 24%). Overall, patients with IBD did not significantly differ in prevalence of sexual dysfunctions from controls: female patients 52%, female controls 44%, male patients and male controls both 25%. However, men and women with an active disease scored significantly lower than patients in remission and controls, indicating impaired sexual functioning during disease activity. Significant associations were found between active disease, fatigue, depressive mood, quality of life, and sexual function for both male and female patients. The association between disease activity and sexual function was totally mediated by depression.

CONCLUSION

Male and female IBD patients with an active disease show impaired sexual function relative to patients in remission and controls. Depression is the most important determinant for impaired sexual function in IBD.