Sexuality and intimacy play an important role in the quality of life for nearly everyone, including those with a chronic illness such as multiple sclerosis (MS). In MS, sexual dysfunction may be one of the less talked-about symptoms of the disease. Recognizing and understanding this symptom is important to adequately address the different issues that may be involved.
Several factors may contribute to sexual dysfunction in MS, including physical limitations as well as psychological, emotional, and cognitive challenges. In this writing, sexual dysfunction is divided into three areas: “primary,” referring to symptoms in sexual function caused by MS damage to the central nervous system; “secondary,” referring to other MS symptoms that can interfere with sexual function; and “tertiary,” referring to the psychological, emotional, and cognitive aspects of MS that can impact sexuality and intimacy.
The first step to managing sexual dysfunction is to recognize and discuss it with your partner and MS team or a sexual counselor. Other important steps are to review medications for side effects and to make various lifestyle changes, such as timing medications, avoiding certain drinks and foods, conserving energy, and doing specific exercises. Treatment options can include medications as well as counseling through a sex therapist and other members of your healthcare team.
Intimacy may be defined as anything that makes one feel closer to another, particularly in a personal and private way.1 Intimacy plays an important role in the sexual lives of people with MS and their partners.
Both women and men may experience sexual dysfunction. Some studies suggest it affects between 40 and 80 percent of women and 50 to 90 percent of men.2 Other studies suggest sexual dysfunction increases over time in people with MS and may be associated with some of the other physical symptoms of the disease – such as bowel and bladder dysfunction, limited mobility, spasticity, and fatigue – as well as psychological and emotional problems that individuals may also experience.
People are at times reluctant to discuss sexual dysfunction with their MS care team as they may feel awkward discussing things that seem so personal. However, to successfully address this problem, as one would with other symptoms, it first must be recognized and discussed.
The causes of sexual dysfunction in MS may be divided into three categories: primary, secondary, and tertiary.
Primary sexual dysfunction is the result of damage to the central nervous system caused by MS. Motor and sensory pathways may be disrupted by damage to the neurons. This can result in a slowing of the impulses sent from the brain to the body, including the genitals. Symptoms that result can manifest as decreased sexual sensation, decreased vaginal lubrication, or erectile dysfunction.
Secondary sexual dysfunction can be the result of other symptoms of the disease. Limited mobility, fatigue, and spasticity can all greatly impact one’s ability to maintain certain positions and engage in sexual activity. Bowel and bladder dysfunction can also be a major issue.
Tertiary sexual dysfunction results from primary and secondary causes and includes psychological disturbances, depression, and cognitive dysfunction. Some people with MS experience a loss of self-esteem or an altered body image. Additionally, receiving or providing intimate physical care for a person with MS can also affect one’s interest in sexual activity.
A number of MS symptoms may play a role in one’s ability to enjoy and take part in sexual activity. By managing the specific symptoms that may contribute to problems with intimacy, individuals can better plan for and engage in sexual relations. To follow are some examples of how the symptoms of MS may interfere with intimacy, and in the next section, strategies are provided for managing these types of symptoms.
A very common symptom of MS, limited mobility may lead to the inability of the person with MS to maintain certain positions necessary to engage in sexual activity. Fatigue is also a major contributor to sexual dysfunction. Often the demands of daily life combined with fatigue in MS result in a decreased libido and a decreased willingness to attempt to engage in sexual activity.
Spasticity may limit the types and number of positions a person with MS can maintain during sexual activity. A sudden onset of painful spasms can certainly interrupt attempts at sexual activity. Bowel and bladder dysfunction are also known to contribute to sexual dysfunction. People with MS who have difficulty controlling their bowels or bladder may be inclined to avoid intimate contact fearing an embarrassing accident.
People with MS often focus a significant amount of time and energy on the other physical symptoms of the disease. This may leave them simply too tired to consider sexual activity. They may also be embarrassed by the use of other devices such as urinary catheters or extremity splints.
Providing intimate physical care, such as catheterization, for a person with MS and then engaging in sexual activity with that person may be overwhelming. Concerns about the possibility of pregnancy and having a child with MS can also impact sexual function. In addition, many of the medications used by people with MS can contribute to sexual dysfunction, including antispasticity and antidepressant drugs.
Other possible causes that have nothing to do with MS should also be considered. These problems may be associated with the normal aging process. Vaginal dryness and decreased libido may be the result of menopause in women. Lack of erectile function in men may be associated with aging or vascular disease, or medications such as anti-hypertension drugs.
The first step to managing sexual dysfunction in MS is to recognize and discuss it with your partner and MS team or a sexual counselor.3 MS presents many physical challenges that can be recognized and managed, resulting in a more satisfying sexual life.
Another important first step is to review medications, since many medications can impact sexual performance. A discussion of these with your healthcare team may result in some changes that can improve sexual function. Doses may be changed or medications may be switched if necessary.
Timing a sexual encounter is also important. Fatigue often worsens as the day progresses, so setting aside time early in the day may enhance the sexual experience.
Other simple measures can include avoiding beverages such as caffeinated drinks (coffee, tea, carbonated sodas) and spicy foods immediately before sexual intimacy, which can reduce the possibility of a bowel or bladder accident. Emptying the bowels and bladder immediately prior to a sexual encounter can reduce the risk of elimination dysfunction during intimacy.
Pelvic floor exercises taught by a physiotherapist can serve to strengthen the muscles used in many sexual encounters. Hot or cold therapy, biofeedback, and electrical stimulation may also help with mobility limitations or spasticity. Timing sexual encounters at least 30 minutes after a dose of antispasticity medications is important. Personal lubricants may be useful for women with vaginal dryness.
Several medications are available by prescription for erectile dysfunction. These and all medications should be discussed with the MS team before making any changes to one’s treatment regimen. Different types of creams and vaginal preparations are also available for vaginal dryness. It is important to remember that sexual function is more than just a single physical action, and several factors are involved to create optimum intimacy between partners.
Sexuality and intimacy play an important role in the quality of life for nearly everyone, including those with a chronic disease such as multiple sclerosis (MS). In MS, sexual dysfunction may be one of the more invisible symptoms of the disease. It is important to recognize and understand all of the factors that contribute to sexual dysfunction in order to adequately address it.
Both women and men may experience sexual dysfunction. As mentioned in this section’s introduction, some studies suggest it affects between 40 to 80 percent of women and 50 to 90 percent of men.2 Other studies suggest that sexual dysfunction increases over time in people with MS, and in addition to physical symptoms, may be associated with some of the psychological and emotional problems that individuals may also experience.
People are at times reluctant to discuss sexual dysfunction with their MS-care team, as they may feel awkward discussing things that seem so personal. In order to address these problems as one would address other symptoms, they first must be recognized and discussed.
Another important issue is that some people with MS experience a loss of self-esteem or an altered body image. For example, a man who is no longer able to work and needs physical care from his partner may not imagine himself to be a sexual being and will thus avoid sexual contact. This may be true for care partners as well.
Depression is a psychological disorder seen frequently in people with MS that often impacts sexual function. People with MS who are depressed may have a decreased libido and a fear of developing relationships. Men may also experience erectile dysfunction.
The best treatment for depression is usually psychotherapy along with medication and exercise. Seeking strength in spiritual beliefs can also help.
Depression can affect care partners as well and may increase as disability increases. Care partners need to recognize and treat their depression to effectively participate in intimate relations.
In addition to depression, anxiety disorders are frequently overlooked and often undetected. Anxiety disorders are estimated to affect more than 40 percent of those with MS and are also more common among women. Frequently, if anxiety and depression co-exist, only a diagnosis of a depressive disorder is given.
Anxiety can affect sexual function, and similar to depression, care partners are also at risk. When anxiety impacts intimacy, both the anxiety and sexual dysfunction can worsen.
Cognitive impairment is common in MS, affecting as many as 50 percent of individuals with MS, and is not necessarily associated with advanced stages of disease.4 The onset of cognitive impairment in MS is usually not easy to pinpoint. Some people notice distinct changes in their mental functioning that can be attributed to the disease, while others are unaware of how their cognitive limitations may be affecting relationships.
Some of the cognitive functions typically affected in people with MS include: information processing; perceiving; attending/responding to incoming information; information-processing speed; cognitive flexibility, such as attending to multiple stimuli at the same time (“multi-tasking”); problems with storage, manipulation, and retrieval of information; and executive function, which includes planning, working memory, attention, and problem-solving.
Cognitive impairment may affect sexual function and relationships in many ways. Partners may become frustrated if the person with MS becomes easily distracted during intimacy. Distractions such as children in the home, music, and television may interrupt intimate moments if the person with MS is not able to filter out these distractions and remain focused on their partner.
Planning for sexual activity may be complex and overwhelming to the person with MS and they may choose to avoid it altogether. Verbal fluency and word finding may also be a problem leading to a partner who feels not wanted or respected. Fatigue may worsen both cognitive function and the quality of sexual relations as well.
Treatment strategies are available when cognitive impairment has been identified in a person with MS. While studies with medications and supplements aimed at treating memory and cognitive issues in people with MS have not shown any clear benefit, individuals with relapsing forms of MS should be encouraged to begin or remain on an effective disease-modifying therapy (DMT), if advised by their doctor. Based on these agents’ ability to inhibit inflammation and the accumulation of brain lesions, it is likely that they exert some degree of neuroprotection that may limit the progression of cognitive impairment.5
In addition, evidence suggests that exercise training in people with MS has the potential to improve many aspects of cognitive performance. Exercise has been proposed to have positive effects in reducing inflammation and neurologic damage in people with MS.
Counseling is another important treatment strategy and is vital to assist the couple in dealing with cognitive challenges affecting sexual function. Patients can be referred to an occupational therapist to assist with adaptation of certain skills or to a psychosocial therapist for assistance with coping and stress reduction.
