International Journal of Impotence Research (1998) 10, 233±237 ß 1998 Stockton Press All rights reserved 0955-9930/98 $12.00 http://www.stockton-press.co.uk/ijir Sexual dysfunction in men with multiple sclerosis Ð A comprehensive pilot-study into etiology

PEM Lottman1, PJH Jongen2,3, PFWM Rosier1 and EJH Meuleman1

1Department of Urology; 2Department of Neurology, University Hospital Nijmegen, PO Box 9101, 6500 HB, Nijmegen; and 3Multiple Sclerosis Centre Nijmegen, Snelliusstraat 6, 6533 NV Nijmegen, The Netherlands

Ideally, the etiological diagnosis of sexual dysfunction in patients with multiple sclerosis is established on the basis of both objective and subjective tests. Accordingly, we assessed sexual function in 16 male patients with multiple sclerosis and complaints of sexual dysfunction by means of subjective data from interviews and questionnaires and objective data, obtained from (psycho)physiological tests. Psychophysiological investigation consisted of measurement of sleep erections and of erectile response to visual erotic stimulation and penile vibration. Urodynamic investigation was used to assess the neurological status of the genital tract. Sixteen male patients with clinically de®nite multiple sclerosis, complaints of sexual dysfunction and a steady heterosexual relationship participated in the study. The majority of patients had no abnormalities in the objective tests. Only one (1 out of 15) patient showed disturbed sleep-erections, and four (4 out of 12) other patients showed signs of neurological dysfunction of the genital tract. Conclusion: in our patient-group, disturbed sleep erections and abnormal ®ndings on urodynamic investigation appeared unrelated to the complaint of erectile dysfunction. Sexual function was related to psychological factors, decreased general sensitivity, and motor impairment.

Keywords: etiology; sexual dysfunction; multiple sclerosis

Introduction few studies used objective data based on neurophy- siological tests and measurement of sleep-erections to identify the etiology of sexual dysfunction. Multiple sclerosis may affect sexual functioning in Staerman et al 5 found abnormal pudendal evoked many different ways through interference with phy- potentials in 14 out of 16 patients with multiple siological and psychological mechanisms involved in sclerosis and erectile dysfunction, and abnormal 1 sexual function. Lesions in the spinal cord may affect bulbo-cavernosus re¯ex in four patients. He re- the genital neurological pathways and cause erectile- ported normal sleep-erections in more than half of and ejaculatory dysfunction, whereas lesions in the the patients with neurophysiological abnormalities. brain may cause disorders of sexual desire and alter In addition, Kirkeby et al 6 found neurophysiologi- the sensation of orgasm. Furthermore, decreased cal abnormalities in 90% of the patients with sensitivity and pain may interfere with the capacity multiple sclerosis and erectile dysfunction, and to achieve or maintain erection and orgasm through normal sleep-erections in 42% of these patients. tactile stimulation. In addition, patients with muscu- However, due to the scarcity of objective data on lar weakness or spasticity may experience motor physiological and psychological factors that are limitations during sexual activity. Finally, multiple associated with sexual dysfunction in patients with sclerosis may affect sexual life through psychological multiple sclerosis, it is dif®cult to draw conclusions and social factors: loss of personal identity, anxiety, on their relative contribution to the occurrence and depression, dependency, and dif®culty to cope with maintenance of sexual dysfunction. invisible symptoms, such as fatigue and sensory In this pilot-study we investigated the etiology of 2 changes. sexual dysfunction in 16 patients with clinically Traditionally, sexual dysfunction in patients with de®nite multiple sclerosis7 and complaints of sexual multiple sclerosis has been classi®ed on subjective dysfunction by means of psychological, psychophy- 2±4 data from interviews and questionnaires. Only a siological, and physiological tests. Psychological tests included interviews and questionnaires about Correspondence: Dr PEM Lottman. psychosexual functioning and marital satisfaction. Received 2 August 1997; accepted in revised form 7 April Psychophysiological investigation consisted of 1998 measurement of sleep-erections and erectile Sexual dysfunction in men with multiple sclerosis PEM Lottman et al 234 response to visual erotic stimulation and penile compared scores on these subscales between our vibration. Physiological assessment included uro- group of patients and 16 men of similar age selected dynamic investigation to evaluate the sensory and from a normal healthy population.12 The Maudsley motoric neurological status of the genital tract Marital Questionnaire consists of twenty Likert- indirectly. scale questions that evaluate marital, social satisfac- tion, and sexual satisfaction. We focussed on the subscale for marital satisfaction (5 items; score 0 ± Material and methods 40). Marital satisfaction is considered normal if the score for marital items is < 20.13 The Symptom Checklist 90 is a self-report inventory that consists Patients were recruited on the department of of ninety questions to assess psychological symp- Neurology where they were treated for multiple toms. We focussed in this study on scores for sclerosis. The median age of the patients was 41.0 y depression and anxiety. The score for depression (range 31 ± 54). The age at onset of multiple sclerosis and anxiety is considered to be within normal range varied between 18 and 49 y (median 31.5) and the if the Symptom Checklist 90-score is < 23 and < 15, duration of the disease varied between 2 and 26 y respectively (namely, according to the criteria for (median 10.5). Four patients were able to walk the normal healthy population, Derogatis et al 14). without restrictions, whereas eight patients used Quality of erectile response to visual erotic walking-aids and four patients were wheelchair- stimulation with and without vibration was bound. Nine patients were employed and seven measured with Rigiscan1. The Rigiscan device patients were retired due to their illness. Fifteen provides simultaneous, continuous measurement patients had a steady heterosexual relationship and of both tumescence and rigidity. Vibration was were married or in committed relationships for administered with a ring-shaped vibrator at a 13.0 y (median, range 2 ± 29). At the moment of the frequency of 50 Hz. Visual erotic stimulation con- interview, one patient had recently divorced his sisted of two heterosexual erotic ®lms showing wife. various types of sexual activities. After placing the Before investigation, written informed consent two wire loops of the Rigiscan at the penile base and was obtained from patients. Patients underwent a tip, the vibrator was positioned at the penile shaft psychosexological assessment by means of inter- between the wire loops. The subject viewed two views and questionnaires. Following psychosexolo- erotic ®lms, each of 10 min length, sitting in a gical assessment, erectile responses to visual erotic comfortable chair in front of a video monitor. The stimulation with and without vibration were mea- ®rst ®lm was presented without vibration and the sured. Sleep erections were measured on three second ®lm with vibration. After each ®lm the consecutive nights. Urodynamic investigation was subject was asked to ®ll in a form containing performed within the period between six months questions about subjective arousal, genital and before and after the psychophysiological assessment extragenital sensations, together with the maximal in 12 patients. Motor function of the pelvic ¯oor degree of erection he experienced during the ®lm. muscles, re¯exes in the sacral segments, and We considered an increase  15 mm of tumescence sensitivity of the genital area were tested in as a cut-off value of erectile response.15,16 respectively seven, nine and six patients within Sleep erections were measured on three consecu- the aforementioned period. tive nights using the Erectiometer.17 The Erecti- The nature of the sexual problem, psychological ometer consists of a 2 cm-wide felt band with a factors (depression, anxiety, fear of failure), relation- sliding collar fastened to one end. The band requires ship issues, physiological factors (decreased sensi- a force of about 250 g to initiate expansion. For this tivity, pain, motor impairment) and sexual reason, the device responds when penile tumes- performance status were assessed in a semi-struc- cence involves increases in both circumference and tured interview and by means of three question- rigidity. All patients were instructed in the use and naires: the Questionnaire for screening Sexual interpretation of the Erectiometer. The patients were Dysfunctions,8 the Maudsley Marital Question- requested to ®ll in the results of the Erectiometer in naire,9 and the Symptom Checklist 90.10 The a diary at home and to return this together with the Questionnaire for screening Sexual Dysfunctions Erectiometer. It is well documented that sleep consists of 76 questions to assess sexual problems. erections are suppressed by depression, anxiety We focussed in this study on six of the 12 subscales, and disturbed sleep.18,19 Therefore, we explicitly frequency of (score 1 ˆ almost never; 3 ˆ frequently; investigated these items and asked patients to report 5 ˆ always) and trouble with (score 1 ˆ no trouble; their sleep performance during the nights of the 3 ˆ trouble; 5 ˆ very much trouble) the following measurement of sleep erections. sexual problems: erectile problems (6 items), sexual The relevant parameters of urodynamic investiga- excitement problems (6 items), ejaculation problems tion consisted of cystometry and pressure-¯ow (4 items), orgasm problems (6 items), genital pain (2 study together with electromyography registration items), and genital insensitivity (4 items).11 We of the pelvic ¯oor muscles. Early or late ®rst Sexual dysfunction in men with multiple sclerosis PEM Lottman et al 235 sensations during storage, hypoactivity, overactivity showed a higher frequency and were more troubled and dyssynergia were considered to be indicative of with erectile problems, orgasm problems and genital the presence of neurological lesions. insensitivity. In the majority of patients sexual function was impaired by motor limitations and decreased gen- Results eral sensitivity. Twelve patients reported impaired mobility during sexual activity due to muscular weakness and spasticity. Ten patients reported Data obtained from interviews indicated that 15 diminished genital- and extragenital response to patients experienced sexual dysfunction following sexual stimulation. the diagnosis of multiple sclerosis, whereas in one The scores on the Maudsley Marital Question- patient the sexual dysfunction preceded the diag- naire showed that the majority of patients (15 out of nosis. Fourteen men attributed sexual dysfunction 16) reported normal marital satisfaction (score to multiple sclerosis and two men to marital < 20). The scores on the Symptom Checklist-90 problems or fatigue. The majority of patients indicated that four patients experienced anxiety and reported that their sexual dysfunction had a gradual three patients depression. Table 2 shows the mean onset, only three patients reported it started scores of the Symptom Checklist-90 in our group of abruptly. Six patients responded with perfor- patients in comparison with a normal healthy male mance-anxiety and feelings of disappointment. population and a outpatient psychiatric population. Although the majority of men reported a satisfactory Note that depression and anxiety scores in our group sexual relationship (10 out of 15), most of these of patients is comparable with the healthy popula- patients (9 out of 10) said to be dissatis®ed with tion. their sexual functioning. The scores on the Ques- Maximal increases in penile circumference in tionnaire for screening Sexual Dysfunctions showed response to visual erotic stimulation (VES), VES and that: seven patients experienced erectile problems, vibration (VES ‡ VIB) and during sleep (NPT) of four patients orgasm problems, three patients ejacu- every individual patient are shown in Figure 1. Note lation problems (remarkable only one patient was that only ®ve patients responded to visual erotic troubled by this problem), and three patients genital stimulation with an increase of circumference of insensitivity; genital pain was only experienced by more than 15 mm. Furthermore, it is remarkable that one patient. Table 1 shows the mean scores on six visual erotic stimulation in combination with vibra- subscales of the Questionnaire for screening Sexual tion did not enhance erectile response (Two patients Dysfunctions in our group of patients in comparison showed even a signi®cant ( < 15 mm) lower re- to a population of normal healthy males of similar sponse), and that there was no correlation age.12 Note that patients with multiple sclerosis between sleep-erections (as measured with NPT)

Table 1 Mean (s.d.) scores on six subscales of the Questionnaire for screening Sexual Dysfunctions. Both frequency- and trouble-scores are given for 16 patients with multiple sclerosis (MS) and sexual problems (SP) and 16 normal healthy men of similar age12

MS patients with SP Normal healthy men

Item Frequency of a Trouble with b Frequency of a Trouble with b

Erectile problemsc 2.8 (1.4) 2.8 (1.2) 1.4 (0.4) 1.4 (0.6) Excitement problems 1.4 (0.5) 1.6 (0.8) 1.3 (0.3) 1.3 (0.5) Orgasm problemsd 1.9 (1.1) 2.0 (1.1) 1.3 (0.4) 1.2 (0.4) Ejaculation problems 1.5 (1.0) 1.5 (0.9) 1.3 (0.2) 1.1 (0.2) Genital pain 1.2 (0.4) 1.3 (0.6) 1.0 (0.0) 1.0 (0.0) Genital insensitivityd 1.5 (0.6) 1.6 (0.9) 1.0 (0.1) 1.1 (0.1)

aFrequency: 1 ˆ (almost) never; 3 ˆ frequently; 5 ˆ always. bTroubled by: 1 ˆ no trouble; 3 ˆ trouble; 5 ˆ very much trouble. cP < 0.01 for difference in both frequency of and trouble with sexual problems between groups. dP < 0.05 for difference in both frequency of and trouble with sexual problems between groups.

Table 2 Mean (s.d.) scores on the depression and anxiety scale of the Symptom Checklist-90 in 16 patients with multiple sclerosis (MS) and sexual problems (SP) together with those of a normal healthy male population and an outpatient psychiatric population14

Variable Normal healthy population MS patients with SP Psychiatric population

Depression 20.7 (6.3) 17.8 (5.9) 39.3 (14.4) Anxiety 13.0 (4.3) 12.9 (5.3) 24.5 (9.5) Sexual dysfunction in men with multiple sclerosis PEM Lottman et al 236 frequency and were more troubled by erectile and orgasm problems and genital insensitivity than normal healthy men of similar age. Although the majority of patients was dissatis®ed with sexual functioning, they reported a satisfactory sexual relationship. It is remarkable that only one patient with erectile problems appeared to have abnormal sleep-erection. This ®nding is consistent with the study of Staer- man et al. 5 One reasonable explanation for this ®nding is that in the majority of patients with multiple sclerosis the efferent part of the genital nervous system, through which sleep-erections are generated is intact or consists of suf®ent alternative pathways. Consequently, abnormal sleep-erections indicate lesions in the efferent nervous system, after other causes for disturbed sleep-erection such as anxiety, depression, disturbed sleep patterns or drug use are excluded. Abnormal ®ndings on urodynamic investigation were found in four patients. No relation could be established between the ®ndings on urodynamic investigation and the quality of sleep-erections: all patients with signs of dysfunc- tion as assessed with urodynamic investigation had normal sleep-erections. There are two possible explanations for this on ®rst sight remarkable ®nding. Firstly, erection which mainly relies on central excitatory mechanisms is less susceptive to disturbances in the central nervous system than bladder function, that relies mainly on central inhibitory mechanisms. Secondly, erection is more dependent on the autonomic system than bladder Figure 1 Erectile response to visual erotic stimulation (VES), function that is more dependent on the somato- VES and vibration (VES ‡ VIB), and nocturnal penile tumescence sensoric system, which is relatively more suscep- (NPT). tible for multiple sclerosis lesions. It may therefore be hypothesized that sexual function in our patients and stimulated erectile response. Only one patient was not primarily related to lesions in the spinal showed an abnormal sleep-erection, which was not cord, but to supraspinal lesions or psychological associated with sleeping disorders nor with abnor- factors such as fear of failure, decreased sexual mal psychological functioning in terms of anxiety arousal, and secondary erectile- and orgasm pro- and depression. blems. Six patients experienced bladder dysfunction. Although this hypothesis is supported by the Abnormal ®ndings on urodynamic investigation results of the interviews and psychometric tests and were found in four out of twelve patients: two the study of Mattson et al,2 it has to be con®rmed in patients with overactivity and dyssynergia and two future research consisting of detailed radiological patients with late sensation and hypoactivity. All studies of the central nervous system. The predo- patients with abnormal ®ndings on urodynamic minant physiological factors in our study are loss of investigation had normal sleep erections. Motor genital and extragenital sensation and motor im- dysfunction of the pelvic ¯oor muscles was found pairment. in two out of seven patients. No abnormalities were The average erectile response to visual erotic found in the re¯exes in the sacral segments (n ˆ 9) stimulation is comparable to that in men with non- and in the sensitivity of the genital area (n ˆ 6). neurogenic erectile dysfunction in other studies.18,20 However, in contrast to men with non-neurogenic Discussion erectile dysfunction, erectile response was not enhanced by vibration. This ®nding suggests a decreased sensitivity of the penis to vibration Sexual problems in our patient-group consisted of probably due to lesions in the sensory limb of the erectile-, orgasm-, and ejaculation problems, genital genital re¯ex pathway. insensitivity and pain. Erectile problems were most Although the majority of patients were troubled often reported. Our patient-group showed a higher by sexual problems, professional help was sought by Sexual dysfunction in men with multiple sclerosis PEM Lottman et al 237 only a few patients: one patient was treated by a 5 Staerman F et al. Value of nocturnal penile tumescence and psychologist, and three patients were on intracaver- rigidity (NPTR) recording in impotent patients with multiple nous injection therapy. However, it is noteworthy sclerosis. Int J Impot Res 1996; 8: 241 ± 245. 6 Kirkeby HJ, Poulsen EU, Petersen T, Dorup J. Erectile that the patients in this study reported to appreciate dysfunction in multiple sclerosis. Neurology 1988; 38: the discussion of their sexual problems. Patients 1366 ± 1371. indicated that they were helped by receiving 7 Poser CM et al. New diagnostic criteria for multiple sclerosis: information on possible alternations in their sexual guidelines for research protocols. 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