What surgeons aren't saying about sex after hip replacement

As far as follow-up appointments go, this one was routine. My 65-year-old patient had undergone hip replacement surgery two weeks prior, and we discussed her pain level, progress with physical therapy, and eagerness to return to everyday activities. But as she stood up to leave the exam room, I could tell there was something left unsaid. She stepped out the door then stopped, turned around, and leaned in close to whisper, “When is it safe to have sex again?”

Pain during sex is rarely mentioned as an indication for hip replacement surgery. But for millions of seniors, osteoarthritis in the hip causes discomfort during sex and becomes an obstacle to intimacy. Numerous studies have demonstrated that patients with hip arthritis have lower levels of sexual satisfaction, with 19 percent of patients considering their sexual difficulties to be “severe to extreme” and 7 percent of patients citing hip pain as the cause of tension or unhappiness in their relationships.

This is especially prevalent among patients who suffer from femoroacetabular impingement (FAI), which is a condition that is increasingly recognized as a precursor to hip osteoarthritis. Patients who suffer from FAI have difficulty with deep hip flexion, causing discomfort during sexual intercourse.

Total hip replacement provides relief from pain during sex, but a return to normal sexual activities doesn’t take place overnight. Before they can safely resume having intercourse after surgery, patients typically need to wait six to 12 weeks, and they should exercise caution to avoid dislocation.

Of course, it’s rare for patients to bring up their sex lives as we go through the list of questions they’ve written down during their pre-op and post-op appointments. Without patients bringing up the topic themselves, it’s easy for physicians to gloss over what could be a sensitive or embarrassing discussion. But by failing to adequately discuss what sex will be like following hip replacement surgery, we as surgeons are doing our patients a disservice. Patients notice the oversight, as well, even if they’re too embarrassed to ask about it.

A new reality

Most patients who undergo hip replacement are not adequately prepared for what their sexual relationships will be like following surgery. Nine in 10 patients say they desire more information about sexual function after hip replacement, according to researchers at the Hospital for Special Surgery.

Without the proper education, patients overestimate the dangers associated with sex after hip replacement, and they may be too nervous about the possibility of dislocation to fully relax. Prescription pain medications also cause drowsiness, which impedes sexual intimacy.

The good news is that most people quickly return to healthy, pain-free, sexual relationships after surgery. Whether the surgeon used an anterior or posterior approach will impact how quickly a patient resumes sexual activity, as well as the specific precautions they must keep in mind. Patients who’ve undergone surgery with the anterior approach will generally be allowed to return to these activities sooner and with fewer restrictions.

Sex after hip replacement will never be exactly like it was before. Patients are encouraged to use pillows, firm cushions, or rolled towels to support the hip while they lie on their back, and they should always avoid lifting heavy objects (like a partner). Slow and steady is the key. Some patients report more favorable encounters when they take mild pain medication 20 to 30 minutes before having sex, although prescription medications, which could mask warning pain, should be avoided.

At risk positions

Even once patients have gotten the all clear to resume sexual activities after total hip replacement, the risk of dislocation still remains. As the soft tissues around the hip continue to heal, the risk of dislocation decreases. However, the risk of dislocation will never be as low as it was before surgery.

One way to decrease this risk is by avoiding dangerous sexual positions. For example, women who have had posterior hip replacement should avoid bending at the waist or hips excessively. Any position that requires the legs to be rotated outward, or legs to be moved backwards (hip extension) should be avoided for patients who have undergone the anterior approach. Other common precautions include avoiding bending the hip more than 90 degrees and avoiding rotating the foot on the operated leg inward.

The single most commonly recommended position for men and women is with both partners standing, the woman slightly bending at the waist and the man approaching from behind. Another position that patients should be able to master safely is the traditional missionary position. As long as the person with the new hip is on the bottom, this position does a great job of limiting pain, and it doesn’t require a lot of energy.

Sexual function is still a taboo topic among many older men and women seeking joint replacement surgery, but that doesn’t diminish the role that intimacy plays in all of our lives. Physicians owe it to their patients to openly discuss what sex will be like after hip replacement, and to dispel some of the myths that prevent patients from enjoying what is arguably one of the greatest benefits of hip replacement surgery.