SEMINARS I N NEUROLOGY-VOLUME

12, N O . 2 JUNE 1992

Sexual Aspects of Multiple Sclerosis

'~ For two-thirds of the patients with multiple associated with personality d i s ~ r d e r s . l ~ -Philisclerosis (MS), the onset of the disease occurs popoulos et a l l V o u n d promiscuity in 8 of 18 within the age interval 20 to 40 years. There is women with MS, and a recent study reported fea preponderance of women, especially for the tichism in connection with MS.20Mention has been younger age gr0ups.l T h e median lifetime after di- made of hypospermia in a single case report,21 agnosis of MS is about 30 years2 and sexual dys- but the condition has not been systematically invesfunction can be one of its symptom^.^ Conse- tigated. quently, questions concerning sexuality can arise at Gradually, with the growing openness on sexany time during the course of MS. Since our ual matters in recent decades, it has been recogknowledge of this aspect of MS has become greater nized that sexual dysfunction in MS is a complex in the last few decades and the topic has been matter, although, in particular, hypersexuality is mentioned only briefly in Seminars in Ne~rology,~.~ not frequently seen. Within the past few years we will present a review of sexual dysfunction in physiologic investigations have made it possible to MS and put forward proposals on treatment pos- distinguish between sexual dysfunction due to orsibilities. ganic and psychologic causes. This article is based on the results obtained.

HISTORICAL ASPECTS FREQUENCY Descriptions of sexual dysfunction are found in case histories from early reports on MS, especially those dealing with the psychiatric aspects of the disease. Both hyposexuality and hypersexuality have been described. Hyposexuality has mainly concerned impotence in males with MS. One of the first descriptions dates from 1863, although it is uncertain whether the patient involved in fact had MS.6 To our knowledge, the first decription of impotence in a diagnosed MS male was made by Vulpian in 1886.7Subsequently, scattered reports have ap~eared.~-~~ Hypersexuality has been described more frequently. An early report from 1903 describes hypersexuality in a male.13 In 1921, hypersexual thoughts in a demented woman were described.14 In a German textbook from 1928 it was concluded that affective disorders and in part dementia are associated with hypersexuality.15 Subsequently, hypersexuality was reported in MS case studies, often

Sexual dysfunction occurs frequently in patients with MS. In a study of 74 consecutively admitted MS patientsz2 and in another covering 117 representatively selected MS patients,23it was found that approximately one-half to two-thirds of the patients involved experienced changes in their sex lives after onset of the disease. A small percentage reported that sexual dysfunction was a symptom at onset of MS.24Usually, there is a delay of several years from the appearance of the first symptom until the diagnosis is made.25A study has reported that 15 to 16% have sexual symptoms at the time of diagnoskZ5Furthermore, sexual dysfunction can arise at any time during the course of MS.23 A difference has been found between the sexes for the frequency of sexual dysfunction. Approximately 75% of the men and 50% of the women with MS report symptoms of sexual dysfunction.22,27,28

Clinical Neuro-Psychiatric Research Unit, Odense University Hospital, Odense, Denmark Copyright 0 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 100 16. All rights reserved.

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Egon Stenager, M.D., Elsebeth Nylev Stenager, M.D., and Knud Jensen, M.D., Ph.D.

MULTIPLE SCLEROSIS AND SEX-STENAGER,STENAGER, JENSEN

MEN

find it hard to accept a handicapped sex partner or the eventuality of a less active sex life. This applies to both sexes." In some cases MS patients refuse to engage in sexual activity because, with their physical impairment, they perceive themselves as unattractive or even repulsive. In many other situations patients are dependent on the help of their partners and the dependency influences the way in which they cope with their sex life.31

Seventy-five percent of men with MS have sexual problems and about two-thirds complain of erectile d y s f u n c t i ~ n . ' ~The . ~ ~complaints are various. Some have erectile dysfunction but are capable of having sexual intercourse, whereas others have totally lost the ability to obtain erection. Men frequently report that their erection is not strong enough to penetrate or is too transitory. CONSEQUENCES OF SEXUAL Men with premature ejaculation may describe DYSFUNCTION it as erective dysfunction or loss of sexual power.3 When asked, some men reply that their penile senIt is important to recognize that sexual dyssations and furthermore the quality of their orfunction is only one of the difficulties facing MS gasm have changed, or that orgasm has totally dispatients and their relatives. Other problems may appeared.28 be connected with work, education, family deApproximately one-third of the males report mands, social and leisure activities, cognitive defireduced libido,28and sometimes explain it by tiredcits, mental disorders, or lack of knowledge of efness o r lack of interest in sexual matters. It should fective treatment.30-33 Why many MS patients be remembered that fatigue is a frequent comchoose to accept their situation rather than atplaint in MS. tempting to change it can perhaps be explained by some of these difficulties. WOMEN When asked, almost 50% of MS patients reObviously, there are sex differences in the type plied that they had completely or partly lost interof complaints made, and the frequency of those est in a sex life27~'8 and that the frequency of interthat are common to both sexes is also different. course dropped after the onset of the disea~e.'~ Fifty percent of the women complain of sexual Young people are those most concerned by dysfunction, frequently reporting changes in changes in their sex life. There is some indication sensation in the genital region and thigh^.^^,'^ The that men under 45 years are most affected by the most distressing complaint is dysesthesia, especially changes incurred by the disease.23 In addition to when it is painful. age, there may be other parameters that could be Approximately one-third report lack of ability used for identification of the MS patients most afto achieve ~ r g a s m ,and ~ ~ complaints .~~ of reduced fected by sexual dysfunction. However, no correlibido, fatigue, and loss of interest in sexual activity lation between sexual dysfunction and age at onset, are f r e q ~ e n t . In ~ ' a few cases complaints of dryness disease duration, extent of physical impairment, or in the vagina or reduced lubrication are made.27x2g depression has been f o ~ n d . ' ~ , There ' ~ , ~ ~is a tenWomen with MS rarely complain of d y ~ p a r e u n i a . ~dency ~ for patients with the greatest disability to be least affected by sexual d y s f ~ n c t i o n .A~ ~correlaBOTH SEXES tion between sexual dysfunction and bladder disA number of problems are common to both orders and spasticity has been found in many studmen and women. Paresis and paralysis become a ies.22r28.2g It has not been possible, however, to practical problem when having sexual intercourse. reproduce the finding in a study with the largest Spasticity can cause cramp^^^,^^ and tonic seizures patient material," which does, however, report a may be elicited by sexual intercourse and are very correlation between sexual and cerebellar dysfuncunpleasant for the patient.30 Pain syndromes are tion, a result not easy to explain. frequent in MS30 and may affect intercourse and the patient's desire for it. Bladder disturbances, such as incontinence, PHYSIOLOGIC EXAMINATION may interfere with sexual activity. Because of incontinence, a number of patients have catheters in In the last few decades, methods have been the bladder, which obviously can give rise to prob- developed to determine whether the cause of erlems. ectile dysfunction in general is organic or psychoAll these difficulties affect not only the pa- logic, and attempts have been made to localize the tients but also their sexual partners, who need organic lesion responsible. T h e methods used ingreat tolerance to surmount them. A spouse may clude examination of penile arterial blood pres-

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SYMPTOMS

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sure, Doppler investigation of penile arterial blood flow, penile perception of threshold of touch, bulbocavernosus reflex, pudendal evoked potential, cavernosometry, and cavern~sography.~~ Using measurements of penile arterial blood flow, penile circumference, pudendal evoked potential, and bulbocavernosus reflex in MS patients, Kirkeby et found that for 26 of 29 MS males the cause of erectile dysfunction was an organic lesion. Earlier, erectile dysfunction in MS had often been ascribed to psychologic factors, especially if the patient had nocturnal erection. However, nocturnal erection is not a useful indicator of psychologic factors, because approximately one-third of men with MS who have an organic erectile dysfunction have spontaneous nocturnal erections.35

sexual intercourse (20 to 60 mg).38 The patient should be instructed in injecting himself. However, if he is not capable of doing so, his partner could perhaps be taught the technique. It is advisable that examination and instruction take place only at centers having specially trained staff.39Side effects, such as priapism, hematoma, ecchymosis, and induration have been reported, but are rare.39 No follow-up studies on the use of papaverine in MS have as yet been published. The clinical impression is that some patients give up using papaverine because of difficulties in managing the injections. Use of a penile prosthesis instead of papaverine injections is recommended in some centers. A systematic study of this form of treatment in the case of MS has not yet been made.

PREGNANCY AND CHILDBIRTH

MEDICINAL TREATMENT

Pregnancy and childbirth play a significant role in sexuality. Earlier studies36have shown that approximately 20% of female MS patients have onset of the disease during pregnancy or in the first 6 months after ~ h i l d b i r t h . In ~ , ~the ~ MS patient, childbirth is associated with the risk of exacerbation of the disease. Retrospective studies have shown that during pregnancy the risk is about 1096, and in the 6 months succeeding childbirth it is approximately three times greater than that for MS women who have not given birth.37 However the latter figure may be too low because a prospective study of 8 MS patients showed that exacerbation occurred in 6 patients.37 Obviously, the decision on whether to have a child or not will be influenced by awareness of the risk i n v o l ~ e d . ~ ,In ~ ~communities .~' where reliable contraceptives are not available, fear of pregnancy can also play a significant role in sexual dysfunction. A hitherto unrecognized problem in MS is that of men with erectile dysfunction and hypospermia or aspermia who wish to have a child. Insemination is a possibility if they can produce sperm. T h e procedure is carried out only at centers specifically intended for the purpose. Careful discussion with the patient and spouse on all the aspects of having a child is, however, advocated before such treatment is sought.

Aphrodisiacs are known in most communities. Yohimbine is listed in the Danish "PharmacopC," but it has never been systematically tested in MS males. Dysesthesia in the genital region is usually difficult to treat. Some patients benefit from tricyclic antidepressants. However, systematic studies have not been made. Spasticity is another important element in sexual dysfunction. It can be relieved by medicinal treatment such as baclofen, tizanidin, dantrolene, or benzodiazepines. Cramps &ay respond to benzodiazepines. A practical measure against cramps is to place a box at the foot of the bed so that the patient can relieve the pain by pressing his foot on it.24Tonic seizures are relieved by carbamazepine or oxcarbazepine. As an alternative, phenytoin may be used. Bladder symptoms should be investigated thoroughly so that the patient is ensured proper treatment. Urinary infections and incontinence should be treated with medication (antibiotic). If the presence of a catheter is the problem, the patient or the partner can be instructed in the use of intermittent bladder catheterization.

MECHANICAL REMEDIES Patients with erectile dysfunction usually benefit from papaverine injections in the penis before 122

VOLUME 12, NUMBER 2 JUNE 1992

PHYSICAL TREATMENT Women complaining of dyspareunia should be given a thorough gynecologic examination to exclude other causes before the symptom is attributed to MS. Creams such as exploration or hormone creams should be used in cases of vaginal dryness.

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SEMINARS IN NEUROLOGY

MULTIPLE SCLEROSIS AND SEX-STENAGER,STENAGER, JENSEN

COUNSELING The form of sexual dysfunction in MS can be very varied, and the problems that arise often involve many different factors, which may be of organic, social, practical, or psychologic origin. Consequently, whenever an MS patient reports sexual dysfunction, a careful interview exposing the actual problem for the patient and his partner is advocated. Ideally both the patient and the sexual partner should take part in the interview because of the complexity of the situation. It should be kept in mind that problems occur regardless of the sexual orientation of the patient (heterosexual, homosexual, or bisexual). The pattern of sexual orientation among MS patients on the whole probably matches that of the healthy pop~lation.'~ A pertinent description of the sexual problems makes it easier to ensure that the psychologic and practical counseling given to the patient and partner is relevant. The couple involved could be advised on alternative forms of sexual intercourse. Furthermore, the discussion of problems in itself .may reveal that the patient's main problem is lack of acceptance of his handicap or the partner's aversion to having sex with a handicapped person. Such a discussion could be the first step in solving the problems encountered. The adviser should realize that sexual symptoms, like other symptoms in MS, can fluctuate and that they need to be thoroughly elucidated. Problems associated with pregnancy and birth usually require cooperation between the patient, the neurologist, and the obstetrician. A problem nursing staff may experience is that a patient with sexuat needs may be unable to satisfy them himseIf. There is no easy solution to the problem, bat an open and frank discussion among the staff is advisable. Finally, assurance that many forms of sexual dysfunctidn in MS are of organic origin is often met with relief by the MS patient.

CONCLUSION Sexual dysfunction in MS is frequent. There is a large variety of symptoms and they are often due to organic lesions, but a psychologic element may also be present. Sexual dysfunction is just one facet

of the problems connected with MS, problems that are often ignored by the patient. In addition, the general practitioner often refrains from questioning the patient on the subject. Some of the symptoms can be treated medically. However, if the MS patient and his partner are to have the possibility of a better sex life, the treatment should always be accompanied by pertinent and well-informed counseling. There is still great room for improvement.

REFERENCES 1. Koch-Henriksen N, Hyllested K. Epidemiology of multiple sclerosis: incidence and prevalence rates in Denmark 1948-64 based on the Danish Multiple Sclerosis Registry. Acta Neurol Scand 1988;78:369-80 2. Poser S, Kurtzke JF, Poser W, Schlaf G. Survival in multiple sclerosis. J Clin Epidemiol 1989;42: 159-68 3. Stenager E, Stenager EN, Jensen K. Multiple sclerosissexual and obstetrical aspects. Nord Med 1991;106: 45-7 4. Siroky MB. Neurophysiology of male sexual dysfunction in neurologic disorders. Semin Neurol 1988;8: 137-40 5. Strasberg PD, Brady SM. Sexual functioning of persons with neurologic disorders. Semin Neurol 1988;8: 1 4 1 4 6. Salomonsen LW. Den progressive motoriske ataxi. Bibl Laeger l863;6: 101-149 7. Vulpian A. Maladies du systeme nerveux. Paris: Doin, 1886; p 709 8. Krabbe K. Dissemineret sklerose. Ugeskr f Laeger 1922; 84:723-30 9. Miiller R. Studies on multiple sclerosis with special reference to symptomatology, course and prognosis. Acta Med Scand Suppl 1949;222:87 10. Langworthy OR, Kolb LC, Androp S. Disturbances of behavior of patients with multiple sclerosis. Am J Psychiatry 1941;98:243-9 11. Geocaris K. Psychotic episodes heralding the diagnosis of multiple sclerosis. Bull Menninger Clin 1957;21: 107-16 12. Goodstein RK, Ferrell RB. Multiple sclerosis-presenting as depressive illness. Dis Nerv Syst 1977;38:127-31 13. Lannois M. Troubles psychiques d a m un cas de scl6rose en plaques. Rev Neurol 1903; 11:876-81 14. Brown S, Davis TK. T h e mental symptoms of multiple sclerosis. Arch Neurol Psychiatry 1921;7:629-34 15. Bumke 0. Handbuch der Geisteskrankheiten, vol 7, 3rd ed. Berlin: Springer Verlag, 1928:625-6 16. Ombredane A. Sur les troubles mentaux d e la sclerose en plaques. These. Le Presse Universitaires de France, Paris, 1929: 123-5 17. Hollender MH, Steckler PP. Multiple sclerosis and schizophrenia: a case report. Psychiatry Med 1972; 3:251-7 18. Matthews WB. Multiple sclerosis presenting with acute remitting psychiatric symptoms. J Neurol Neurosurg Psychiatry 1979;42:859-63 19. Philipopoulos GS, Wittkower ED, Cousineau A. The etiological significance of emotional factors in onset and exacerbations of multiple sclerosis. Psychosom Med 1958;20:458-74 20. Huws R, Shubsachs APW, Taylor PJ: Hypersexuality, fetichism and multiple sclerosis. Br J Psychiatry 1991; 158:280-1 21. Mei-Tal V, Meyerowitz S, Engel GL. The role of psychological process in a somatic disorder: multiple sclerosis. Psychosom Med 1970;32:67-86

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Paretic patients should receive physiotherapy and be instructed in muscle-strengthening exercises, and, in general, horseback riding can be beneficial.

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22. Szasz G, Paty DW, Maurice WL. Sexual dysfunction in multiple sclerosis. Ann NY Acad Sci 1984;436:443-52 23. Stenager E, Stenager EN, Jensen K, Boldsen J. Multiple sclerosis: sexual dysfunction. J Sex Educ Ther 1990; 16:262-9 24. Vas J. Sexual impotence and some autonomic disturbances in men with multiple sclerosis. Acta Neurol Scand 1969;45: 166-82 25. Stenager E, Knudsen L, Jensen K. When should the patient with multiple sclerosis be told his diagnosis? In: Jensen K, Knudsen L, Stenager E, Grant I, eds: Mental disorders and cognitive deficits in multiple sclerosis. London: John Libbey, 1989: 191-5 26. Kristensen E, Pedersen E. Disturbances of sexual functions in multiple sclerosis. In: Pedersen E, Clausen J , Oades L, eds: Actual problems in multiple sclerosis research. Copenhagen: FaDL, 1983:165-6 27. Lilius HG, Valhonen EJ, Wikstrom J. Sexual problems in patients suffering from multiple sclerosis. Scand J Soc Med 1976;4:41-4 28. Vallery MC, Kraft GH. Sexual dysfunction in multiple sclerosis. Arch Phys Med Rehabil 1984;65: 125-8 29. Lundberg PO. Sexual dysfunction in patients with multiple sclerosis. Sex Disab 1978; l :2 18-22 30. Stenager E, Knudsen L, Jensen K. Acute and chronic pain syndromes in multiple sclerosis. Acta Neurol Scand 1991;84: 197-200

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31. Stenager E, Knudsen L, Jensen K. Multiple sclerosis: the impact of physical impairment and cognitive dysfunction on social and sparetime activities. Psychother Psychosom 1991;56: 123-8 32. Stenager E, Knudsen L, Jensen K. Psychiatric and cognitive aspects of multiple sclerosis. Semin Neurol 1990;10:351-64 33. Stenager EN, Stenager E, Koch-Henriksen N, et al. Risk of suicide in multiple sclerosis. An epidemiological investigation. J Neurol Neurosurg Psychiatry (in press) 34. Gerstenberg TC, Nordling J , Hald T, Wagner G. Standardized evaluation of erectile dysfunction in 95 consecutive patients. J Urol 1989;141:857-62 35. Kirkeby HJ, Poulsen EV, Pedersen T, D6rup J. Erectile dysfunction in multiple sclerosis. Neurology 1988;38: 1366-7 1 36. Stenager E, Stenager EN, Jensen K. Pregnancy, birth, gynecological operations and multiple sclerosis. Acta Obstet Gynecol Scand (in press) 37. Birk K, Ford C, Smeltzer S, Ryan D, et al. Pregnancy and multiple sclerosis. Semin Neurol 1988;8:205-13 38. Birk K, Ford C, Smeltzer S, et al. T h e clinical course of multiple sclerosis during pregnancy and the puerperium. Arch Neurol 1990;47:738-42 39. Kirkeby HJ, Petersen T, Poulsen EU. Pharmacologically induced erections in patients with multiple sclerosis. Scand J Urol Nephrol 1988;22:241-4

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SEMINARS IN NEUROLOGY

Sexual aspects of multiple sclerosis.

SEMINARS I N NEUROLOGY-VOLUME 12, N O . 2 JUNE 1992 Sexual Aspects of Multiple Sclerosis '~ For two-thirds of the patients with multiple associated...
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