Sexual dysfunction after cauda equina syndrome: a systematic review of long-term outcomes

Sexual dysfunction is a recognised but underreported outcome following cauda equina syndrome (CES), with existing evidence fragmented and methodologically heterogeneous. Its true prevalence and clinical significance remain unclear. To systematically evaluate the prevalence, characteristics, and predictors of long-term sexual dysfunction following CES.

A systematic review was conducted in accordance with PRISMA guidelines. Studies reporting sexual function outcomes following CES were identified from database inception to 16 December 2025. Eligible studies included adult patients undergoing surgical decompression for CES with extractable long-term sexual function data. Data were synthesised narratively with exploratory quantitative pooling where appropriate.

Five studies were included. Sexual dysfunction was common, with reported prevalence ranging from 48% to 67% and a pooled estimate of 58.4% at long-term follow-up. Dysfunction affected both men and women and extended beyond erectile dysfunction to include impairments in arousal, orgasm, and satisfaction. Studies using validated patient-reported outcome measures generally reported broader and higher burdens of dysfunction than studies relying on descriptive or neurological assessment alone. Limited evidence suggested associations with increasing age, longer duration of pre-operative bladder dysfunction, and markers of sacral nerve root involvement, including bowel dysfunction and perianal sensory loss. Timing of surgery was not consistently associated with long-term sexual outcomes. Baseline sexual function was rarely reported.

Sexual dysfunction affects more than half of patients following CES and represents a persistent and under-recognised component of long-term morbidity. Current evidence is limited by heterogeneity and lack of baseline assessment, but suggests that outcomes are driven more by severity of neural compromise than timing alone. Routine assessment using validated patient-reported measures should be incorporated into CES follow-up to better define recovery and guide patient counselling.