Sexual Health After Metabolic and Bariatric Surgery: A Structured Narrative Review and a Surgeon-Oriented Clinical Framework

Background and Objectives: Sexual dysfunction is highly prevalent among candidates for metabolic and bariatric surgery (MBS), yet it is rarely screened for, documented at consent or tracked as a postoperative outcome. Existing reviews have answered whether MBS improves sexual function but not what the surgeon should then do in clinic. We aimed to synthesise the evidence published between 2015 and 2026 and to convert it into a stepwise perioperative framework for the surgical team. Materials and Methods: A structured narrative review was performed. PubMed/MEDLINE, Scopus and Web of Science were searched from January 2015 to June 2026 for studies reporting validated sexual-function outcomes after sleeve gastrectomy, Roux-en-Y gastric bypass, one-anastomosis gastric bypass or biliopancreatic diversion; 32 publications, including 11 systematic reviews or meta-analyses, were included. Results: Erectile function shows the most consistent improvement, with pooled gains of approximately 5 points in the International Index of Erectile Function (IIEF) erectile-function domain and 9 points in the 15-item IIEF total score. In women, total Female Sexual Function Index scores improve by approximately 5 points and the odds of sexual dysfunction fall by about 75% (odds ratio 0.24), but benefit is uncertain for the pain domain, women aged 40 years and over and women with pelvic floor disorders. Total testosterone and sex hormone-binding globulin rise in men, whereas free testosterone findings are inconsistent and semen parameters do not improve consistently. Sleeve gastrectomy and Roux-en-Y gastric bypass have not been shown to differ. Heterogeneity is high for most pooled outcomes. Improvement is most consistently documented at 6–24 months and partially attenuates by 4–5 years. Conclusions: Sexual health should be handled as a measurable surgical outcome. We propose a pragmatic, not yet validated framework: a five-phenotype preoperative classification with a mixed category, a defined follow-up schedule, explicit referral thresholds and a research agenda accounting for confounding by incretin-based pharmacotherapy.