Prevalence of Sexual Dysfunctions Among Women with Multiple Sclerosis

Summary of the 2024 Update of the European Association of Urology Guidelines on Neurourology

BACKGROUND AND OBJECTIVE

Most patients with neurourological disorders require lifelong medical care. The European Association of Urology (EAU) regularly updates guidelines for diagnosis and treatment of these patients. The objective of this review is to provide a summary of the 2024 updated EAU guidelines on neurourology.

METHODS

A structured literature review covering the timeframe 2021-2023 was conducted for the guideline update. A level of evidence and a strength rating were assigned for each recommendation on the basis of the literature data.

KEY FINDINGS AND LIMITATIONS

Neurological conditions significantly affect urinary, sexual, and bowel function, and lifelong management is required for neurourological patients to maintain their quality of life and prevent urinary tract deterioration. Early diagnosis and effective treatment are key, and comprehensive clinical assessments, including urodynamics, are crucial. Management should be customised to individual needs and should involve a multidisciplinary approach and address sexuality and fertility. Lifelong monitoring and follow-up highlight the importance of continuous care for neurourological patients.

CONCLUSIONS AND CLINICAL IMPLICATIONS

The 2024 EAU guidelines on neurourology provide an up-to-date overview of available evidence on diagnosis, treatment, and follow-up for neurourological patients.

PATIENT SUMMARY

Neurological disorders very frequently affect the lower urinary tract and sexual and bowel function and patients need lifelong management. We summarise the updated European Association of Urology guidelines on neurourology to provide patients and caregivers with the latest insights for optimal health care support.

Classification and management of sexual dysfunctions in multiple sclerosis patients: A review of current literature

Multiple sclerosis (MS) is the most frequent neurological disease in young adults, with the greatest incidence between age of 30 and 35 years. Sexual dysfunctions (SDs) are frequent, but are often underestimated in patients with MS, and can have a significantly high impact on patient's quality of life. Aim of this review is to summarize sexual dysfunctions in male and female MS patients and to illustrate current and emerging therapeutic options for treatment.

Expectations about the management of sexual dysfunction in women with multiple sclerosis and association with clinical characteristics

BACKGROUND

Sexual dysfunction (SD) is common in women with multiple sclerosis (MS) and affects their quality of life.

OBJECTIVES

The primary aim is to assess their expectations concerning SD management. The secondary aim is to identify if expectations were associated with specific patient's characteristics.

METHODS

All women with MS who underwent a urodynamic assessment in a neuro-urology clinic and had a standardized assessment of SD expectations between June 2020 and November 2022 were retrospectively screened. Demographic data and assessment of bladder, bowel, and sexual dysfunctions with validated questionnaires were collected.

RESULTS

One hundred and sixty-seven patients were included in the study (mean age 47.9 ± 12.5 years). Expectations on SD information or management were reported by 112 (67.1%) patients. Interest in SD information and management was less frequent after menopause (56% vs 80%, p = 0.004), and in those with EDSS>6 (49% vs 74%, p = 0.03) and progressive type of MS (54% vs 71% p = 0.003). In multivariate analysis, the progressive type of MS was the only criterion related to a lack of interest (OR=2.9 IC95% [1.09; 7.72]).

CONCLUSIONS

Women with MS have high expectations on treatment and information about SD. A systematic screening of SD expectations should be encouraged.

Feasibility of Telerehabilitation-Based Pelvic Floor Muscle Training for Urinary Incontinence in People With Multiple Sclerosis: A Randomized, Controlled, Assessor-Blinded Study

BACKGROUND AND PURPOSE

Urinary incontinence is a common symptom in people with multiple sclerosis. The primary aim was to investigate feasibility of telerehabilitation-based pelvic floor muscle training (Tele-PFMT) and compare its effects on leakage episodes and pad usage with home exercise-based pelvic floor muscle training (Home-PFMT) and control groups.

METHODS

Forty-five people with multiple sclerosis with urinary incontinence were randomized into 3 groups. Tele-PFMT and Home-PFMT groups followed the same protocol for 8 weeks, but Tele-PFMT performed exercises 2 sessions/week under a physiotherapist's supervision. The control group did not receive any specific treatment. Assessments were made at baseline, weeks 4, 8, and 12. Primary outcome measures were feasibility (compliance to exercise, patient satisfaction, and number of participants included in the study), number of leakage episodes, and pad usage. Secondary outcomes included severity of urinary incontinence and overactive bladder symptoms, sexual function, quality of life, anxiety, and depression.

RESULTS

Participant eligibility rate was 19%. Patient satisfaction and compliance to exercise were significantly higher in Tele-PFMT than in Home-PFMT ( P < 0.05). No significant differences in the change of leakage episodes and pad usage were found between Tele-PFMT and Home-PFMT. No significant differences in secondary outcomes were found between PFMT groups. Participants in both the Tele-PFMT and Home-PFMT groups had significantly better scores for some measures of urinary incontinence, and overactive bladder and quality of life in compared with the control group.

DISCUSSION AND CONCLUSIONS

Tele-PFMT was feasible and acceptable in people with multiple sclerosis, and this mode of delivery was associated with greater exercise compliance and satisfaction compared with Home-PFMT. However, Tele-PFMT did not exhibit superiority in terms of leakage episodes and pad usage compared with Home-PFMT. A large trial comparing Home-PFMT and Tele-PFMT is warranted.Video Abstract available for more insights from the authors (see the Video, Supplemental Digital Content, available at: http://links.lww.com/JNPT/A440 ).

Pelvic Floor Muscle Training and Its Benefits for Multiple Sclerosis Patients Suffering From Urinary Incontinence and Sexual Dysfunction

Several reports have been published during the last decade studying the effect of pelvic floor muscle training (PFMT) in treating urinary incontinence and sexual dysfunction in multiple sclerosis (MS) patients. The aim of the current study is to bring up-to-date findings of earlier systematic reviews, taking into account data published up till June 2023. Databases such as PubMed, Scopus, and EBSCOhost were screened for randomized controlled studies, clinical trials, and systematic reviews. The keywords for the current review were MS, urinary incontinence, sexual function, and PFMT. The implementation of predetermined eligibility criteria permitted an appropriate and convenient study selection. English language publications alone were considered. After removing duplicates and screening the initially recovered articles, an initial search within the present review identified 19 studies. Finally, 10 randomized control trials and two systematic reviews were eligible for evaluation and included in the current review. The outcome measures were the severity of incontinence or overactive bladder, leakage episodes, sexual dysfunction, health-related quality of life, and adherence to PFMT. PFMT is a convenient and effective treatment tool that can significantly improve health-related quality of life and reduce the severity of urinary incontinence and overactive bladder symptoms in people with MS. The present review confirms the effectiveness of specific exercises on leakage episodes, pad usage, sexual dysfunction, compliance to treatment, and treatment satisfaction. Further research is needed to strengthen the reported results.

Sexual dysfunction in multiple sclerosis: The impact of different MSISQ-19 cut-offs on prevalence and associated risk factors

BACKGROUND

Although multiple sclerosis (MS) Intimacy and Sexuality Questionnaire-19 (MSISQ-19) is a widely applied tool, no unique definition of sexual dysfunction (SD) based on its score exists.

OBJECTIVE

To explore the impact of different MSISQ-19 cut-offs on SD prevalence and associated risk factors, providing relevant information for its application in research and clinical settings.

METHODS

After defining SD according to two different MSISQ-19 cut-offs in 1155 people with MS (pwMS), we evaluated SD prevalence and association with sociodemographic and clinical features, mood status and disability via logistic regression.

RESULTS

Depending on the chosen cut-off, 45% to 54% of pwMS reported SD. SD defined as MSISQ-19 score >30 was predicted by age (OR=1.01, p=0.047), cognition (OR=0.96, p=0.004) and anxiety (OR=1.03, p=0.019). SD defined as a score >3 on any MSISQ-19 item was predicted by motor disability (OR=1.12, p=0.003) and cognition (OR= 0.96, p=0.002).

CONCLUSION

Applying different MSISQ-19 cut-offs influences both the estimated prevalence and the identification of risk factors for SD, a finding that should be considered during study planning and data interpretation. Preserved cognition exerts a protective effect towards SD regardless from the specific study setting, representing a key point for the implementation of preventive and therapeutic strategies.

Prevalence and risk of developing sexual dysfunction in women with multiple sclerosis (MS): a systematic review and meta-analysis

OBJECTIVE

To estimate the pooled prevalence of sexual dysfunction (SD) in women with multiple sclerosis (MS).

METHODS

We systematically searched PubMed, Scopus, EMBASE, Web of Science, and google scholar and also gray literature up to October 2021. The search strategy includes: ("Multiple Sclerosis" OR "MS" OR "Disseminated Sclerosis" OR (Disseminated AND Sclerosis) OR (Sclerosis AND Multiple)) AND ("Sexual Dysfunction" OR (Sexual AND Dysfunction) OR (Sexual AND Dysfunctions) OR (Sexual AND Disorders) OR (Sexual AND Disorder) OR "Sexual Dysfunctions" OR "Sexual Disorders" OR "Sexual Disorder" OR "Psychosexual Dysfunctions" OR (Dysfunction AND Psychosexual) OR (Dysfunctions AND Psychosexual) OR "Psychosexual Dysfunction" OR "Psychosexual Disorders" OR (Disorder AND Psychosexual) OR (Disorders AND Psychosexual) OR "Psychosexual Disorder" OR "Hypoactive Sexual Desire Disorder" OR "Sexual Aversion Disorder" OR (Aversion Disorders AND Sexual) OR (Disorders AND Sexual Aversion) OR "Sexual Aversion Disorders" OR "Orgasmic Disorder" OR (Disorders AND Orgasmic) OR "Orgasmic Disorders" OR "Sexual Arousal Disorder" OR (Arousal Disorders AND Sexual) OR (Disorders AND Sexual Arousal) OR "Sexual Arousal Disorders" OR "Frigidity").

RESULTS

We found 2150 articles by literature search, after deleting duplicates 1760 remained. Fifty-six articles remained for meta-analysis. The pooled prevalence of SD in MS patients estimated as 61% (95%CI:56-67%) (I²:95.7%, P < 0.001). The pooled prevalence of Anorgasmia in MS patients estimated as 29% (95%CI:20-39%) (I²:85.3%, P < 0.001). The pooled odds of developing SD in MS women estimated as 3.05(95%CI: 1.74-5.35) (I²:78.3%, P < 0.001). The pooled prevalence of decreased vaginal lubrication in MS patients estimated as 32%(95%CI:27-37%) (I² = 94.2%, P < 0.001). The pooled prevalence of reduced libido was 48%(95%CI:36-61%) (I²:92.6%, P < 0.001). The pooled prevalence of arousal problems was 40%(95%CI: 26-54%) (I²:97.4%, P < 0.001). The pooled prevalence of intercourse satisfaction was 27% (95%CI: 8-46%) (I²:99%, P < 0.001).

CONCLUSION

The result of this systematic review and meta-analysis show that the pooled prevalence of SD in women with MS is 61% and the odds of developing SD in comparison with controls is 3.05.

Sexual Motivation in Persons with Multiple Sclerosis: A Controlled Cross-Sectional Study

Purpose

Sexual motives are major determinants of sexual behaviour. It has been known that sexual motives may vary according to circumstances. Multiple sclerosis (MS) is a chronic disease causing a broad range of symptoms and disabilities, that often interfere with sexual activities. We aimed to investigate the sexual motives in persons with MS.

Patients and Methods

Cross-sectional study in 157 persons with MS and 157 controls matched for age, gender, relationship, duration of relationship and educational status via propensity score matching. The Reasons for Having Sex (YSEX) questionnaire assessed the proportion with which a person had engaged in sexual intercourse for each of 140 distinct motives to have sex. Estimated mean differences in scores for four primary factors (Physical, Goal attainment, Emotional, Insecurity) and 13 sub-factors, and sexual satisfaction and importance of sex were calculated as Average Treatment Effect of the Treated using 99% confidence intervals.

Results

Persons with MS reported a lower proportion of engaging in sex compared with the controls for the factors Physical (-0.29), Emotional (-0.23) and Insecurity (-0.10); and for the physical sub-factors Pleasure (-0.48), Experience seeking (-0.32), Stress reduction (-0.24), and Physical desirability (-0.16), the emotional sub-factors Love and commitment (-0.27) and Expression (-0.17), and the insecurity sub-factor Self-esteem boost (-0.23). In the control group seven of the top 10 sexual motives were physical versus five in the MS group. The importance of sex was lower in the MS group (-0.68).

Conclusion

Findings of this controlled cross-sectional study suggest a reduction in the number of sexual motives in persons with MS, especially of physical motives related to pleasure and experience seeking. Health care professionals may consider assessing sexual motivation when dealing with persons with MS who suffer from decreased sexual desire or another sexual dysfunction.

Discussing sexuality with patients with neurological diseases: A survey among neurologists working in Saudi Arabia

Background

Neurological diseases frequently affect sexual activity, and the resulting sexual dysfunction can cause much distress for patients. However, despite the importance of such complaints, neurologists frequently do not ask patients about their sexual symptoms or how their neurological illness and medications are affecting their sexual health. This study aimed to identify these difficulties as well as potential obstructions to conversations for addressing sexual dysfunction in patients with neurological diseases.

Methods

This cross-sectional study was performed by sending invitation letters and questionnaires to registered neurologists in Saudi Arabia. The questionnaire was constructed to determine the possibility of discussing sexual activities and function with patients with neurological diseases and the possible obstacles neurologists face in this regard. Statistical analyses were performed using the Statistical Package of Social Sciences (SPSS) program version 25, and p-values of <0.05 were considered statistically significant.

Results

A total of 258 of 750 neurologists (34.4%) returned the survey, of which 252 had completed the entire survey; therefore, their responses were considered suitable for further analysis. The majority of the respondents (63.1%) seldom discussed sexuality with their patients, more than half of the participants never discussed sexuality with female patients, and patients aged 60 years or older. The most commonly reported barriers were the lack of spontaneous communication by patients regarding their sexual problems (82.1%), insufficient consultation time (60.7%), and barriers based on language/culture/religion (53.6%). The majority of the respondents (61.9%) expressed the need for training on discussing sexuality as a measure that may enhance the discussion of sexual life with patients. Most of the respondents (92.9%) considered the patients responsible for bringing up problems in their sexual functioning during a patient interview.

Conclusion

Sexual dysfunction is rarely discussed with patients showing neurological diseases, particularly with female patients. This is due to the patient's inability to articulate their sexual problems freely as well as a lack of consultation time. Training on discussing sexuality may enhance the discussion of sexual life with patients.

The global prevalence of sexual dysfunction in women with multiple sclerosis: a systematic review and meta-analysis

BACKGROUND

Sexual function is often impaired following neurological disorders such as multiple sclerosis (MS). Young women with MS encourage disruptions in sexual function, sexual behaviors, and family formation as common global problems. Thus, the aim of the present systematic review and meta-analysis study was to investigate the global prevalence of female sexual dysfunction (FSD) worldwide.

METHODS

Various databases (PubMed, Scopus, Web of Science, Embase, and ScienceDirect) along with Google Scholar search engine were hired for systematic searching in the field of the prevalence of FSD (by July 2022). The heterogeneity of the studies was assessed using I² index, and random effects model was used to perform the analysis (CMA software, v.2).

RESULTS

Following assessment of 14 included studies with the sample size of 2115 women, a total prevalence of sexual dysfunction (SD) in women with MS was reported 62.5% (95% CI 53.9-70.5). Meta-regression assessment also showed that FSD accelerates following increasing the sample size and the year of the studies.

CONCLUSION

The total prevalence of SD in women with MS was found considerably high (62.5%) in the world, which needs more serious attention by health policymakers. Correct implementation of health policies can potentially increase the society's awareness and successful treatment of SD in MS patients.

Quantitative spinal cord MRI and sexual dysfunction in multiple sclerosis

Background

Sexual dysfunction (SD) is frequently reported in multiple sclerosis (MS) and is likely related to MS-related damage to the spinal cord (SC).

Objective

To assess associations between SD and quantitative MRI measures in people with MS (pwMS).

Methods

This pilot study included 17 pwMS with SD who completed questionnaires assessing SD, mood, and fatigue. All participants underwent brain, cervical, and thoracic SC-MRI at 3T. Quantitative brain and SC-MRI measures, including brain/SC atrophy, SC lesion count, diffusion-tensor imaging (DTI) indices (fractional anisotropy [FA], mean, perpendicular, parallel diffusivity [MD, λ_⊥, λ_||]) and magnetization-transfer ratio (MTR) were obtained. Associations between quantitative MRI measures and SD were assessed while controlling for the extent of mood and fatigue symptomatology.

Results

Subjects were a mean age of 46.9 years and 29% female. All subjects had self-reported SD (MSISQ-19 = 40.7, SQoL: 55.9) and 65% had a concurrent psychiatric diagnosis. When correlations between SD severity were assessed with individual brain and SC-MRI measures while controlling for psychiatric symptomatology, no associations were found. The only variables showing independent associations with SD were anxiety (p = 0.03), depression (p = 0.05), and fatigue (p = 0.04).

Conclusion

We found no correlations between quantitative MRI measures in the brain and SC and severity of SD in pwMS, but psychiatric symptomatology and fatigue severity demonstrated relationships with SD. The multifactorial nature of SD in pwMS mandates a multidisciplinary approach.

Influence of Sociodemographic and Clinical Characteristics on Sexual Function Domains of Health Related Quality of Life in Multiple Sclerosis Patients

BACKGROUND

Multiple sclerosis is a progressive inflammatory disease of the the central nervous system. Problems with sexual functions are the common features of multiple sclerosis and important factor that contribute to the quality of life among affected persons.

OBJECTIVE

The aim of the study was to evaluate the influence of sociodemographic and clinical characteristics on sexual functions domains of health related quality of life (HRQOL) in multiple sclerosis patients.

METHODS

This study included 100 MS patients treated at the Department of Neurology, Clinical Center University of Sarajevo. Inclusion criteria were an Expanded Disability Status Scale score between 1.0 and 6.5, age between 18 and 65 years, stable disease on enrollment. HRQOL was evaluated by the Multiple Sclerosis Quality of Life-54 questionnaire. Mann-Whitney and Kruskal-Wallis test were used for comparisons between sociodemographic and clinical characteristics and HRQOL scores.

RESULTS

Out of 60% of patients reported to have sexual dysfunction, and 55 % were female patients. Younger patients had statistical significant higher median value of sexual function score (91.68 vs. 58,28, p=0.001) and satisfaction with sexual life scores (62.5 vs 37.5 , p =0.019) comparing to older patients. Employed patients also showed statistical significant higher median value of sexual function score (82 vs. 66.7, p=0.003) comparing to unemployed patients and also statisticaly significant higher median scores considering satisfaction with sexual life among employed patients (p=0,001). There were no differences in sexual functions scores considering gender, marital status and education. Patients with higher level of disabilty, progressive type of disease, more relapses and longer diseas duration had statistical significant lower median value of sexual function score and also satifaction with sexual life scores, except for disease duration.

CONCLUSION

Aging, dysability and progression are major factors that contribute to lower sexual function scores and satisfaction with sexual life among multiple sclerosis patients. Althoug women reported sexual problems more often then men, impact of these problems on quality of life are similar in men and women with MS.

Female sexual dysfunction in newly diagnosed egyptian patients with neuromyelitis optica spectrum disorder

Background

Few research works have explored female sexual dysfunction (FSD) in patients with Neuromyelitis optica spectrum disorder (NMOSD) which remains an ignored disease symptom. This work aimed to describe the frequency, patterns, and predictors of FSD in a sample of newly diagnosed AQP4-ab seropositive NMOSD patients.

Methods

This case-control study was conducted on 28 seropositive NMOSD patients and 31 age matched healthy controls. All included patients were asked to privately fill and hand back the following questionnaires: female sexual function index questionnaire (FSFI), Beck depression inventory II (BDI) and fatigue severity scale (FSS). Also, Modified Modified Ashworth scale (MMAS) and Expanded disability status scale (EDSS) were applied to all included patients.

Results

NMOSD patients had significantly lower total FSFI scores and significantly higher BDI and FSS scores than controls (P < 0.001). FSS scores were negatively correlated with total scores of FSFI as well as desire, lubrication, orgasm, and satisfaction scores. BDI scores was negatively correlated with desire and orgasm scores. The uncorrected visual FS score was negatively correlated with lower total scores of FSFI as well as arousal, orgasm, and satisfaction scores. The pain score was negatively correlated with the scores of the MMAS. The only predictors of FSFI total score were fatigue and visual disability. Visual disability was also a predictor of dysfunction in arousal and satisfaction domains, whereas spasticity in the lower limbs predicted sexual related pain.

Conclusions

Sexual dysfunction in patients with NMOSD is strongly related to fatigue, depression, visual disability, and lower limbs spasticity.

Prevalence of Sexual Dysfunction and Related Risk Factors in Men with Multiple Sclerosis in Iran: A Multicenter Study

INTRODUCTION

Sexual dysfunction (SD) is a common complaint in patients with multiple sclerosis (MS). The aim of this study was to assess the prevalence of SD and its related risk factors in men with MS in Iran.

METHODS

In this cross-sectional study, 320 men who had been diagnosed with MS according to the McDonald revised criteria were recruited from January to June 2019, from the north, south, east, west, and central parts of Iran. Patients were assessed using the Male Sexual Health Questionnaire (MSHQ), International Index of Erectile Function (IIEF), The Multiple Sclerosis Intimacy and Sexuality Questionnaire-(MSISQ 19), Sexual Quality of Life-Men (SQOL-M), and Standard General Health Questionnaire (GHQ).

RESULTS

Sexual dysfunction, defined as total IIEF score ≤ 45 was present in 114 patients (35.6%). The results of univariate logistic regression showed that there were significant direct relations between age (OR 1.050, 95% CI 1.02-1.08), Expanded Disability Status Scale (EDSS) (OR 1.45, 95% CI 1.24-1.7), duration of MS (OR 1.005, 95% CI 1.002-1.009), MSISQ-19 (OR 1.103, 95% CI 1.078-1.128), GHQ (OR 1.04, 95% CI 1.03-1.06), SQOL-M (OR 0.930, 95% CI 0.914-0.947), smoking (OR 1.941, 95% CI 1.181-3.188), non-MS chronic disease (OR 1.91, 95% CI 1.20-3.04), having a main sexual partner (OR 2.56, 95% CI 1.32-4.94), and significant inverse relations between exercise (OR 0.584, 95% CI 0.364-0.936) and regular sexual activity (OR 0.241, 95% CI 0.15-0.40), with the prevalence of SD. The results of multiple logistic regression indicated that the age, MSISQ-19, and SQOL-M were the only independent predictive factors for SD in these patients.

CONCLUSION

The prevalence of SD in men with MS in Iran is relatively high. These patients should be screened, diagnosed, and treated for SD and influencing factors.

Inflammation predicts sexual arousability in healthy women

Background

Though many women report sexual arousal difficulties, the mechanisms driving these difficulties are unclear. Sexual response relies on a host of psychophysiological processes that have bidirectional relationships with inflammation. Additionally, chronic inflammation may impair genital blood flow, which in turn may impact sexual arousal. C-reactive protein (CRP) is an acute-phase marker of inflammation produced in response to cytokine signaling throughout the body, which makes it a useful marker of systemic inflammation.

Aim

The present study examined interactions between inflammation and women's sexual arousal.

Methods

CRP, self-reported frequency of partnered sexual activity, and subjective and vaginal arousal were assessed in 91 healthy, pre-menopausal women. Data were collected during a single laboratory session.

Main outcome measures

Subjective sexual arousal and vaginal pulse amplitude (a measure of vaginal arousal) were the main outcome measures.

Results

Change in subjective sexual arousal in response to a sexual film was unaffected by baseline CRP and sexual frequency. However, there were significant interactions between inflammation and sexual frequency in predicting vaginal arousal during the sexual film. Among women reporting more frequent sexual activity, higher CRP predicted lower magnitude arousal response and longer time to maximum vaginal arousal. Among women reporting less frequent sex, higher CRP predicted shorter time to maximum arousal and greater magnitude of arousal response. Controlling for cortisol strengthened the effects seen for time to maximum vaginal arousal but weakened those observed for percent change.

Conclusions

Among healthy young women, higher CRP may be associated with vaginal arousal, but not subjective sexual arousal. Specifically, our results suggest that higher baseline CRP is associated with lower genital sexual arousal for women who have sex frequently, which is consistent with clinical evidence that elevated inflammation can be detrimental to sexual function.

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Among healthy young women, higher CRP may be associated with vaginal sexual arousal, but not subjective sexual arousal.

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Frequency of sexual activity interacts with CRP levels to contribute to vaginal arousal in healthy women.

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Higher CRP predicted lower genital sexual arousal in women who engage in sexual activity more than once a week.

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However, higher CRP predicted greater genital sexual arousal in women who engage in sexual activity less than once a week.

Effectiveness of Physical Therapy in Addressing Sexual Dysfunction in Individuals with Multiple Sclerosis: A Systematic Review and Meta-analysis

BACKGROUND

Individuals with multiple sclerosis (MS) frequently report sexual dysfunction, a condition that may result in low sexual satisfaction and decreased quality of life. Although sexual dysfunction is usually treated pharmacologically, physical therapists, especially those trained in pelvic floor physical therapy (PT), are well-equipped to address a variety of impairments that contribute to poor sexual function. The current evidence for effectiveness of PT interventions in improving sexual dysfunction, sexual satisfaction, and the emotional well-being aspect of quality of life was analyzed.

METHODS

The PubMed, CINAHL, and PEDro databases were searched through December 2019. Articles were included if participants had a clinical diagnosis of MS, reported sexual dysfunction or pain with intercourse, and had an intervention within the PT scope that addressed sexual dysfunction. Means and SDs were extracted from each study independently by two authors. Effect sizes (d) and 95% CIs were calculated within and across studies.

RESULTS

Eight studies met the inclusion criteria. Combined effects were significant and large across six studies for sexual function (d = 0.82, 95% CI, 0.57-1.06), moderate across seven studies for sexual satisfaction (d = 0.65, 95% CI, 0.43-0.87), and moderately large across two studies for emotional well-being (d = 0.78, 95% CI, 0.17-1.40). Between-group differences reached significance for sexual satisfaction (d = 0.29, 95% CI, 0.03-0.55).

CONCLUSIONS

Sexual function, sexual satisfaction, and emotional well-being can all be effectively addressed with various PT interventions. Highly effective interventions included pelvic floor muscle training and mindfulness. Future research should compare PT interventions with non-PT controls to determine best practice in this population.

Experience of women with multiple sclerosis about their sexuality

PURPOSE

To understand how women with multiple sclerosis (MS) experience their sexuality.

MATERIAL AND METHODS

This was a qualitative study in which eight women belonging to MS associations in Elche or Alicante (Spain) completed semi-structured interviews. We subsequently carried out a thematic analysis of this data.

RESULTS

Four main themes and multiple sub-themes were identified. The first theme was the 'influence of stereotypes on sexual expression', which included social and gender perspectives; the second theme was 'physical and emotional causes of sexual dysfunction', which were classified as primary, secondary, and tertiary; the third theme was 'experiencing sexuality in a personalised way', which included relationships with a partner, the concept of sexuality, and resources for improving sexual function; and the final theme was 'external support', which included sexual assistance, professional care, and peer support.

CONCLUSIONS

Sexual needs change in women with MS after diagnosis of the disease. However, this is not addressed routinely by health professionals. In their search for resources, women with MS highlighted that support from partners and from associations, could constitute a support network for the expression of their sexuality.IMPLICATIONS FOR REHABILITATIONWomen with MS refer changes in their sexual function, and these changes are not addressed routinely by healthcare providers.Inclusion of the sexual partners of women with MS in consultations regarding the treatment of sexual dysfunctions should be considered with previous consent.The positive experience of a woman with MS who used sexual assistant services may justify further research.MS associations can also play an important role in the sexual field as a meeting place for peers with shared experiences.

Sexuality and Multiple Sclerosis: Patient and Doctor Perspectives

BACKGROUND

Little is known on how to address sexuality in clinical care for patients with multiple sclerosis (pwMS).

AIM

To describe and contrast the perception of sexuality and associated aspects of communication in pwMS and their treating neurologists ("MSologists") and provide a standard of care.

METHODS

Patients were surveyed using a 13-item questionnaire investigating perception on their own sexuality and opinions on communication about sexuality in context with MS. Certified MSologists in Austria received an 18-item survey regarding their approach to taking a sexual history of their patients.

OUTCOMES

We report the frequency of answers given in this survey and propose a possible standard of care how sexuality could be addressed in clinical routine.

RESULTS

Ninety-three pwMS (mean age 39 ± 11 years, 57% female) and 75 MSologists (mean age 43 ± 9 years, 63% male) completed this survey. Seventy-six percent of patients report their own sexuality as being (very) important to them and 95% think that sexual dysfunction would influence their quality of life. 84% would like to be asked about their sexuality by their MSologist. In contrast, only 15% of MSologists reported discussing sexuality with every patient. The most common reason for not doing so was a fear of crossing personal borders (34%). There is a strong desire for further medical education on this subject (76%).

CLINICAL IMPLICATIONS

Discussing sexuality is important to pwMS and MSologists should consider their patients' wishes and needs to talk about it.

STRENGTHS & LIMITATIONS

This is the largest survey contrasting the views of patients and their treating physicians on the topic of communication about sexuality. The use of an empirical unvalidated questionnaire may have introduced bias. Moreover, patients that are open to talk about their sexuality may be potentially overrepresented in this study.

CONCLUSION

MSologists should offer their patients an open opportunity and appropriate framework to discuss their sexuality during a consultation. Altmann P, Leithner K, Leutmezer F, et al. Sexuality and Multiple Sclerosis: Patient and Doctor Perspectives. J Sex Med 2021;18:743-749.

Neuroprotective Methodologies in the Treatment of Multiple Sclerosis Current Status of Clinical and Pre-clinical Findings

Multiple sclerosis is an idiopathic and autoimmune associated motor neuron disorder that affects myelinated neurons in specific brain regions of young people, especially females. MS is characterized by oligodendrocytes destruction further responsible for demyelination, neuroinflammation, mitochondrial abnormalities, oxidative stress and neurotransmitter deficits associated with motor and cognitive dysfunctions, vertigo and muscle weakness. The limited intervention of pharmacologically active compounds like interferon-β, mitoxantrone, fingolimod and monoclonal antibodies used clinically are majorly associated with adverse drug reactions. Pre-clinically, gliotoxin ethidium bromide mimics the behavioral and neurochemical alterations in multiple sclerosis- like in experimental animals associated with the down-regulation of adenyl cyclase/cAMP/CREB, which is further responsible for a variety of neuropathogenic factors. Despite the considerable investigation of neuroprotection in curing multiple sclerosis, some complications still remain. The available medications only provide symptomatic relief but do not stop the disease progression. In this way, the development of unused beneficial methods tends to be ignored. The limitations of the current steady treatment may be because of their activity at one of the many neurotransmitters included or their failure to up direct signaling flag bearers detailed to have a vital part in neuronal sensitivity, biosynthesis of neurotransmitters and its discharge, development, and separation of the neuron, synaptic versatility and cognitive working. Therefore, the current review strictly focused on the exploration of various clinical and pre-clinical features available for multiple sclerosis to understand the pathogenic mechanisms and to introduce pharmacological interventions associated with the upregulation of intracellular adenyl cyclase/cAMP/CREB activation to ameliorate multiple sclerosis-like features.

Predisposing Factors for Sexual Dysfunction in Multiple Sclerosis

Sexual dysfunction (SD) in people with multiple sclerosis (pwMS) has a detrimental impact on individual health-related quality of life (HRQoL). It is not clear whether SD in multiple sclerosis (MS) is an independent symptom or merely a byproduct of other symptoms such as depression or anxiety. This cross-sectional study of 93 pwMS determines risk factors for SD in MS based on prevalence, HRQoL, and associated disease outcomes. Diagnosis of SD was determined based on the Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19) and correlated with physical disability (measured by Expanded Disability Status scale, EDSS), depression and anxiety [Hospital Anxiety and Depression Scale (HADS)], and HRQoL [Multiple Sclerosis Quality of Life-54 (MSQoL-54)]. Multivariate regression models were performed to determine independent risk factors for SD in pwMS. Almost half of the participants in this study (46%) reported SD. HRQoL was significantly poorer in patients with MS suffering from SD (median [IQR] MSQoL-54 scores: physical subscale 52 [41–68] vs. 81 [69–89], p < 0.001; mental subscale 50 [38–82] vs. 86 [70–89], p < 0.001). In the multivariate model, EDSS was the only independent risk factor for SD (OR 18.1 for EDSS ≥4 [95% CI 3.3–31.4, p < 0.001]), while depression and anxiety were not. We conclude that the risk for SD is growing with increasing EDSS and is independent of depression or anxiety. Screening for SD becomes particularly relevant in patients with growing disability.

Evaluation of sexual self-efficacy and sexual function in women with multiple sclerosis in Mashhad, Iran, in 2019: A cross-sectional study

Background: In chronic illnesses, sexual dysfunction (SD) is one of the most prevalent complaints. Sexual self-efficacy (SSE) is an individual's beliefs about his/her ability to perform an effective sexual function and be favorable to their partner. The aim of the present study was to assess SSE and sexual function in women with multiple sclerosis (MS). Methods: This cross-sectional study was carried out in 2019 on 260 married women referring to the MS clinic and MS society of Khorasan-Razavi in Mashhad, Iran. The research population was selected using convenience sampling. The Sexual Self-Efficacy Questionnaire (SSEQ), Multiple Sclerosis Intimacy and Sexuality Questionnaire‎-19 (MSISQ-19), and the Female Sexual Function Index‎ (FSFI)‎ were completed by the participants who had the inclusion criteria. The collected data were analyzed using descriptive statistics and Spearman's rank correlation coefficient in SPSS software. Results: The participants had a mean age of 35.2 ± 8.4 years and their mean duration of MS was 4.46 ± 3.71 years. The findings showed a negative correlation between SSE and SD (r = -0.606; P = 0.001) and a positive correlation between SSE and sexual function (r = 0.644; P = 0.001). Moreover, MSISQ-19 and FSFI scores supported each other (r = -0.675; P = 0.001). Conclusion: SD is prevalent among women with MS. Moreover, sexual function is substantially associated with SSE in these women.

Does sexual functioning improve with migraine improvements and/or weight loss?-A post hoc analysis in the Women's Health and Migraine (WHAM) trial

BACKGROUND

Despite plausibility of migraine headaches contributing to impaired sexual function among women, data are inconsistent and point to obesity as a potential confounder. Prospective studies that assess the relative importance of migraine improvements and weight loss in relation to sexual function could help elucidate associations among migraine, obesity and female sexual dysfunction (FSD).

OBJECTIVE

To evaluate sexual function changes and predictors of improvement after behavioural weight loss (BWL) intervention for migraine or migraine education (ME).

METHODS

Women with migraine and overweight/obesity were randomized to 16 weeks of BWL (n = 54) or ME (n = 56). Participants completed a 4-week smartphone headache diary and the Female Sexual Function Index (FSFI) at pre- and post-treatment. A validated FSFI total cut-off score defined FSD. We compared changes in FSFI scores and FSD rates between conditions and evaluated migraine improvements and weight loss as predictors of sexual functioning in the full sample.

RESULTS

Among treatment completers (n = 85), 56 (65.9%) participants who reported sexual activity at pre- and post-treatment were analysed. Migraine improvements were similar between conditions, whereas BWL had greater weight losses compared with ME. FSD rates did not change overall (48.2% to 44.6%, p = .66) or by condition (BWL: 56.0% to 40.0% vs. ME: 41.9% to 48.4%, p = .17). Similar patterns were observed for changes in FSFI total and subscale scores. Across conditions, larger weight losses predicted greater improvements in FSFI total and arousal subscale scores, whereas larger migraine headache frequency reductions predicted greater improvements in FSFI satisfaction subscale scores.

CONCLUSION

Sexual functioning did not improve with either BWL or ME despite migraine headache improvements in both conditions and weight loss after BWL. However, weight loss related to improvements in physiological components of the sexual response (i.e., arousal) and overall sexual functioning, whereas reduced headache frequency related to improved sexual satisfaction. Additional research with larger samples is needed.

Psychobehavioral Treatment Options for Sexual Dysfunction in Multiple Sclerosis: A Systematic Review

BACKGROUND

Sexual dysfunction in multiple sclerosis (MS) is a significant but overlooked impairment, and treatment options are rare. The aims of this systematic review were to identify psychological interventions used to treat sexual dysfunction in MS, to estimate their benefit, and to note appropriate treatment approaches for research projects and clinical use.

METHODS

A systematic review update was conducted to find psychological interventions aiming to improve sexual dysfunction in MS. A comprehensive search and review of MEDLINE, PsycINFO, CINAHL, and PubMed were completed, and the effects and quality of selected studies were reported.

RESULTS

Six publications with 295 participants were identified. All selected studies assessed the effectiveness of psychological interventions on sexual dysfunction or sexual satisfaction in people with MS; four studies directly targeted sexual dysfunction in MS, one was a mindfulness yoga program to improve fatigue and quality of life, and one other presented a secondary analysis of a study targeting depression in MS. All six studies reported significant improvements in sexual dysfunction or sexual satisfaction and somewhat in psychological variables.

CONCLUSIONS

A pressing need for development and adequate evaluation of psychological interventions for sexual dysfunction in MS remains. In addition, assessment of sexual dysfunction in MS and its treatment should be more focused in clinical care.

Sexual Satisfaction in Fully Ambulatory People with Multiple Sclerosis: Does Disability Matter?

Primary sexual dysfunctions (SD) are a direct result of neurological changes that affect the sexual response. Secondary SD result from the symptoms that do not directly involve nervous pathways to the genital system, such as bladder and bowel problems, fatigue, spasticity, or muscle weakness. Tertiary SD are the result of disability-related psychosocial and cultural issues that can interfere with sexual feelings and experiences. The aim of this study was to assess the sexual satisfaction (SS) in people with multiple sclerosis (PwMS) without significant mobility impairment and to estimate the influence of SD, the score on the Kurtzke Expanded Disability Status Scale (EDSS), lowered mood, and stress coping strategies on SS. Methods. 76 PwMS with the EDSS score < 5.0 points were enrolled in the study. The subjects completed the Montgomery-Asberg Depression Scale (MADRS), the Coping Inventory for Stressful Situations (CISS), the Multiple Sclerosis Intimacy and Sexuality Questionnaire (MSISQ-19), and the Sexual Satisfaction Questionnaire (SSQ). Results. The level of SS in PwMS was not significantly lower compared to that of the general population. It correlated with the primary, secondary, and tertiary SD and lowered mood. However, it did not correlate with disability measured by the EDSS. Conclusions. The level of SS in PwMS with the EDSS score below 5.0 points was not significantly lower. SS depended on SD, lowered mood, and stress coping style, and it was not significantly related to the level of disability in patients with the EDDS score below 5.0.

Epidemiology, diagnosis and management of sexual dysfunction in multiple sclerosis

Multiple sclerosis (MS) is the most common chronic neurological disorder in young adults, with numerous potential effects on neurologic function. Sexual dysfunction (SD) is a common and very stressful one in persons with MS and represents a significant burden of disease. It has been shown that proportion of SD in MS is greater than in other neurological diseases, and almost five times higher than in the general population. Since there is no consistent definition in the literature for the diagnosis of SD, various studies reported a prevalence of SD of 40-80% in women and 50-90% in men with MS. The nature of sexual changes in this chronic illness is best defined as primary, secondary, and tertiary. Recently, it has been emphasized that detailed sexual history is crucial for all SD assessments and diagnoses. Committee 3 of the international consultation on sexual medicine suggested an updating algorithm for diagnostic evaluation of SD in both genders, with specific recommendations related to sexual history taking and diagnostic evaluation. Because treatments and preventive strategies might manage SD, it is necessary to increase the focus on these aspects of the disease when counselling patients. Management of SD should be comprehensive because the symptoms could be somatic, psychological, or related to relationship problems.

Managing Urological Disorders in Multiple Sclerosis Patients: A Review of Available and Emerging Therapies

Multiple sclerosis (MS) is a progressive neurological autoimmune disease with a diverse range of urological symptomatology, and most MS patients experience 1 or more moderate to severe urinary symptoms, as well as bladder and/or sexual disorders. Urologists play the director's role in evaluating and treating these patients. Therefore, identifying the proper evaluation tools and the most suitable therapeutic options for specific patients requires a thorough understanding of this disease process.

The Association Between Sexual Disorders and the Quality of Life of Woman Patients With Multiple Sclerosis: Findings of a Prospective, Observational, and Cross-Sectional Survey

Introduction

Multiple sclerosis (MS) is a progressive, chronic inflammatory demyelinating disease of the central nervous system, whose symptoms include sexual disorders. Sexual dysfunctions can influence on quality of life (QOL) of patients with MS.

Aim

To evaluate the occurrence of sexual disorders among women with MS and correlations between QOL, prevalence of sexual disorders, and level of sexual satisfaction.

Methods

Polish women (n = 101) aged 22–66 years with diagnosed MS were included in the study.

Main Outcome Measures

The Female Sexual Function Index, the Sexual Satisfaction Questionnaire, the Satisfaction with Life Scale, and the Multiple Sclerosis International Quality of Life Questionnaire were used. In addition, an Authors-Designed Questionnaire was used to collect sociodemographic data.

Results

More than half of the patients surveyed were totally or somewhat unsatisfied with their sex life, and 44.55% of the patients were diagnosed with significant sexual disorders. It was shown that patients with diagnosed sexual disorders and a low level of sexual satisfaction rated their QOL the lowest among all the surveyed patients.

Conclusion

Our findings indicate that sexual disorders and the level of sexual satisfaction correlate significantly with QOL in patients with MS. Sexual dysfunctions are a significant problem in women with MS; thus, they should be considered with comprehensive care.

Kołtuniuk A, Przestrzelska M, Karnas A, et al. The Association Between Sexual Disorders and the Quality of Life of Woman Patients With Multiple Sclerosis: Findings of a Prospective, Observational, and Cross-Sectional Survey. Sex Med 2020;8:297–306.

Sexual dysfunction in women with multiple sclerosis: prevalence and impact on quality of life

BACKGROUND

Sexual function is a component of quality of life, and sexual dysfunction entails reduced satisfaction with life and impaired mood and quality of relationships and affects not only the individual's quality of life, but her partner's life as well. Since Sexual Dysfunction (SD) is among the most common complaints of patients with Multiple Sclerosis (MS), this study was conducted to determine the prevalence of SD among women with MS and its effect on quality of life.

MATERIALS AND METHODS

This cross-sectional study was conducted in 2018 on 300 women with MS aged 22-50 years in Isfahan, Iran, selected through systematic random sampling. Data were collected using the standard Female Sexual Function Index (FSFI) and MSQOL-54 and analyzed in SPSS using descriptive and analytical statistics.

RESULTS

The overall prevalence of SD was found as 69.8% in women with MS, with the dimension of sexual desire being affected in 38.6% of the cases, sexual arousal in 38.6%, lubrication in 23.7%, orgasm in 37.3%, satisfaction in 23.4% and pain in 16.9%. SD was found to have significant relationships with age, duration of marriage, fatigue, EDSS and the combined physical and mental health aspects of quality of life (P <  0.05). Moreover, logistic regression analysis revealed that there was a higher probability of a sexual dysfunction among patients with MS and a high fatigue score [1.228(1.003 to 1.504); P = 0.047]. The mean score of the combined physical and mental health aspects of quality of life was lower in the group of women with MS and SD compared to those without SD, and the difference between the two groups was statistically significant (P <  0.05).

CONCLUSION

Sexual dysfunction is highly prevalent among women with MS and affects various dimensions of quality of life. Greater attention should be paid to the sexual problems faced by MS patients in order to improve their quality of life.

Effectiveness of interventions aimed at improving the sexuality of women with multiple sclerosis: a systematic review

Objective:

To evaluate the effectiveness of interventions aimed at improving the sexuality of women with multiple sclerosis.

Data sources:

MEDLINE, CINAHL, PsycINFO, Web of Science, Scopus, Embase and the Cochrane Library, as well as doctoral thesis databases Teseo and ProQuest Dissertations & Theses Global and the grey literature database Opengrey were searched, last on 15 October 2019. Journals related to the topic were also consulted. The bibliographic references of the articles included were reviewed.

Method:

Studies were selected if they included women with multiple sclerosis in whom interventions aimed at reducing sexual dysfunction were applied. Data extraction was carried out by two independent reviewers. The Jadad scale was used to evaluate the methodological quality of the studies included.

Results:

In total, 12 clinical trials were selected, and 611 patients were examined. Studies were classified into six interventions: sexual therapy (4), pharmaceutical drugs (3), pelvic floor exercises (2), yoga (1), mindfulness (1) and vaginal devices (1). Most of them improved some primary outcomes of sexual dysfunction such as lubrication, arousal, desire or orgasm. Pain was the most common secondary outcome evaluated and it became better in two studies including sexual therapy and in one intervention with pelvic floor exercises. Tertiary outcomes such as anxiety or depression were rarely examined, and they improved with sexual therapy and with OnabotulinumtoxinA.

Conclusion:

Sexual therapy, administration of OnabotulinumtoxinA, pelvic floor muscles exercises alone or combined with electrostimulation and the use of clitoral devices could be the most recommended interventions to improve the sexuality in women with multiple sclerosis.

Persian Adaptation of Actionable Bladder Symptom Screening Tool Among Patients with Multiple Sclerosis

Purpose

Multiple sclerosis (MS) is the most neurologic disease among individuals of 20–45 years. About 75% of MS patients report bladder problems that have a moderate-high impact on their life. The present study aimed to translate and determine the validity and reliability of the Persian version of ABSST questionnaire.

Methods

The standard validation process for preparing the Persian version of ABSST was performed by means of an expert committee. After a pilot study and confirming the harmonized translated form, we tested the final version of questionnaire on 40 patients with a definite diagnosis of MS symptoms, once at the baseline and another after two weeks in order to prevent recall-induced agreement. Test-retest reliability was calculated as Spearman's correlation coefficient. Also, content validity indices (CVIs), as well as internal consistency were analyzed in STATA.

Results

Forty participants with a mean age of 38.8 years were included in this study. Only 20% of them were male. The Persian version achieved a good internal consistency with a Cronbach-α value of 0.91, relatively similar to the original version. The coefficients for measuring the correlation between each item score with the total score of our questionnaire were between 0.58–0.89. This value confirmed an appropriate validity for the Persian version of ABSST. Regarding test-retest reliability assessment, total Spearman`s coefficient was 0.85; with 0.84 for the severity of symptoms and 0.87 for the impact of urologic disorders on patients` social life.

Conclusion

The current findings proved that this accurate questionnaire could be used to investigate urinary symptoms among Persian-speaking MS patients.

Systematic review of the prevalence, symptomatology and management options of sexual dysfunction in women with multiple sclerosis

AIMS

Sexual dysfunction (SD) is highly prevalent in women with multiple sclerosis (MS), however little is known about treatment options. The aim of this paper is to review the prevalence, symptomatology, and management options of sexual dysfunction in women with MS.

METHODS

The Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL, AMED, PsycINFO, PEDro, Database of International Rehabilitation Research, Occupational Therapy Systematic Evaluation of Evidence, ClinicalTrials.gov, and Current Controlled Trials databases were searched. No limitations were placed on the date. A critical appraisal of the literature on SD in women with MS was performed according to the PRISMA statement. Two reviewers screened and extracted data. Study quality was evaluated using a standardized tool.

RESULTS

A search of 12 databases identified 61 relevant studies (33 observational, 14 case-control, 4 follow up, 10 interventional). Significant variability in the prevalence of SD and questionnaires used to evaluate SD were observed. The most commonly reported sexual difficulties were problems with desire, arousal, and orgasm. Different demographics and MS-related characteristics were found to contribute to SD. Few studies have evaluated interventions for treating SD, and bias was high because of the weak quality of trial designs.

CONCLUSIONS

SD in women with MS is multidimensional, comparable in prevalence with other neurological disorders and increases with advancing disease. Studies evaluating practical strategies and pharmacological interventions are few, and properly designed trials using MS-specific validated outcome measures of SD are required to inform evidence-based treatment options for this high impact MS-related dysfunction.

A practical approach to assessing and managing sexual dysfunction in multiple sclerosis

Sexual dysfunction is common in both men and women with multiple sclerosis but is often under-reported and undertreated. Neurologists report that a major barrier to discussing sexual dysfunction with patients is their lack of knowledge. Here we review the common presentations of sexual dysfunction, discuss its causes in people with multiple sclerosis, and provide a practical approach for neurologists to assess and manage these problems.

Discussing sexuality with Parkinson's disease patients: a multinational survey among neurologists

Sexual dysfunction is a major non-motor feature of Parkinson’s disease (PD) that may affect the quality of life of many patients. In a Dutch survey, we demonstrated that neurologists often fail to discuss sexuality with their patients. Our objective was to determine to which extent neurologists in Spain and Germany address sexuality with their patients and whether cross-cultural differences exist. A 30-item questionnaire was sent out to 1650 German and 460 Spanish neurologists. The questionnaire addressed attitudes, knowledge, barriers, and feelings of responsibility regarding sexuality in PD. 160 German and 32 Spanish respondents completed and returned the questionnaire. The majority of German and Spanish participants discuss sexual dysfunction ‘regularly’ with male patients (61.7% and 78.9%, respectively), but ‘seldom’ with female patients (68.8% and 78.1%, respectively). Important barriers for German and Spanish respondents to discuss sexual dysfunction were patients not expressing sexual complaints spontaneously (52.9% and 75.0%, respectively) and insufficient consultation time (32.2% and 71.9%, respectively). Sexual dysfunction in PD was considered important by 68.3% of German and 96.9% of Spanish participants. German and Spanish neurologists do not routinely discuss sexual dysfunction with their patients, although many of them consider it important to address this topic. It is unclear why this lack of discussing sexual dysfunction is especially found for female patients and whether cultural aspects are involved. We recommend a self-assessment tool for patients to track their symptoms prior to consultation visits and advocate local guidelines that formulate who is responsible for discussing sexual dysfunction.

The Assessment of Sexual Dysfunction in Male Patients with Multiple Sclerosis

Introduction

To investigate the effects of multiple sclerosis (MS) on male sexuality.

Methods

While 61 men with MS were included into the study group, 60 healthy men constituted the control group in the study. In MS patients, such parameters as functional status and depression levels were assessed with the Expanded Disability Status Scala (EDSS) and the Beck Depression Scale (BDS), other parameters such as pain levels, sexual function and quality of life (QoL) were evaluated with the Visual Analog Scala (VAS), the International Index of Erectile Function (IIEF) and the short form-36 (SF-36), respectively.

Results

Patients with MS were classified as 45 with EDSS <5.5 and 19 with EDSS >5.5. Mean VAS and BDI scores patients with MS were found statistically significantly higher, compared with those of the controls (p<0.05). Mean IIEF and all sub-group scores of SF-36 of patients with MS were found to be statistically significantly lower, compared with those of the control group (p<0.05). Mean EDSS in patients with MS was 2.75±2.42. While there was a positive correlation between IIEF scores of patients with MS, and mean mental and physical components of SF-36, a negative correlation was found between IIEF scores in MS patients, and age, disease duration, number of attacks, number of marital years and scores of EDSS, VAS and BDI (p<0.00). When BDI ≥17 was accepted as the threshold for depression, the depression was detected in 62.5% of patients with MS and 11.7% of the controls (p<0.001).

Conclusion

Sexual functions are affected negatively in male patients with MS and seem to be associated with increased disability, pain and accompanying depression. Therefore, male patients with MS should also be evaluated with regard to sexual function, as well as disability during their follow-ups.

Association Between Multiple Sclerosis and Risk of Female Sexual Dysfunction: A Systematic Review and Meta-Analysis

INTRODUCTION

It has been reported that multiple sclerosis (MS) would increase the susceptibility to female sexual dysfunction (FSD).

AIM

To assess whether MS was a risk factor for FSD through a comprehensive literature review and meta-analysis.

METHODS

MEDLINE (PubMed), Embase, Cochrane Library, and PsychINFO databases were systematically searched for all studies reporting sexual function in women with MS. The protocol for this meta-analysis is available from PROSPERO (CRD42018094392).

MAIN OUTCOME MEASURES

The association between MS and risk of FSD was summarized using relative risk or standard mean differences with 95% CI. Subgroup and sensitivity analyses were conducted to detect potential bias.

RESULTS

Overall, 1,485 women participants (the mean age ranged from 29.15 to 45.89 years) were included from 9 studies (4 cross-sectional and 5 case-control studies); 826 of them were patients with MS, with a mean disease duration from 2.7 to 16.51 years. Synthesis of results revealed that MS was significantly associated with an increased risk of FSD (relative risk 1.87, 95% CI 1.25-2.78, P = .002; heterogeneity: I² = 89.0%, P < .001). Women with MS had significantly lower values in total Female Sexual Function Index scores as compared with healthy controls (standard mean differences -2.41,95% CI -3.87 to -0.96, P = .017; heterogeneity: I² = 97.2%, P = .001). The grading of recommendations assessment, development, and evaluation-relevant outcomes revealed that the absolute effect of MS on FSD was 434 more per 1000 (from 125 more to 888 more); and the overall quality of the evidence was judged as low.

CLINICAL IMPLICATIONS

The present meta-analysis indicates that women patients with MS have a significant elevated risk of sexual dysfunction, which should raise awareness of the potential association between MS and FSD by both neurologists and urologists.

STRENGTHS & LIMITATIONS

This the first study to summarize all available evidence for combining the odds on the association between MS and the risk of developing FSD. However, all the included studies were observational design, which may downgrade this evidence.

CONCLUSION

Results of this meta-analysis revealed a potential hazardous effect of MS for developing FSD. High-quality stringently controlled studies with large sample size are still warranted to validate this relationship. Zhao S, Wang J, Liu Y, et al. Association Between Multiple Sclerosis and Risk of Female Sexual Dysfunction: A Systematic Review and Meta-analysis. J Sex Med;15:1716-1727.

Human T-Lymphotropic Virus-1-Associated Myelopathy/Tropical Spastic Paraparesis Is Associated With Sexual Dysfunction in Infected Women of Reproductive Age

Introduction

Human T-lymphotropic virus (HTLV)-1–associated myelopathy/tropical spastic paraparesis (HAM/TSP) is a neurological disorder that mostly affects women. This disease is characterized by a progressive loss of motor function and disruptions in sensory function in the lower limbs. HTLV-1 is also associated with isolated neurologic dysfunctions, overactive bladder, and erectile dysfunction. The occurrence of sexual dysfunction in HTLV-1–infected women remain unclear.

Aim

To investigate associations between HTLV-1 infection and sexual dysfunction in both asymptomatic infected women and those diagnosed with HAM/TSP compared with uninfected women.

Methods

HTLV-1–infected and uninfected women were assessed for sexual dysfunction using the Female Sexual Function Index instrument. Sexual dysfunction was considered if global Female Sexual Function Index scores were <26.5. Crude and adjusted prevalence ratios (PR) with 95% CI were calculated to identify associations between sexual dysfunction (outcome) and HTLV infection status–asymptomatic or HAM/TSP (main exposure), compared with uninfected women, and adjusted by sociodemographic and/or clinical characteristics (covariables).

Results

HTLV-1–infected women (n = 72; 57 asymptomatic; 15 HAM/TSP) and HTLV-1 uninfected women (n = 49) were evaluated. The overall sexual dysfunction prevalence was 53.7% (65/121), which was higher in the HAM/TSP group (80.0%; adjusted PR 1.89; 95% CI 1.23–2.90) when compared with non-infected individuals (44.9%). Sexual dysfunction was found in 54.4% of the HTLV-1–infected asymptomatic women (PR 1.21; 95% CI 0.82–1.79). Sexual dysfunction was associated with income lower than 1 minimal wage (∼US $300, October 2017) and number of previous birthday.

Conclusion

The obtained results indicate that sexual dysfunction is associated with HAM/TSP in women infected with HTLV-1 of reproductive age.

Lima Lopes Martins A, Rios Grassi MF, de Aquino Firmino A, et al. Human T-Lymphotropic Virus-1–Associated Myelopathy/Tropical Spastic Paraparesis Is Associated With Sexual Dysfunction in Infected Women of Reproductive Age. Sex Med 2018;6:324–331.

[Female sexual dysfunction and multiple sclerosis: A case-control study]

OBJECTIVES

To compare the scores of the different dimensions of sexual function of women with multiple sclerosis to a group of control women and to identify possible factors associated with sexual dysfunction in women with multiple sclerosis.

METHODS

This is a descriptive and analytical case-control study. Twenty-six women with multiple sclerosis were compared to 26 control women matched for age and socioeconomic status. The evaluation focused on demographic and clinical data. Patients with multiple sclerosis were evaluated by Expanded Disability Status Scale (EDSS) for functional status, by Female Sexual Function Inventory (FSFI) for sexual function and by Beck Depression Inventory-Short Form (BDI-DF) for severity of depression.

RESULTS

Our results confirmed the high prevalence of sexual dysfunction among patients with multiple sclerosis (69.2%) compared to controls (26.9%) (P=0.002). Sexual desire, arousal and orgasm were the most altered sexual phases in our study. Total FSFI, and FSFI subscale scores (sexual desire, arousal, lubrication, orgasm and satisfaction) were lower in women with multiple sclerosis compared with controls. The analytical study showed that in women with multiple sclerosis, the total FSFI score was correlated with age (r_s=-0.68; P<0.001), duration of marriage (r_s=-0.57; P=0.002), level of disability (r_s=-0.45; P=0.021) and BDI-SF score (r_s=-0.51; P=0.008). FSFI score was also associated to low education level (P=0.02) and urinary dysfunction (P=0.04).

CONCLUSION

Our study highlighted the importance of sexual dysfunction in women with multiple sclerosis. The inclusion of this aspect in the clinical assessment will improve the quality of life of these patients.

LEVEL OF EVIDENCE

3.

Sexual behaviours and sexual health outcomes among young adults with limiting disabilities: findings from third British National Survey of Sexual Attitudes and Lifestyles (Natsal-3)

OBJECTIVE

To explore whether the sexual behaviours and sexual health outcomes of young adults with self-reported disabilities that they perceive limit their activities ('limiting disability') differ from those without disability.

DESIGN

Complex survey analyses of cross-sectional probability sample survey data collected between September 2010 and August 2012 using computer-assisted personal interviewing and computer-assisted self-interview.

SETTING

British general population.

PARTICIPANTS

7435 women and men aged 17-34 years, resident in private households in Britain, interviewed for the third National Survey of Sexual Attitudes and Lifestyles.

MAIN OUTCOME MEASURES

Self-reported sexual behaviour and sexual health outcomes.

RESULTS

Approximately 1 in 10 participants reported having a limiting disability. Sexual behaviours were similar between those with limiting disability and those without, with a few exceptions. Women and men with limiting disability were less likely to report having sexual partner(s) (past year, adjusted ORs (AORs) for age and social class: AORs: 0.71, 0.75, respectively). Women with limiting disability were more likely to report having same-sex partner(s) in the past 5 years (AOR: 2.39). Differences were seen in sexual health outcomes, especially among women; those with limiting disability were more likely to report having experienced non-volitional sex (ever, AOR: 3.08), STI diagnoses (ever, AOR: 1.43) and sought help/advice regarding their sex life (past year, AOR: 1.56). Women with limiting disability were also more likely to feel distressed/worried about their sex life than those without limiting disability (AORs: 1.61). None of these associations were seen in men.

CONCLUSIONS

Young adults with limiting disability, especially women, are more likely to report adverse sexual health outcomes than those without, despite comparatively few behavioural differences. It is important to ensure that people with disabilities are included in sexual health promotion and service planning, and targeted policy and programme interventions are needed to address negative sexual health outcomes disproportionally experienced by people with disabilities.

Caring for Women with Multiple Sclerosis Across the Lifespan

PURPOSE OF REVIEW

Caring for women with multiple sclerosis (MS), whose first symptoms typically begin during the childbearing years, requires a comprehensive approach to management across a range of reproductive exposures, and beyond through menopause.

RECENT FINDINGS

This article summarizes what is known about the disease course in women with MS, how it differs from men, and the current state of knowledge regarding effects of reproductive exposures (menarche, childbearing, menopause) on MS-related inflammation and neurodegeneration. Recent findings regarding pregnancy-associated relapses in the treatment era, protective effects of breastfeeding, and care for women during the menopausal transition are reviewed. Then, updated recommendations to guiding women during childbearing-including pre-conception counseling, discontinuation of MS therapies, and management of postpartum relapses-are provided. Whenever possible, areas of uncertainty and avenues for future research are highlighted. From childhood through the postreproductive life stages, gender and hormonal exposures appear to shape an individual's risk for MS, as well as the experience of living with MS.

Sexual dysfunctions in MS in relation to neuropsychiatric aspects and its psychological treatment: A scoping review

OBJECTIVE

Sexual dysfunction in multiple sclerosis (MS) is a significant, but often underestimated and overlooked suffering. Interventions to treat sexual dysfunction in MS are rare. The relation between sexual dysfunction in MS and psychological as well as neuropsychological aspects is evident. However, this field of research remains markedly underdeveloped in this severe chronic illness. The aim of this scoping review is to describe the relevant knowledge in this area and to identify psychological interventions to treat sexual dysfunctions in MS.

METHODS

A scoping review was conducted to answer the following questions: (1) Which psychological and neuropsychological factors impact on sexual dysfunction in MS and vice versa? (2) What kind of psychological interventions aiming to improve sexual dysfunctions in MS are available? A comprehensive search and review of MEDLINE, PsycINFO, and CINAHL was completed by using a recent methodological framework for scoping reviews.

RESULTS

23 publications covering a total of 13,259 people with MS and 532 healthy controls were identified. Sexual dysfunction was found to be very common in MS and there is an obvious relation to psychological disorders as e.g. depression and anxiety and also to psychological aspects as partner relationship and quality of life. The relation between sexual dysfunction in MS and neuropsychological impairment has only rarely been studied and no clear results were found. Only two studies were identified, assessing the effectiveness of psychological intervention studies on sexual dysfunction in people with MS, and a third study presenting a secondary analysis of a study targeting depression. All three studies reported significant improvements in sexual dysfunction as well as partly in psychological variables.

CONCLUSIONS

There is a pressing need for the development and adequate evaluation of psychological interventions for sexual dysfunctions in MS. In addition, sexual dysfunction and its impact on psychological wellbeing should be more focussed in clinical care.

REGISTRATION

This review is registered with PROSPERO; Registration number: CRD42016033066.

Sexual dysfunction in female patients with relapsing-remitting multiple sclerosis

INTRODUCTION

Sexual dysfunction (SD) is one of the common symptoms of multiple sclerosis (MS) and is often underdiagnosed, especially in women. Relapsing-remitting multiple sclerosis (RRMS) is the most widespread form of the disease, but the data on SD occurrence in this particular group of patients is limited. The aim of the study was to analyze the associations between demographic factors, symptoms and signs of MS, psychiatric comorbidities and SD in female patients with RRMS.

MATERIAL & METHODS

A subgroup of 86 sexually active women with RRMS out of 218 total MS respondents was analyzed. Exclusion criteria included active relapse, EDSS score equal or higher than 6.5, and current pregnancy. All patients completed questionnaires including demographic data, questions about symptoms and signs of MS, Female Sexual Function Index (FSFI) for sexual performance, Patient Health Questionnaire 9 (PHQ-9) for depression, and Fatigue Severity Scale (FSS) for fatigue evaluation.

RESULTS

According to FSFI, SD occurred in 21 (27.27%) of the respondents. SD occurrence was associated with depression (p < .05) and speech disturbances (p < .04). A negative effect on sexual performance was associated with depression intensity (p < .003), fatigue intensity (p < .05), more advanced age at diagnosis (p < .02), lower education level (p < .05), and smaller area of residence (p < .002).

CONCLUSIONS

SD in women with RRMS is mostly associated with psychosocial parameters. Patients who are more depressed, presenting speech problems, less educated, and from smaller towns, should be considered high-risk for sexual dysfunction.