Sexual Dysfunction

Physical Symptoms of Sexual Dysfunction

Sexuality and intimacy have an important impact on 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 less talked-about symptoms of the disease. It is important to recognize and understand this symptom in order to adequately address it.

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.

Males and females 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 xMS and may be associated with some of the other physical symptoms of the disease, including limited mobility, spasticity, and bowel and bladder dysfunction.

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, like others, it first must be recognized and discussed.

The causes of sexual dysfunction 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 and back. 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 may result in the inability of the person with MS to maintain certain positions 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 physical 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 often avoid intimate contact fearing an embarrassing accident.

Depression has also been found to have a significant effect on sexuality. Many of the medications used by people with MS can also contribute to sexual dysfunction, including antispasticity and antidepressant drugs.

Tertiary sexual dysfunction results from primary and secondary causes and includes psychological disturbances, cognitive dysfunction, and depression. 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.

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 also.

Providing intimate physical care for a person with MS such as catheterization 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.

There may be other possible causes that have nothing to do with MS yet should be considered. These problems may be associated with a 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.

Common symptoms of sexual dysfunction may include:

decreased libido
decreased sensation
orgasmic dysfunction
painful intercourse
decreased vaginal lubrication
erectile dysfunction
ejaculatory dysfunction

The first step to managing sexual dysfunction is to recognize and discuss it with your partner and MS team or a sexual counselor. 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. Many 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.

Other simple measures can include avoiding beverages such as caffeinated drinks (coffee, tea, carbonated sodas) and spicy foods immediately prior to sexual intimacy, which can reduce the possibility of a bladder or bowel accident. Emptying the bladder and bowels immediately prior to a sexual encounter may also reduce the risk of elimination dysfunction during intimacy. 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.

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.

There are several medications available by prescription for erectile dysfunction. Men should discuss these and all medications with the MS team. It is important to remember that sexual function is more than just a physical action. In the next issue of The Motivator, the topic of emotional and psychological symptom management, including sexuality, will be addressed.

As noted at the beginning of this section, sexuality and intimacy have an important impact on the quality of life for nearly everyone, including those with a chronic disease such as MS. There are many ways to manage sexual dysfunction in MS. The first step is recognizing and discussing sexual function with your MS healthcare team.

The following medications may be used to treat sexual dysfunction (as listed on MSAA’s website at mymsaa.org under Symptoms). Please see MSAA’s website for more information about these drugs, such as prescribing information and side effects.

For erectile dysfunction:

Viagra® (sildenafil)
Levitra® (vardenafil)
Cialis® (tadalafil)

For vaginal dryness:

Lubrication agents
Estrogen-containing vaginal preparations
Topical creams

Psychological Symptoms of Sexual Dysfunction

Sexuality and intimacy have a significant impact on 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 the factors that contribute to sexual dysfunction in order to adequately address it.

Both men and women may experience sexual dysfunction. Some studies suggest it affects between 40 to 80 percent of women and 50 to 90 percent of men.⁴ Other studies suggest that sexual dysfunction increases over time in people with MS and may be associated with some of the emotional and psychological problems that they 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.

How Cognitive Problems Affect Sexual Function

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.⁵ 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 his or her partner.

Planning for sexual activity may be complex and overwhelming to the person with MS, and he or she may choose to avoid it all together. Verbal fluency and word finding may also be a problem leading to a partner who feels he or she is not wanted or respected. Fatigue may worsen both cognitive function and the quality of sexual relations as well.

Once cognitive impairment has been identified in a person with MS, what can be done to treat this condition? First, people with relapsing forms of MS should be encouraged to begin or remain on an effective disease-modifying therapy (DMT), if advised by his or her 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.

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.⁶ Counseling is vital to assist the couple 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.

How Depression and Anxiety Affect Sexual Function

Depression is another psychological disorder seen frequently in people with MS that often impacts sexual function. People with MS who are depressed may have a decreased libido, difficulty with certain sexual positions, and 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 also affect care partners and may increase as disability increases. Care partners need to recognize and treat depression to effectively participate in intimate relations.

Anxiety can affect sexual function as well, and care partners are also at risk. When anxiety impacts sexual function, both of these symptoms can worsen.

Enhancing Intimacy

Intimacy may be defined as anything that makes one feel closer to another, particularly in a personal and private way.⁴ People with MS who are experiencing emotional or psychological difficulties may find intimacy particularly challenging. Depression, anxiety, and cognitive dysfunction are all likely to interfere with attempts at intimacy. Recognizing and treating the underlying cause is the best way to enhance intimacy.

Emotional and psychological impairment affects quality of life, which includes intimate and sexual relationships. Recognizing these impairments in people with MS and their care partners is the first step to a healthy sexual relationship. Quality of life can be impacted and treatment for many of the underlying emotional and psychological causes of sexual dysfunction should be investigated. With early recognition and treatment, a healthy and satisfying sexual relationship is certainly possible.

References

Krawchuk LR Rediscovering Intimacy. The Motivator Fall 2004
Orton SM, Herrera BM, Yee IM, et al. Sex ratio of multiple sclerosis in Canada: a longitudinal study. Lance Neurol. 2006;5:932-936.
Association of Reproductive Health Professionals. “Sex Therapy for Non-Sex Therapists.” Accessed August 31, 2013 at www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/SHF-Therapy
Orton SM, Herrera BM, Yee IM, et al. Sex ratio of multiple sclerosis in Canada: a longitudinal study. Lancet Neurol. 2006;5:932-936.
Chiaravalloti ND, DeLuca J. Cognitive impairment in multiple sclerosis. Lancet Neurol. 2008;7:1139-1151.
Comi G. Effects of disease modifying treatments on cognitive dysfunction in multiple sclerosis. Neurol Sci. 2010;31:S261-264.
Krawchuk LR. Rediscovering Intimacy. The Motivator. Fall 2004.

By Amy Perrin Ross, APN, MSN, CNRN, MSCN
Advanced Practice Nurse
Loyola University Medical Center