In the last of the series I will be addressing tertiary causes of sexual dysfunction.

Whether a person is in an intimate relationship or not, it is a challenge to maintain a sexual identity and take care of one’s sexual self-esteem (how one feels about oneself as a sexual being) while dealing with a chronic illness such as MS.

Sexual changes in MS can best be characterised as primary, secondary, or tertiary.

Primary sexual dysfunction has been dealt with in parts 2 and 3.  Secondary was dealt with in part 4. In this article I am going to deal with tertiary sexual dysfunction but I am simply going to lay out the symptoms. A more advanced course is available which covers possible courses of action to take given the symptom.

Tertiary sexual dysfunction
The onset of MS can alter a person’s perception of himself or herself as an individual, altering sexual development and expressions of sexuality and it can have a negative impact on sexual and intimate functioning. These are known as the tertiary sexual problems of
MS, derived from the resultant psychological and social changes, as distinct from the direct neurological dysfunction (primary sexual problems) and the symptoms of MS (secondary sexual problems).

People with MS can find it difficult to see themselves as being “sexual”, having sexual thoughts, desires and needs whilst at the same time identifying with the role of a person with a chronic illness.

Individuals see themselves as complete persons in terms of their roles within families, friendship circles, sporting clubs, activities and occupations. Any feelings of loss of control over events or unplanned changes because of MS can affect one’s confidence and self-esteem and alter the dynamics of relationships, especially close and intimate ones.

Dealing with the impact of MS and symptoms can leave one neglecting the emotional and psychological aspects of life in general. Simply attending to the physical needs of life’s daily activities can leave little time or energy for emotional contemplation and intimate relationships. This is particularly evident if fatigue is experienced as a symptom of the MS.

What you can do

If you experience problems with intimacy and sexuality, you need to allow yourself time to assess your overall situation and to feel confident about communicating any difficulties to those close to you.

Counselling can help individuals to explore feelings and facilitate discussion in a respectful and professional way. You can identify negative emotions such as guilt, anger and resentment, see them in context, and work through them, in a non-judgemental environment.
Here you can discuss topics, perhaps seen as too embarrassing to discuss alone, in an open and supportive atmosphere. Strategies for improving the situation, or adopting new ways of considering and developing sexuality, can be introduced.

Drugs that affect sexual functioning

Some people with MS may experience depression and/or anxiety, and medications prescribed for these conditions can affect sexual functioning.

The drugs used to treat depression and anxiety belong to a family called ‘Selective Serotonin Reuptake Inhibitors’ (SSRIs). Commonly prescribed SSRIs include Fluoxetine, Sertraline, Fluvoxamine, Paroxetine, Citalopram and Venlafaxine.

Conclusion

Sexuality is an important aspect of human life and must not be neglected when considering the impact of MS on an individual.

Increasing awareness and acknowledgement of the effects of MS on sexuality has greatly improved the management and treatment options available for people with MS experiencing difficulties in this area.

While this is often a difficult and sensitive subject, discussing sexual difficulties with your GP or neurologist is the first step to identifying effective strategies to manage any problems, and to support your need for sexual expression.

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In  the fourth part of this series I will be addressing secondary causes of sexual dysfunction.

While life changes affect everyone, changes from MS can directly and indirectly affect sexuality.

Sexual changes in MS can best be characterised as primary, secondary, or tertiary.

Primary sexual dysfunction has been dealt with in parts 2 and 3. In this article I am going to deal with secondary sexual dysfunction but I am simply going to lay out the symptoms. A more advanced course is available which covers possible courses of action to take given the symptom.

Secondary sexual dysfunction

MS changes can affect sexual response by making sexual activity difficult physically and emotionally. Symptoms common to MS, such as fatigue or changes in muscle tone, lack of coordination or pain, can frustrate sexual expression and extinguish desire. Bowel and bladder dysfunction can inhibit and cause embarrassment. Cognitive changes challenge the most devoted couple, yet in the presence of any of these symptoms; it is possible to find creative ways to keep the physical expressions of love alive.

Fatigue

This is perhaps the most common symptom reported by people with

MS, and it can be the most disabling.

Weakness

Muscle weakness may necessitate alterations in sexual practices.

Lack of coordination and tremor

Lack of coordination may make sex and sexual expression feel clumsy, as can tremor. But besides being awkward, these symptoms may also interfere with the couple’s style of having sex.

Bowel and bladder problems

Another source of anxiety and distress can be bowel and bladder disturbances. These problems go hand in hand with sexual dysfunction, since nerve pathways are shared or close to each other. Incontinence, or even fear of having an accident, can cause a person to avoid sex entirely, thus depriving them of the closeness it brings.

Pain

This can impact significantly on interest in sex as well as performance ability. Understanding the type of pain can influence the best way to manage it. Muscle tightness, intense itching and spasticity may all be called “pain”. Also, medications used to relieve pain may add to sleepiness or fatigue.

What you can do

Medications that bring relief must be well prescribed for the type of pain they treat and used in just the right dose and frequency to give relief with the least disadvantageous side-effects. An extra or well-timed dose before intimacy can often provide effective symptom management and reassure the partner that he/she is not adding to discomfort.

It is also important that a symptom such as adductor spasms (which cause involuntary pulling together of the legs) is not seen as an indication of the person’s interest or willingness to have sex. Again, communication is the key to avoiding misunderstanding and hurt feelings.

Water soluble lubricants can make intercourse more comfortable, without predisposing to urinary tract infection.

Sensory issues

Changes in sensation can also interfere with sexual pleasure. Non-genital symptoms such as numbness and tingling can distract and discourage either partner. Impaired genital sensations can diminish pleasure, while heightened sensitivity may make even the lightest touch unbearable. What feels good at one time may be excruciatingly painful on another occasion

Mobility

Mobility devices used to compensate for loss of function can also damage your confidence and self-image. They may be seen as less than sexy. Canes, wheelchairs, braces and walkers are often identified with being “sick” or “old”. Spontaneity can be a problem if great effort has to be made to get about.

Cognition

Cognitive changes can be amongst the most potentially damaging to the relationship, since they can undermine the person’s sense of who he/she is. A partner may feel this is no longer the person they once knew. Changes in attention and concentration may be perceived as lack of interest or love, and may irreparably strain the relationship. Changes in mood, memory loss and depression can be frightening, frustrating and sometimes infuriating. All interfere with intimacy. Individual or couples counselling may be advised.

Conclusion

Sexuality is an important aspect of human life and must not be neglected when considering the impact of MS on an individual.

Related posts

• Sexuality and intimacy in MS – part 5 Tertiary (0)
• The Challenge of Working with MS (5)
• Sexuality and intimacy in MS – part 3 Male sexual dysfunction (0)
• Sexuality and Intimacy in MS – part 2 Female sexual dysfunction (0)
• Living with MS (0)
• Promising psychosocial treatments for pain in MS (4)
• Pain in multiple sclerosis part 2 – Neurogenic pain (4)

Many symptoms of MS are invisible while others are painfully obvious. Whether a person is in an intimate relationship or not, it is a challenge to maintain a sexual identity and take care of one’s sexual self-esteem (how one feels about oneself as a sexual being) while dealing with a chronic illness such as MS

Male sexual dysfunction
Sexual activity for men usually requires the co-ordination of arousal, penile erection and orgasm including ejaculation, along with the many other emotional and relationship components that are integral for satisfaction. Direct disruption of nerve pathways controlling erection and ejaculation are common.

Erectile dysfunction (ED) is the commonest sexual dysfunction in men and usually is due to a disease of the vascular or neurological systems, but psychosexual influences are also important. ED can have a major impact on self-esteem, relationships and general well being.

The limited studies of men with MS indicate that ED is a frequent symptom, often affecting younger men and sometimes affecting fertility.

If you are a man with MS, let your neurologist, GP or MS Nurse know if you are having any erectile dysfunction. If you talk to them about it, its impact can be assessed and, if it is considered significant, a full range of treatment options can then be discussed with you.

Treatment is usually erection-promoting medications rather than treating the underlying disorder. Drugs used to modify MS progression may also help. They are generally safe, well tolerated medications and observation of their use in MS and spinal cord injury confirm a high efficacy, with about three-quarters of men experiencing satisfactory outcomes. Patience and perseverance are the most important aspects of the use of these medications. They need to be taken at least half an hour before sex, but some couples find the idea of premeditating their sexual experience off-putting, and this often interferes with treatment. Normal sexual stimulation is required to initiate the erection, therefore the couple needs to be in the mood for sex.

The most commonly-used medications act to enhance the relaxation of muscle cells in the penis. Sildenafil, tadalafil and vardenafil all act in this way through a similar mechanism. They are generally safe, well tolerated medications and observation of their use in MS and spinal cord injury confirm a high efficacy, with about three-quarters of men experiencing satisfactory outcomes. Patience and perseverance are the most important aspects of the use of these medications. They need to be taken at least half an hour before sex, but some couples find the idea of premeditating their sexual experience off-putting, and this often interferes with treatment. Normal sexual stimulation is required to initiate the erection, therefore the couple needs to be in the mood for sex.

Alternative treatments

If these drugs do not work or cannot be safely used, injecting drugs into the penis or the use of mechanical aides may be helpful.
Ejaculatory dysfunction

At ejaculation there is widespread muscle contraction in the pelvic area that leads to expulsion of the semen and much of the sensation
associated with the broader response of orgasm.

Often, delayed ejaculation and complete failure of ejaculation
(anejaculation) are caused by disruption of the nerve pathways and
may be part of a broader orgasmic failure.

Ejaculatory disturbances also occur in MS, although there is less information about the prevalence. Anti-depressant medications that may be used in MS often cause ejaculatory problems as a side-effect. Some men with MS may develop premature ejaculation because of anxiety about their disease

Sexual desire

Testosterone is active in several brain centres important for sexual thoughts and desire (libido) and low levels of it are associated with depression and obesity, both of which can relate to MS. Frequently, desire is affected by factors other than the direct physical component of the disease, and this is particularly so in MS where other physical and psychological factors, such as fatigue, may play a major role.

The importance of assessing both the man with MS and his partner cannot be over-emphasised, particularly if initial treatment is not successful. This will require more developed skills that not all doctors will have. Your doctor may be able to refer you to another professional for further help.

Related posts

• Sexuality and intimacy in MS – part 5 Tertiary (0)
• Sexuality and intimacy in MS – part 4 Secondary (0)
• Sexuality and Intimacy in MS – part 2 Female sexual dysfunction (0)
• Sexuality and intimacy in MS – part 1 (0)
• Promising psychosocial treatments for pain in MS (4)
• Pain in multiple sclerosis part 2 – Neurogenic pain (4)
• Living with MS (0)

Whether a person is in an intimate relationship or not, it is a challenge to maintain a sexual identity and take care of one’s sexual self-esteem (how one feels about oneself as a sexual being) while dealing with a chronic illness such as MS

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 condition. This is estimated to be as high as 80 per cent, compared to the general female population, in which only 20-50 percent of women are affected. Sexual dysfunction has a major impact on quality of life and interpersonal relationships. For many women it is a physically disquieting, emotionally disturbing and socially disruptive disorder.

In spite of its high prevalence, these aspects of an individual’s wellbeing have been considerably neglected until recently, making female sexual dysfunction a very important but often overlooked

Symptoms most commonly reported include:
•     Reduced genital sensation (48%):
•     Reduced vaginal lubrication and difficulty with arousal (35%);
•     Difficulty or inability reaching orgasm (72%).

Pain during intercourse is also a frequently reported symptom in
women with MS, which may be due to vaginal dryness, spasticity or sensitivity.

Changes in sensation can also interfere with sexual pleasure. Non-genital symptoms such as numbness and tingling can distract and discourage either partner. Impaired genital sensations can diminish pleasure, while heightened sensitivity may make even the lightest touch unbearable. What feels good at one time may be excruciatingly painful on another occasion.

Where diminished genital sensation occurs, you can increase stimulation through oral stimulation or use mechanical vibrators, which are widely available by mail order online

Painful or irritating genital or body sensations can be relieved with medication. Amitriptyline (Amitrip®), carbamazepine (Tegretol®) and phenytoin (Dilantin®) can be prescribed to help manage this.

It is not yet clear how helpful oral medicines like Viagra or Cialis could be for women with MS. These are targeted at sexual dysfunction in men to increase blood flow to the genitals.

Lowered libido

Loss of sex drive, or libido, can be a frequent sexual symptom among women with MS. There are currently no effective medicines for this. However, there are reports that sex therapy combined with MS symptom management and communication skills training, can be successful.

How and why MS can affect sexual functioning

Sexual dysfunction in women has many causes and effects:

•    Abnormalities in blood circulation
•    Lesions in the brain can interfere with the interpretation of sexual stimuli as arousing.
•    Lesions in the sacral (lower) spinal cord can also cause primary sexual dysfunction, , resulting in diminished or absent clitoral swelling and/or vaginal lubrication.
•    In primary sexual dysfunction, MS lesions in the spinal cord may make it difficult to sustain clitoral/vaginal engorgement during the plateau phase (between arousal and orgasm).
•    In addition, sensory changes in the genitals can interrupt or diminish nerve signals that initiate and/or maintain vasocongestion at both the spinal cord and cerebral cortex (brain) levels.

Types and frequencies

It is known that approximately 80 per cent of women with MS experience sexual dysfunction at some time during the course of the disease. Some women just stop engaging in sexual relations, while others (approximately 40 per cent) have reported that participating
in sexual relations is significantly unsatisfactory.

Symptoms most commonly reported include:
•     Reduced genital sensation (48%):
•    Reduced vaginal lubrication and difficulty with arousal (35%);
•    Difficulty or inability reaching orgasm (72%).

Pain during intercourse is also a frequently reported symptom in women with MS, which may be due to vaginal dryness, spasticity or sensitivity.

Vaginal dryness and tightness

Vaginal lubrication may be compromised by MS. The best way to cope with vaginal dryness is to apply liberal amounts of water-based lubricants (e.g., K-Y® Jelly).

Oestrogen creams may be useful for women experiencing vaginal dryness, pain or burning. Another treatment is a vaginal suppository. Ask your GP or pharmacist about what is best for you.

Conclusion
Sexual dysfunction is highly prevalent among women with MS. While identification, assessment and treatment of sexual problems can be embarrassing and complicated, addressing them is important. In this way you can identify and manage the symptoms that can have a negative impact on your personal life as well as that of your partner.

Related posts

• Sexuality and intimacy in MS – part 5 Tertiary (0)
• Sexuality and intimacy in MS – part 4 Secondary (0)
• Sexuality and intimacy in MS – part 3 Male sexual dysfunction (0)
• Sexuality and intimacy in MS – part 1 (0)
• Promising psychosocial treatments for pain in MS (4)
• Pain in multiple sclerosis part 2 – Neurogenic pain (4)
• Multiple Sclerosis and Emotions! (0)

Sexual complaints are common in the general population and are capable of having a profound impact on quality of life and relationships. Adding chronic illness to the picture makes problems more likely. Unfortunately these concerns and complaints are not always discussed with partners or health care professionals, but, strategies exist which can be used to cope with and manage symptoms, promote intimacy, strengthen relationships and encourage sexual pleasure and expression

Many symptoms of MS are invisible while others are painfully obvious. All can impact on quality of life and sense of wellbeing. While life changes affect everyone, changes from MS can directly and indirectly affect sexuality. Successful management requires creativity, communication, and patience so that a person is able to maintain his or her sexual identity.

Whether a person is in an intimate relationship or not, it is a challenge to maintain a sexual identity and take care of one’s sexual self-esteem (how one feels about oneself as a sexual being) while dealing with a chronic illness such as MS. This is particularly challenging in cultures where society places importance on qualities that are not always consistent with chronic illness, such as beauty, health and independence.

Sensory issues
Changes in sensation can  interfere with sexual pleasure. Non-genital symptoms such as numbness and tingling can distract and discourage either partner. Impaired genital sensations can diminish pleasure, while heightened sensitivity may make even the lightest touch unbearable. What feels good at one time may be excruciatingly painful on another occasion.

Sexual changes in MS can best be characterised as primary, secondary, or tertiary.

Primary sexual dysfunction stems from changes to the nervous system that directly impairs the sexual response and/or sexual feelings. Primary disturbances can include partial or total loss of libido (sexual desire), unpleasant or decreased sensations in the genitals, decreased vaginal lubrication or erectile capacity, and decreased frequency and/or intensity of orgasm.

Secondary sexual dysfunction refers to MS-related physical changes that indirectly affect the sexual response. Bladder and/or bowel dysfunction, fatigue, spasticity, muscle weakness, problems with attention and concentration, hand tremors, and non-genital changes in sensation are amongst the most common MS symptoms that can
cause secondary sexual dysfunction.

Tertiary sexual dysfunction results from psychosocial and cultural issues that can interfere with sexual feelings and sexual response. Depression, performance anxiety, changes in family roles, lowered self-esteem, body-image concerns, loss of confidence, and internalised beliefs and expectations about what defines a “sexual man” or a “sexual woman” in the context of having a disability, can all be expressions of, or contribute to, tertiary sexual dysfunction

In the following articles I will be addressing Female and Male sexual dysfunction separately

Related posts

• Sexuality and intimacy in MS – part 5 Tertiary (0)
• Sexuality and intimacy in MS – part 4 Secondary (0)
• Sexuality and intimacy in MS – part 3 Male sexual dysfunction (0)
• Sexuality and Intimacy in MS – part 2 Female sexual dysfunction (0)