Sexual disorders in men with multiple sclerosis: Evaluation and management

Impact of multiple sclerosis on male sexual and reproductive health

Multiple sclerosis (MS) is a chronic inflammatory and autoimmune neurodegenerative disease characterized by the destruction of myelin in the central nervous system, leading to significant health and quality of life burdens for patients. MS is most prevalent in younger individuals aged 20-40, a critical period when many patients hope to establish relationships and start families. While neurological disability, such as fatigue, sensory dysfunction, spasticity, and cognitive dysfunction, have been greatly improved with the advances in managing MS, physicians are frequently confronted with sexual and reproductive problems among younger male people with MS (PwMS). These issues mainly include erectile dysfunction, ejaculatory disorders, reduced libido, decreased sperm quality, and impaired male fertility. Despite recent studies indicating that MS negatively impacts the sexuality and fertility of male PwMS, these issues have not received sufficient attention. Genetic factors, autoimmunity, chronic inflammation, psychological factors, and the use of drugs may contribute to sexual/reproductive dysfunction in PwMS. However, like the overall understanding of MS pathophysiology, the complete mechanisms of its development remain unclear. In this study, we review the existing literature to summarize the range of sexual and reproductive issues unique to males with MS, explore potential underlying mechanisms, and aim to improve these issues in male PwMS. By shedding light on this overlooked aspect of MS, we hope to enhance the care and well-being of male PwMS facing these challenges.

Assisted Reproductive Techniques in Multiple Sclerosis: Recommendations from an Expert Panel

INTRODUCTION

Multiple sclerosis (MS) is mainly diagnosed in women of reproductive age. However, there is a paucity of guidelines jointly prepared by neurologists and gynaecologists on managing women with MS and the desire for motherhood. Therefore, in this review we propose recommendations for such cases, with an particular focus on those requiring assisted reproductive techniques (ART).

METHODS

A group of seven MS experts (4 neurologists and 3 gynaecologists) came together for three discussion sessions to achieve consensus.

RESULTS

The recommendations reported here focus on the importance of early preconception counselling, the management of disease-modifying therapies before and during ART procedures, important considerations for women with MS regarding ART (intrauterine insemination, in vitro fertilisation and oocyte cryopreservation) and the paramount relevance of multidisciplinary units to manage these patients.

CONCLUSIONS

Early preconception consultations are essential to individualising pregnancy management in women with MS, and an early, well-planned, spontaneous pregnancy should be the aim whenever possible. The management of women with MS and the desire for motherhood by multidisciplinary units is warranted to ensure appropriate guidance through the entire pregnancy.

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.

Factors that influence quality of life in patients with multiple sclerosis in Saudi Arabia

PURPOSE

To study the factors which may contribute to quality of life (QOL) in patients with multiple sclerosis (pwMS) in Saudi Arabia.

METHODS

175 pwMS and 71 age-, gender-, and BMI-matched healthy subjects participated in this cross-sectional study. QOL was studied by the multiple sclerosis quality of life-54 (MSQOL-54) while depression, disability, and fatigue were measured by the beck depression inventory-II (BDI-II), the expanded disability status scale (EDSS), and the modified fatigue impact scale (MFIS), respectively. The effects of demographic and clinical characteristics on MSQOL-54 were studied.

RESULTS

QOL was worse in pwMS. A better QOL in pwMS was linked to being male, having relapsing-remitting MS, having lower BMI, being employed, having a low disability, having no or minimal depression, and not fatigued. Age, disease duration, marital status, living status, and level of education did not affect the QOL. QOL showed a moderate to strong correlation with depression and fatigue and a weak correlation with EDSS. Depression and fatigue were the strongest predictors of QOL. Other predictors included gender and BMI but not EDSS.

CONCLUSIONS

Many of the factors which seem to influence QOL in pwMS are modifiable. Evaluation and management of such factors may improve QOL in pwMS.Implications for rehabilitationAssessment of QOL (using a proper tool) should be part of every pwMS evaluation.Depression and fatigue are the main predictors of QOL in pwMs, therefore, attention should be paid for their evaluation and management.Sexual dysfunction and pain should be assessed and managed early in the course of the disease.

Male fertility in relapsing-remitting multiple sclerosis patients treated with natalizumab and ocrelizumab: A prospective case-control study

Scarce data are available about the impact of natalizumab (NTZ) and ocrelizumab (OCR) on male fertility in relapsing-remitting multiple sclerosis (RRMS). In this case-control prospective study, the gonadal steroids and the sperm parameters have been analysed at the time of the RRMS diagnosis and after 12 months from the beginning of the investigated therapies. Sixteen men with RRMS and sixteen matched healthy controls were included. At enrolment and after 12 months on therapy, the gonadal steroids and the sperm parameters of men with RRMS did not differ from the healthy controls. In conclusion, therapy with NTZ and OCR had no impact on fertility status in our cohort of men with RRMS. Further randomized and prospective studies are needed.

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.

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.

Lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis

OBJECTIVES

To assess the prevalence and interrelationship between lower urinary tract symptoms and sexual dysfunction in men with multiple sclerosis (MS).

METHODS

In a cross-sectional study, we evaluated 41 men (mean age 41.1±9.9 years) with MS from February 2011 to March 2013, who were invited to participate irrespective of the presence of lower urinary tract symptoms or sexual dysfunction. Neurological impairment was assessed with the Expanded Disability Status Scale; lower urinary tract symptoms were evaluated with the International Continence Society male short-form questionnaire, and sexual dysfunction was evaluated with the International Index of Erectile Function. All patients underwent transabdominal urinary tract sonography and urine culture.

RESULTS

The mean disease duration was 10.5±7.3 years. Neurological evaluation showed a median Expanded Disability Status Scale score of 3 [2-6]. The median International Continence Society male short-form questionnaire score was 17 [10-25]. The median International Index of Erectile Function score was 29 [15-46]. Twenty-nine patients (74.4%) had sexual dysfunction as defined by an International Index of Erectile Function score <45. Voiding dysfunction and sexual dysfunction increased with the degree of neurological impairment (r=0.02 [0.02 to 0.36] p=0.03 and r=-0.41 [-0.65 to -0.11] p=0.008, respectively). Lower urinary tract symptoms and sexual dysfunction also displayed a significant correlation (r=-0.31 [-0.56 to -0.01] p=0.04).

CONCLUSIONS

Most male patients with MS have lower urinary tract symptoms and sexual dysfunction. The severity of the neurological disease is a predictive factor for the occurrence of voiding and sexual dysfunctions.

Practical Evidence-Based Recommendations for Patients with Multiple Sclerosis Who Want to Have Children

Multiple sclerosis (MS) management presently aims to reach a state of no (or minimal) evidence of disease activity. The development and commercialization of new drugs has led to a renewed interest in family planning, since patients with MS may face a future with reduced (or no) disease-related neurological disability. The advice of neurologists is often sought by patients who want to have children and need to know more about disease control at conception and during pregnancy and the puerperium. When MS is well controlled, the simple withdrawal of drugs for patients who intend to conceive is not an option. On the other hand, not all treatments presently recommended for MS are considered safe during conception, pregnancy and/or breastfeeding. The objective of the present study was to summarize the practical and evidence-based recommendations for family planning when our patients (women and men) have MS.Funding TEVA Pharmaceutical Brazil.

A Review of Pathophysiology and Management Options for Delayed Ejaculation

INTRODUCTION

Delayed ejaculation (DE) is a poorly defined disorder that entails the delay or absence of orgasm that results in personal distress. Numerous causes of DE exist, and management must be tailored to the specific etiology to maximize treatment success. Management strategies include psychological and sexual therapy, pharmacotherapy, and penile vibratory stimulation.

AIM

This article intends to review the pathophysiology and treatment options for DE discussed in the literature to date.

METHODS

A review of the literature was performed to identify and evaluate the existing data on treatment success for the various forms of DE management.

MAIN OUTCOME MEASURES

Each treatment option was evaluated for method of administration, data supporting its success for DE, and potential risks or side effects.

RESULTS

Different psychosexual therapy strategies have been described for DE but with limited data to describe efficacy. There is no medication for DE approved by the United States Food and Drug Administration. The quality of evidence supporting the off-label use of medications for DE is low. However, there are numerous medications reported in the literature suggested to treat the condition. Cabergoline and bupropion are the two most commonly used. In addition, penile vibratory stimulation has been described as an adjunct treatment option for DE.

CONCLUSION

There are different treatment options reported for DE, all with limited evidence supporting their efficacy. Identifying the etiology of the DE is important to appropriately target therapy. A multimodal approach combining psychosexual therapy with medications and/or penile vibratory stimulation will likely provide the best outcomes.

The pharmacist's role in improving the treatment of erectile dysfunction and its underlying causes

Erectile dysfunction (ED), which worldwide is likely to affect in excess of 300 million men by 2025, is often either untreated or insufficiently treated. It can be a prelude to other serious illnesses and may be a cause or consequence of depression in affected individuals. Among men younger than 60 years of age, ED can be a robust early-stage indicator of vascular disease and type 2 diabetes. Untreated or inadequately treated ED can also be a sign of poor communication between health professionals and service users of all ages. Improved treatment of ED could cost-effectively prevent premature deaths and avoidable morbidity. The extension of community pharmacy‒based health care would enable more men living with ED to safely access effective medications, along with appropriate diagnostic services and support for beneficial lifestyle changes such as smoking cessation in conveniently accessible settings. The task of introducing improved methods of affordably addressing problems linked to ED exemplifies the strategic challenges now facing health care systems globally. Promoting professionally supported self-care in pharmacies has the potential to meet the needs of aging populations in progressively more effective ways.

Evaluation of the association between sexual dysfunction and demyelinating plaque location and number in female multiple sclerosis patients

Purpose To investigate the frequency of sexual dysfunction (SD) in female multiple sclerosis (MS) patients and to explore its association with the location and number of demyelinating lesions. Material and Methods We evaluated 42 female patients and 41 healthy subjects. All patients underwent neurological examination and 1.5 T brain and full spinal MRI. All subjects completed the female sexual function index (FSFI), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and Short-Form 36 Quality of Life Scale (SF-36). All participants were also evaluated for serum thyroid stimulating hormone (TSH), T4, estradiol, and total testosterone. Results No statistically significant differences between the MS and control groups were found for age, body mass index (BMI), serum TSH, T4, E2, and total testosterone level. MS patients had a statistically significantly lower FSFI and SF-36 scores and higher BDI and BAI scores compared with healthy subjects. The location and number of demyelinating lesions were not associated with SD. Conclusion In our cohort, this difference in SD appears unrelated to the location and number of demyelinating lesions. These findings highlight the importance of the assessment and treatment of psychiatric comorbidities, such as depression and anxiety, in MS patients reporting SD.

Genital vibration for sexual function and enhancement: best practice recommendations for choosing and safely using a vibrator

Vibrators are an evidence-based treatment for a variety of sexual dysfunctions and sexual enhancement; however, the use of a genital vibrator lacks best practice recommendations. This aim of this article is to provide current, best practice recommendations regarding the use of vibratory stimulation for the treatment of sexual dysfunction and/or sexual or relationship enhancement. A multidisciplinary team of sexual health specialists collaborated to develop best practice recommendations based on a narrative literature review. Recommendations for the use of vibratory stimulation for the treatment of sexual dysfunction are provided, with special attention to counseling patients on choosing and safely using a vibrator. Further study is needed to determine the most effective methods to counsel patients on vibrator use and to provide evidence-based cleaning recommendations.

Genital vibration for sexual function and enhancement: a review of evidence

Vibration, as provided by a genital vibrator, is commonly regarded as a tool to enhance sexual pleasure and in modern day society falls under the category of a sex toy. However, the vibrator was not originally intended to be a toy, and its benefits reach far beyond that of a plaything. This article is a narrative review of the current evidence regarding the use of vibratory stimulation for the treatment of sexual dysfunction and/or sexual and relationship enhancement. The literature indicates that vibratory stimulation has evidence-based support for the treatment of erectile dysfunction, ejaculatory dysfunction and anorgasmia. Vibratory stimulation is positively correlated with increased sexual desire and overall sexual function. It has also shown benefit for sexual arousal difficulties and pelvic floor dysfunction. Though definitive evidence is lacking, genital vibration is a potential treatment for sexual dysfunction related to a wide variety of sexual health concerns in men and women.

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.

'Hidden' factors influencing quality of life in patients with multiple sclerosis

Traditional outcome measures for patients with multiple sclerosis (MS), whether in clinical trials or clinical practice, are currently in question. The combination of relapses, physical disability progression and magnetic resonance imaging (MRI) disease activity reflect only part of the impact that MS has on a patient's daily life. Quality of life (QoL) is considered by many to be the ideal outcome measure. Since it captures the patient's own perspective of well-being, QoL should be the primary focus when evaluating a patient and the main objective of MS management. Nevertheless, whilst numerous instruments to measure QoL in MS patients are available or proposed, there is no current consensus regarding which is the best tool to use and under what circumstances. QoL in patients with MS is determined by several factors beyond the more obvious; these include coping with the MS diagnosis, understanding the disease and the disease process, dealing with so-called 'hidden' symptoms such as fatigue, cognitive impairment and sexual disturbances, and managing the many associated personal challenges such as social isolation, family issues and working difficulties. Evidence is emerging that psychological interventions may be beneficial in MS patients although more research is required to confirm their utility. This article examines some factors that influence QoL in MS patients which may be overlooked in the general busyness of routine clinical practice.

Fertility treatment in spinal cord injury and other neurologic disease

Infertility in individuals with neurologic disorders is complex in etiology and manifestation. Its management therefore often requires a multimodal approach. This review addresses the implications of spinal cord injury (SCI) and other neurologic disease on fertility, including the high prevalence of sexual dysfunction, ejaculation disorders and compromised semen parameters. Available treatment approaches discussed include assisted ejaculation techniques and assisted reproductive technology including surgical sperm retrieval and intracytoplasmic sperm injection (ICSI).

Evaluation of Sexual Dysfunction in Men With Spinal Cord Injury Using the Male Sexual Quotient

OBJECTIVE

To assess different aspects of sexual function in men with spinal cord injury (SCI) using the Male Sexual Quotient (MSQ), a newly developed tool to assess sexual function and satisfaction.

DESIGN

Cross-sectional study.

SETTING

Tertiary rehabilitation center.

PARTICIPANTS

Patients (N=295) older than 18 years (mean age ± SD, 40.7±14.5y) with SCI for more than 1 year (median time since SCI, 3.6y; range, 1.6-7.0y) were assessed from February to August 2012. Patients completed the MSQ questionnaire and the Sexual Health Inventory for Men (SHIM).

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Performance in various domains of sexual function was evaluated using the MSQ and SHIM questionnaires.

RESULTS

Erectile function, ejaculation, and orgasm were the most severely affected domains. The median MSQ score was 40 (range, 8-66), and the median SHIM score was 5 (range, 0-16). The diagnostic properties of the 2 instruments were similar in the discrimination of sexually active subjects. The area under the receiver operating characteristic curve was .950 (95% confidence interval [CI], .923-.979) for the MSQ and .942 (95% CI, .915-.968) for the SHIM. There was a strong correlation between the 2 instruments (r=.826; 95% CI, .802-.878).

CONCLUSIONS

Different domains of sexual function are severely impaired in men with SCI, although their sexual interest remains high. The MSQ and SHIM scores strongly correlate, but the MSQ provides a more comprehensive assessment of sexual dysfunction in male patients with SCI.

Symptomatic management in multiple sclerosis

Multiple sclerosis (MS) is the commonest cause of disability in young adults. While there is increasing choice and better treatments available for delaying disease progression, there are still, very few, effective symptomatic treatments. For many patients such as those with primary progressive MS (PPMS) and those that inevitably become secondary progressive, symptom management is the only treatment available. MS related symptoms are complex, interrelated, and can be interdependent. It requires good understanding of the condition, a holistic multidisciplinary approach, and above all, patient education and empowerment.