Hypersexual Sensations and Behavior in a Multiple Sclerosis Exacerbation: a Case Report

Case Report Hypersexual sensations and behavior in a multiple sclerosis exacerbation: a case report

CC Yang1*, B Severson2 and JD Bowen3

1Department of Urology, University of Washington, Seattle, Washington, USA; 2Department of Physical Medicine and Rehabilitation, University of Washington, Seattle, Washington, USA; and 3Department of Neurology, University of Washington, Seattle, Washington, USA

International Journal of Impotence Research (2004) 16, 382–384. doi:10.1038/sj.ijir.3901201 Published online 11 March 2004

Keywords: multiple sclerosis; female sexual function; hypersexuality

Introduction completely atypical. After a few days of frequent intercourse, her husband was unable to keep up with her requests for sex. She masturbated fre- Hypersexual sensations and behavior are docu- quently to relieve her sexual desire, and had never mented in a variety of neurologic disorders, includ- done so previously. Masturbation did not always 1 2 ing head trauma, Kluver Bucy syndrome, following result in orgasm, and it was generally not satisfying. 3,4 5 neurosurgical procedures, Parkinson’s disease, and The patient experienced a concurrent increase in 6 stroke. However, hypersexuality associated with generalized body hypersensitivity, breast tenderness 7 multiple sclerosis (MS) is rare. The typical mani- and engorgement, and genital arousal, with and with- festation of a sexual dysfunction in MS is loss of out sexual stimulation. Wearing a bra became uncom- 8–10 libido, sexual arousal, or orgasmic capacity. We fortable, and movement of her pelvis (eg, while riding report on a woman with MS who experienced in a car) increased her genital arousal almost to the hypersexual feelings and behavior as part of an MS point of orgasm. Her sexual responsiveness increased exacerbation. significantly. She had mild urge incontinence due to her MS, but during this episode became more continent of urine and had increased constipation. She also experienced more behavioral impulsive- Case report ness. For the first time, she began swearing at her husband, and bought $200 worth of lottery tickets, A 51-year-old female elementary teacher with MS having never before gambled in her life. presented with a complaint of sudden onset in- The patient’s sexual changes became a significant creased libido and sexual activity. 10 days prior to source of stress. She felt shameful, and worried this, she awoke, from a ‘gunshot’-type sound in her about self-control in the presence of other men, even head. It was immediately followed by two other contemplating marital infidelity to satisfy her sexual similar sounds, localized to above her left ear. urges. She had a history of depression with the onset Following these events, the patient’s sexual appetite of MS, but denied mania or psychotic symptoms. became insatiable. She was happily married for 25 y, She was not on any antidepressants, but was under reported a healthy sex life, but this behavior was the care of a psychologist. Her MS was diagnosed 9 y prior, and was the relapsing–remitting type. Her functional status was still very high, and her primary symptoms due to *Correspondence: CC Yang, Department of Urology, Box MS were fatigue and slight difficulty with balance. 356510, University of Washington, Seattle, WA 98195- 6510, USA. She had undergone a hysterectomy and bilateral Email: [email protected] oophorectomy 20 y prior for benign disease. Her Received 23 September 2003; revised 8 December 2003; medications included gabapentin 800 mg qd, IFN accepted 26 January 2004 beta 1-B (Betaseron) 8 million IU S.C. q.o.d., Hypersexuality and multiple sclerosis CC Yang et al 383 rofecoxib p.r.n., modafinil 200 mg q a.m., estradiol 5 mg symptoms. A few days after the steroid pulse, her i.m. once per week, and estrogen vaginal cream p.r.n. symptoms returned, but with less intensity than the Her neurological examination was essentially original episode. A repeat brain MRI with gadoli- unchanged from previous visits. Remarkable find- nium was unchanged. A second 5-day course of i.v. ings included decreased pinprick left cheek, dimin- methylprednisolone was given, resulting in com- ished motor strength 4/5 left dorsiflexion, knee plete resolution of all of her symptoms. Her FSFI extension, and hip flexion, unsteady gait with an score dropped to 28.4, with the domain of sexual inability to perform heel, toe, or tandem gaits. desire score dropping dramatically. Her external female genitalia was mildly atrophic. The vaginal mucosa was healthy, but dry; the urethral meatus was normal. She had impaired Discussion sensation to light touch and pinprick on both her labia and perianal areas. Sensation to bimanual examination was mildly diminished. A bulbocaver- Hypersexual behavior is rare in MS. Its acute onset nosus reflex was absent. Her pelvic floor contraction and resolution with steroids in this case suggested strength was poor. that it was due to an MS exacerbation. Although She completed the Female Sexual Function Index there was no radiographic change suggesting an 11 (FSFI), a validated measure of female sexual increase in plaque load, there are many studies functioning. She rated her sexual functioning at documenting the lack of association between symp- 33.3 out of a possible 36. The domain with the most toms and MRI findings.12 significant dysfunction was in sexual satisfaction. Other causes of hypersexuality are unlikely in this A brain MRI with gadolinium demonstrated case. MRI did not identify any other central nervous multiple periventricular white matter lesions con- system lesions other than the pre-existing periven- sistent with MS, which was stable from previous tricular MS plaques. Hormonal changes are unlikely studies (Figure 1). Estrogen, progesterone, total as she had been on a stable replacement regimen of testosterone, FSH, LH levels were normal, and an estrogen for 20 y, following gynecologic surgery. Her estradiol level was elevated at 717 pg/ml. Urinalysis, replacement frequency was cut in half during the CBC, comprehensive metabolic panel, and TSH second exacerbation to minimize the possibility of were normal. the hormones exacerbating her problems, but it was Because of the acuity of the episode and the not discontinued as that would have likely wor- constellation of symptoms, this change in sexual sened her emotional lability. Furthermore, the acute behavior was considered to be part of an MS changes in impulsivity, disinhibition, and person- exacerbation. She received methoprednisolone 1 g ality are unlikely to be explained by hormonal i.v. for 5 days, followed by an oral prednisone taper. change, and are more likely to be a result of a frontal This resulted in an immediate reduction in all of her lobe lesion. The patient had been on modafinil for 16 months, and thus this medication would not have been related to the patient’s symptoms. Primary psychiatric conditions would not be expected to improve with corticosteroids. This symptom com- plex is not a result of a lumbosacral spinal lesion because there were no manifestations of lower motor neuron functional loss, which would have been the case with a lesion in that area. Sacral MS plaques typically manifest as loss of bladder, bowel, or sexual function, not improved function.13 From a neuroanatomic standpoint, this case may represent an example of increased sexual desire and responsiveness associated with a frontal lobe lesion. The disinhibition resulted in increased impulsive- ness as well as hypersexual behavior. However, this is all speculative as there were no new identifiable lesions on brain MRI that appeared since her previous studies.

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