MSIF 06 Pp1-28 English

MS in focus Issue 6 2005Sexual dysfunctionin women with MSBy Farida Sharon van Rey, MD,Neuro-urology Research Fellow,University Medical Centre St.Radboud, Nijmegen, The NetherlandsFemale sexual dysfunction is very common inwomen with neurological conditions, including MS.The majority of women with MS suffer from sexualdysfunction at some stage of the disease. Comparedto a general female population, in which 20-50 percent of women are affected, the prevalence ofsexual dysfunction is estimated to be as high as 80per cent in women with MS. Sexual dysfunction hasa major impact on quality of life and interpersonalrelationships. For many women it is a physicallydisquieting, emotionally disturbing and sociallydisruptive disorder. In spite of its high prevalence,these aspects of an individual's well-being havebeen considerably neglected until recently, makingfemale sexual dysfunction a very important but oftenoverlooked symptom of MS.How the body behaves during the sexualresponseTwo basic physical processes that occur during thesexual response: vasocongestion and myotonia.Vasocongestion refers to the concentration of bloodin the blood vessels and the tissues of the genitalsand breasts. In women, this inflow of blood causesthe clitoris to enlarge, the labia to swell, and thevagina to lubricate.Myotonia, or neuromuscular tension, refers to theincrease of energy in the nerves and muscles.During sexual activity, myotonia takes placethroughout the body, not only in the genital region,but throughout the trunk, particularly in the breastand chest wall.The sexual response centres in women6For women, vasocongestion in the vaginal wallscauses vaginal secretion to seep through the vaginal

MS in focus Issue 6 2005lining, moistening the inner surface of the vagina.The amount of lubrication or “wetness” present inthe vagina does not necessarily coincide with awoman's degree of arousal or desire for intercourse.Swelling of the clitoris and of the labia also occurs inresponse to vasocongestion during the excitementphase. In addition, the inner two-thirds of the vaginalengthens and expands, the cervix and uteruselevate, and the outer lips of the vagina flatten andseparate. Nipples may become erect, breasts slightlyenlarged, and the veins in the breasts may appearmore visible.How and why MS can affect sexualfunctioningSexual dysfunction in women has many causes andeffects. Abnormalities in blood circulation, hormonalstate, nerve functioning and mental well-being mayinfluence sexual functioning. Therefore, one or moreof these factors can result in sexual dysfunction.Lesions in the brain can interfere with the interpretation of sexual stimuli as arousing, while lesionsof the spinal cord can interfere in the transmissionof arousing nerve signals to the genitals. Lesions inthe sacral (lower) spinal cord can also causeprimary sexual dysfunction, by inhibiting orpreventing vasocongestion, resulting in diminishedor absent clitoral swelling and/or vaginal lubrication.In primary sexual dysfunction, MS lesions in thespinal cord may make it difficult to sustainclitoral/vaginal engorgement during the plateauphase (between arousal and orgasm). In addition,sensory changes in the genitals can interrupt ordiminish nerve signals that initiate and/or maintainvasocongestion at both the spinal cord and cerebralcortex (brain) levels.Types and frequenciesApproximately 80 per cent of women with MSexperience sexual dysfunction at some time duringthe course of the disease. Some women stopengaging in sexual relations while others(approximately 40 per cent) have reported thatparticipating in sexual relations is significantlyunsatisfactory. Symptoms most commonly reportedinclude reduced genital sensation (48 per cent),reduced vaginal lubrication and difficulty with arousal(35 per cent), and difficulty or inability reachingorgasm (72 per cent). Pain during intercourse is alsoa frequently reported symptom in women with MS,which may be due to vaginal dryness, spasticity orhypersensitivity.AssessmentSince the sexual response in women with MS isrelated to many different factors, acomprehensive assessment of all these aspectsmust be taken into account. An evaluation shouldconsist of a full medical history, physicalexamination and pelvic examination. Althoughsexual dysfunction in women with MS often has aneurological cause, its evaluation is not alwaysincluded in routine clinical practice. Often it ispossible for a clinician to become aware of aproblem and begin to evaluate it based oninformation provided by the individual during thevisit, in response to a few relevant questions.Initiating these questions is not always part of thehealthcare professionals' routine, with the resultthat important information is missed by theprofessional and problems experienced by theperson with MS are left unaddressed.Possible treatmentsOestrogen creams may be useful for womenexperiencing vaginal dryness, pain or burning.Another treatment for these symptoms is a vaginalsuppository, although this form may not be availablein all countries. Unfortunately, many of themedications that appear to be effective for thetreatment of male sexual dysfunction related to MShave proved either to be ineffective for othersymptoms of female sexual dysfunction or have notbeen studied fully at this time.ConclusionsSexual dysfunction is highly prevalent amongwomen with MS. Assessment and treatment ofthese problems is complicated. Addressing sexualproblems during routine visits is important inidentifying and managing symptoms that can havea negative impact on an individual's personal life aswell as on the life of the couple.7

MS in focus Issue 6 2005Sexual dysfunctionin men with MSBy Douglas W. Lording, Medical Director, Melbourne Andrology Centre, Victoria, AustraliaSexual activity for men usually requires the co-ordinationof arousal, penile erection and orgasm includingejaculation, along with the many other emotional andrelationship components that are integral for satisfaction.Direct disruption of nerve pathways controlling erectionand ejaculation are common.Erectile dysfunctionAn erection occurs when there is relaxation of themuscle cells in the wall of the penile blood vesselsand the erectile tissue, leading to the penis fillingwith blood. Relaxation of these muscle cells isinitiated by nitric oxide (NO) release from nervescoming from the lower spinal cord. The messagestransmitted by these nerves usually arise in thebrain and pass down to the lower spinal cord.Erectile dysfunction (ED) is the commonest sexualdysfunction in men and usually is due to disease ofthe vascular or neurological systems, butpsychosexual influences are also important. EDcan have a major impact on self-esteem,relationships and general well-being.In men with MS, lesions in the spinal cord thatinterfere with the passage of nerve impulses fromthe brain may cause ED. The limited studies ofmen with MS indicate that ED is a frequentsymptom, often affecting younger men andsometimes affecting fertility.Ejaculatory dysfunctionAt ejaculation there is widespread musclecontraction in the pelvic area that leads toexpulsion of the semen and much of the sensationassociated with the broader response of orgasm.8The sexual response centres in menThese responses are also triggered by nerveimpulses that traverse the spinal cord fromimportant brain centres.Often, delayed ejaculation and complete failure ofejaculation (anejaculation) are caused by disruptionof the nerve pathways and may be part of abroader orgasmic failure.

MS in focus Issue 6 2005Ejaculatory disturbances also occur in MS,although there is less information about theprevalence. Anti-depressant medications (seepage 16) that may be used in MS often causeejaculatory problems as a side-effect. Some menwith MS may develop premature ejaculationbecause of anxiety about their disease.Sexual desireTestosterone is active in several brain centresimportant for sexual thoughts and desire (libido)and low levels are associated with depressionand obesity, both of which can relate to MS.Frequently, desire is affected by factors otherthan the direct physical component of thedisease, and this is particularly so in MS whereother physical and psychological factors, such asfatigue, may play a major role.Clinical assessmentNot all men with ED (or even healthprofessionals) find it easy to talk about sex, andthey may not raise this distressing issue. It isimportant to note that sexual dysfunction isdiagnosed by taking a careful history; there areno diagnostic tests. Men with MS may have othercauses of sexual dysfunction and the assessmentshould take this into account. Simple blood teststo exclude diabetes, high cholesterol andtestosterone deficiency are recommended.Careful assessment of the impact of medicationsand substance use is important.The importance of assessing both the man withMS and his partner cannot be over-emphasised,particularly if initial treatment is not successful.This will require more developed skills that not alldoctors will have.Treating erectile dysfunctionThe neurologist or MS nurse should ask men withMS if they are having erectile dysfunction. If theydo, the impact of this important disorder needs tobe assessed and, if it is considered significant, afull range of treatment options should bediscussed. Treatment is usually erectionpromoting medications rather than treating theunderlying disorder. However, considerationshould always be given to improving potentiallyreversible aspects. Drugs used to modify MSprogression also could help.The most commonly used medications act toenhance the relaxation of muscle cells in thepenis. Sildenafil, tadalafil and vardenafil all act inthis way through a similar mechanism. They aresafe, well-tolerated medications and observationof their use in MS and spinal cord injury confirm ahigh efficacy, with about three-quarters of menexperiencing satisfactory outcomes.Education about how to achieve the best resultsis the most important aspect of the use of thesemedications. They need to be taken at least halfan hour before sex, but some couples find theidea of premeditating their sexual experience offputting, and this often interferes with treatment.Normal sexual stimulation is required to initiatethe erection, therefore the couple needs to be inthe mood for sex. Apprehension about theoutcome may result in less than optimal resultsfor the first few doses. Persistence, medicalreview and re-instruction are important forsuccessful results.Adverse effectsThese drugs can cause mild headaches, flushing,nasal congestion, indigestion and muscle aches,but these adverse effects usually do not precludetheir use. When sildenafil was launched, muchwas said of possible adverse cardiac effects andTips for successful treatment Discuss sexual dysfunction Involve both partners Go through the history carefully Do not forget non-MS causes Use medications properly Consider sex in broad terms Be prepared to experiment9

MS in focus Issue 6 2005this still worries some men and their partners.There is a potentially harmful reaction with allthese drugs when used with nitrates (mainly usedto treat angina), and men with active heartdisease, for whom the level of physical activityduring sexual intercourse is potentiallydangerous, should use these drugs with caution.Alternative ED treatmentsIf these drugs do not work or cannot be safelyused, injecting drugs into the penis or the use ofmechanical aides may be helpful. ProstaglandinE1 can be injected directly into the penis. Thisrelaxes the muscle cells and usually induces ahard, lasting erection. Significant dexterity andcommon sense are essential for self-injection.Penile pain, nodular scarring within the erectilebodies and unduly prolonged erection may occur.The dosing regimen prescribed must be followedstrictly.Some men with partial ED can obtain a gooderection using a penile ring, usually combinedwith a vacuum device. The latter draws moreblood into the penis while the ring, applied afterblood flow into the penis is sufficient, reducesblood flow out of the penis. If all else fails, a penileGetting the bestfrom ED medications1. Ensure mechanism of action isunderstood, in particular:a. Timing of dosingb. Need for normal sexual stimulationc. Effect of food and alcohol2. Allow at least four attempts at using themedication3. Address secondary and tertiary sexualdysfunction4. Review outcome of treatment afterfirst month5. Remember support and understandingare paramount10prosthesis can be implanted so that cylindersimplanted into the shaft of the penis can be filledfrom a fluid reservoir placed in the scrotum.Treatment of ejaculatory disorders and lowdesireUnlike ED, there is no medication that actsdirectly to improve ejaculatory problems or lowdesire. Emphasis will be on optimising physicaland emotional well-being. The ED drugs are oftentried where there is difficulty achieving ejaculationand orgasm, as there is often a degree of ED aswell. In addition, there is usually heightenedstimulation with a harder erection. Differentpositions help some men to be more stimulatedand some benefit from mechanical assistance, forexample using a vibrator.Couples should be reassured that satisfying sexcan be achieved without full erection andpenetration, and that partner satisfaction can beachieved by a variety of stimulating techniques.

MS in focus Issue 6 2005Secondary causesof sexual problemsBy Dorothea C. Pfohl, RN MSCN, MS Center Clinical Co-ordinator,University of Pennsylvania, Philadelphia, USAMS changes can affect sexual response by makingsexual activity difficult physically and emotionally.Symptoms common to MS, such as fatigue orchanges in muscle tone, lack of coordination or pain,can frustrate sexual expression and extinguishdesire. Bowel and bladder dysfunction can inhibitand cause embarrassment. Cognitive changeschallenge the most devoted couple, yet in thepresence of any of these symptoms, it is possible tofind creative ways to keep the physical expressionsof love alive.A person who does not feel well or thinks of himselfor herself as unattractive because of a less-thanperfect body may shun sex or find their love lifedeteriorating. People who are not in a relationshipmay be reluctant to date and develop new loveinterests. Secondary sexual dysfunction often11

MS in focus Issue 6 2005indirectly affects sexual response and ability toperform in both men and women with MS.Sexual complaints are common in the generalpopulation and are capable of having a profoundimpact on quality of life and relationships. Addingchronic illness to the picture makes problems morelikely, yet such concerns and complaints are notalways shared with partners or healthcareprofessionals. Nevertheless, strategies exist whichcan be employed to cope with and managesymptoms, promote intimacy, strengthenrelationships and encourage sexual pleasure andexpression.FatigueFatigue is perhaps the most common symptomreported by people with MS, and it can be the mostdisabling. For a complete discussion on the differenttypes and causes of fatigue, see Issue 1 of MS infocus (January 2003). Regardless of the type orcause of fatigue, it can have a negative affect oninterest in sex and lead to a reluctance to initiatelovemaking, or even an avoidance of intimacy. Thewell partner may misunderstand this “disinterest”and loss of pleasure and resent the person with MS.This may come at a time when they are assumingadditional responsibilities, coping with changingroles or it may be perceived as a personal rejection.Often, partners fear hurting the person with MS.Effective communication requires that feelings beshared and dealt with openly and honestly, thusmaking it possible to explore options for maintaininga satisfactory sexual relationship despite physicalchanges.Energy conservation measures can be employed tomanage fatigue. These techniques can be appliedto sexual issues as well. Time for intimacy may needto be prioritised, perhaps for the time of day whenthe person with MS has the most energy. Onecouple set up a weekly “date” when both could takea long lunch. Planning and anticipating their timetogether during the day when the children were atschool became a pleasure in itself. Lifestylechanges may need to be made when there are notenough hours in the day to accomplish all thatneeds to be done. Simplifying tasks and accepting12available help can lessen anxiety. Planning for resttime together can lessen fatigue andsimultaneously meet the need for additional timetogether.Medications are available which can be used tocounteract fatigue, but others actually contribute toit. If medication side-effects are suspected to beworsening the fatigue, a schedule adjustmentcould provide respite. A dose can be timed to allowfor more energy when intimacy is planned.Disease-modifying therapy schedules, like othermedications, should be reviewed with a healthcareprovider who can advise and educate aboutadjustments that minimise untoward effects. Attimes, a dose can be skipped or postponed to avoidthe side-effect that is getting in the way of sexualperformance or interest.Both the person with MS and thepartner deserve to have theirsensitivities and willingness to acceptor reject various forms of sexualpleasuring respected.

MS in focus Issue 6 2005WeaknessMuscle weakness may necessitate alterations insexual practices. Comfort measures, such asproperly placed pillows, provide additional supportand can be playfully used to “set the scene” forromance. Discussing new positions and variousexpressions of sexuality, such as massage or oralsex, can add excitement to the relationship andboost, rather than diminish, self-image. Partnersmay or may not be comfortable with such variationsor may be unwilling to engage in “sex play”. Both theperson with MS and the partner deserve to havetheir sensitivities and willingness to accept or rejectvarious forms of sexual pleasuring respected.Rejecting an alternative that compensates forlimitations imposed by MS symptoms need not be arejection of the person, and other ideas can bepursued.De-conditioning (weakness from inactivity) can behelped by a fitness programme modified to workwith the person’s physical limitations. Kegelexercises are a type of exercise that can improvedecreased vaginal tone by strengthening the pelvicfloor muscles. See Issue 2 of MS in focus (July2003) for information on how pelvic floor exercisesare performed.Lack of coordination and tremorLack of coordination may make sex and sexualexpression feel clumsy, as can tremor. But besidesbeing awkward, these symptoms may also interferewith the couple’s style of having sex. It must beremembered that persons with MS still have needsfor contraception and protection from sexuallyt

6 MSinfocus Issue 6 2005 Female sexual dysfunction is very common in women with neurological conditions, including MS. The majority of women with MS suffer from sexual dysfunction at some stage of the disease. Compared to a general female population, in whic