Life with MS

Having and enjoying a healthy sex life is an important part of living well for many people. Furthermore, sexual expression has health benefits including reducing stress, pain, depression, heart disease, prostate cancer and vaginal atrophy, among other benefits. Sexuality is influenced by a range of factors, including physiological, psychological, physical, cultural, and spiritual – some of which can be affected by multiple sclerosis. Between 70 to 90 percent of men and 40-70 percent of women report changes in sexual function at some point in the course of their illness. The importance of psychosocial health and sexuality should not be underestimated.
 
The neurophysiology of sex
 
Sex is complex! The sexual response cycle is divided into several phases including the excitement phase (initial arousal which includes penile erection, vaginal lubrication and engorgement), the plateau phase, orgasm, and resolution. The nervous system is involved in all aspects of sexuality, from sexual arousal and attraction to orgasm and bonding.
 
Networks within and between the brain, spinal cord, and peripheral nerves are involved in sexual function. Networks within the brain interpret sensory information and assign them value, including pleasure, pain, etc. The brain allows us to perceive the world around us and integrates our preferences and experiences with our senses, including visual, auditory, gustatory (taste), olfactory (smell) and tactile (touch) stimuli. Nerves in and under the skin respond to touch, pressure, vibration, and temperature and then send messages to the brain via the spinal cord. The spinal cord also plays a critical role in regulating our perception of tactile sensations and pain. Motor areas of the brain communicate with the spinal cord in order to regulate muscle tone and movements.
 
The autonomic nervous system is responsible for controlling bodily functions that do not involve our conscious input, such as breathing, heart rate, blood pressure and digestive functions. The autonomic nervous system also regulates sexual functions such as erection, vaginal lubrication and orgasm.
 
Sexual function with MS
 
Erectile dysfunction is the most common problem among men with MS, but other issues such as decreased sensation, difficulty achieving orgasm, and problems with ejaculation also occur. Among women, difficulty achieving orgasm is most commonly reported, but decreased desire for sexual activity, difficulty with arousal (such as decreased lubrication) and pain during sexual activity also occur.
 
MS can affect sexual function both directly and indirectly. Direct effects of MS include demyelinating lesions in the brain and spinal cord that cause sensory, motor or autonomic dysfunction such as difficulty achieving and maintaining an erection, vaginal lubrication, and orgasm. MS can also indirectly affect sexuality by decreasing energy, concentration, mobility, and by causing pain and spasticity. Some medications used to treat MS symptoms can affect sexuality as well. Finally, MS can effect psychosocial and emotional changes such as decreased self-esteem, mood, and body image. Depression, stress, and anxiety can also affect sexuality, and sexual dysfunction itself can produce negative emotions such as fear of rejection by a partner or fear of being perceived as less masculine or feminine. In addition, some medications used to treat symptoms of MS can cause sexual side effects.
 
Given the myriad influences on sexual function, it is important to be comprehensive in one’s approach to sexuality — this means enlisting the support of your partner, neurologist, and other physicians (urologist, primary care, etc.), psychologists, therapists, and others in your community whom you can trust if needed. Excellent communication with your partner and healthcare team is essential. Use the language with which you are comfortable and let your doctor know you want to discuss sexual health during the appointment, to make sure there is time in the visit.
 
TIPS:
Get the conversation going. Questions for your neurologist:

• “I am concerned about how MS might affect my sex life. What should I look for and how can I plan for these changes?”
• “I have some questions about how MS might be affecting my sexuality.”
• “I’m not sure how to talk to my (new/ existing) partner about how MS has affected my sexuality. Where can I find resources to help?”

 
Libido/erectile dysfunction:

• Avoid illicit drugs and alcohol
• Flibanserin can be used for decreased libido in women
• Medications such as sildenafil, vardenafil, and tadalafil are highly effective for men with erectile dysfunction, but may be contraindicated for those with a history of heart disease or those taking nitrates
• Penile suppositories, penile injections such as alprostadil can be helpful
• Vacuum erection devices and prostheses can also be used

 
Vaginal dryness:

• Water-based lubricants
• Discuss other options with gynecologist

 
Difficulty achieving orgasm:

• Communication!
• Incorporate more flirting, fantasy, foreplay, or oral sex
• New or different sexual positions
• Incorporating sexual devices such as vibrators

 
Pain during intercourse:

• Vibrators and/or desensitizing lubricants may be helpful for women
• Identify source and cause of pain (nerve pain, pain related to spasticity, injury, etc.) and develop a pain management strategy including relaxation, medications, etc. as appropriate

 
Fatigue:

• Optimize the timing of sexual activity for a time of day when you have the most energy
• Maintaining healthy levels of physical activity, a healthful diet, good sleep routines
• Treatment for depression and anxiety
• Some medications can help with fatigue as well

 
Bladder dysfunction:

• Timed toileting before sexual activity
• Kegel exercises
• Barriers such as condoms, pads on the bed
• Some medications can help reduce leakage
• We do not recommend water fasting given the increased risk UTI with this method

 
Spasticity:

• Stretching exercises
• Different sexual positions or positioning aides such as pillows
• Antispasticity medications such as baclofen or tizanidine
• Focal spasticity that interferes with sex, such as in the muscles that pull the knees together, can be helped with stretching and botulinum injections

 
Depression and antidepressants:

• Talk therapy
• Healthy physical activity
• Antidepressant medications
• Some antidepressants may cause sexual side effects, but others may not. Tell your physician if you think one of your medications is interfering with your sexual function and ask if another medication might be reasonable.

Conclusions

Many people with MS experience changes in their sexual function and MS may challenge your perception of yourself and your sexuality. Sometimes changing the way you think about sexuality and intimacy may be necessary. For example, do you have to experience orgasm to enjoy sex? Are there other ways you can enjoy intimacy with your partner? There are many ways to help manage sexual dysfunction in MS and your healthcare team can help.