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 almost never; 3 frequently; investigated these items and asked patients to report 5 always) and trouble with (score 1