Managing sexual dysfunction

1. Managing sexual dysfunction

2. Sexual difficulties in MS • People with MS have sexual difficulties which may or may not be related to MS • Affects both men and women • 25% said it had a majorimpact ontheir lives (MS Society) • Often a ‘hidden’ problem

3. Sexual difficulties in MS • MS almost always affects the spinal cord, which can lead to a disturbance of sexual function • can correlate with spasticity and bladder & bowel disturbances • Sexual difficulties complex and relate to: • Sexual behaviour affected by: • neurological symptoms • psychosocial impact of MS • Physiological sexual dysfunction • eg Erectile dysfunction and disorders of arousal mechanisms • Consider in wider context of sexual behaviour and relationships

4. Sexual difficulties in MS • Precise frequency unknown • Figures range up to 91% of males and 72% of females • 71% of people with MS and sexual dysfunction have associated relationship problems • 70% people with MS report sexual dysfunction - compared to • 40% of with non-neurological disability • 12% general population • Neurological damage is the single most common primary cause Zorzon M et al. Multiple Sclerosis 1999;5:418-27 Mattson D et al. 1995. Archives Neurology. 52: 862 -868

5. Sexual difficulties in men • 75% - Sexual problems • 63% - Erectile dysfunction • 55% - Decreased sensation • 51% - Fatigue Valleroy ML & Kraft GH. 1984 Archives of Physical Medical Rehabilitation. 65:125-128

6. 60% - Decreased sexual desire 37% - Decreased lubrication 38% - Diminished orgasmic capacity 62% - Sensory disturbance in genitals 12% - Anorgasmic . 56% - Sexual Dysfunction Symptoms: fatigue decreased sensation decreased libido decreased frequency or loss of orgasm difficulty with arousal Sexual difficulties in women with MS Hulter BM and Lundborg PO 1995 Journal Neurology, Neurosurgery & Psychiatry. 59:83-86 Valleroy ML & Kraft GH. 1984 Archives of Physical Medical Rehabilitation. 65:125-128

7. Sexuality and the brain • Sexuality is a complex yet vital part of life • Many myths associated with sex • Male and female views and needs often differ! • Intimacy does not have to lead to intercourse on every occasion

8. Classification of sexual difficulties Sexual difficulties can be categorised into one of three groups depending on precipitating factors • Primary Sexual Dysfunction • Secondary Sexual Dysfunction • Tertiary Sexual Dysfunction

9. Precipitating factors Primary Direct effects of the MS disease process MS plaques that sit along nerve pathways, sacral plexus Secondary Fatigue Continence problems Spasticity Pain Immobility Medication Tertiary Body Image Low self esteem Depression Stress Lack of a partner Other Medications Smoking/alcohol Cannabis

10. Primary Direct effects of MS: • Decreased or absent libido • Altered genital sensation (numbness, painful intercourse, heightened sensitivity) • Decreased frequency/intensity of orgasms • Erectile dysfunction • Decreased vaginal lubrication and clitoral engorgement • Decreased vaginal muscle tone

11. Secondary Linked to: • Bladder or bowel dysfunction • Fatigue • Non genital sensory paraesthesias • Spasticity • Tremor • Cognitive impairment • Pain • Side effects of medication

12. Tertiary Due to Psychological & social factors : • Changes in self or body image • Demoralisation and grief • Clinical depression • Social isolation • Anxiety: performance / rejection • Role changes / conflict / less communication • Feeling of guilt • Reduced concentration

13. Management

14. Barriers to management • Most individuals or couples never receive the help they need • Individuals uncomfortable asking for help • Professionals own lack of confidence re discussing sex and sexuality • Lack of knowledge about local resources • Lack of treatment options Kalb RC 2000. International Journal of MS Care. Supp

15. Barriers to management Health professionals inhibited • Lack of training / outside own speciality • Embarrassment / lack of confidence • Too intrusive for patients • Lack of referral options once detected • Lack of time • Religious or personal views RCN 2000

16. NICE guidelines Health service professionals in regular contact with people with MS should consider in a systematic way whether the people with MS has hidden problems contributing to their clinical situation, such as fatigue, depression, cognitive impairment, impaired sexual function or reduced bladder control NICE MS Guidelines. National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care 2004

17. NICE Recommendations • Individual (or couple) should be sensitively asked, or given opportunity to discuss any difficulties • Offer information and direct to appropriate local services • Everyone with persisting sexual dysfunction should be offered: • Opportunity to see a specialist • Appropriate advice and sexual aids NICE MS Guidelines. National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care 2004

18. Men with MSNICE Recommendations • Should be asked whether they experience ED • Relative or absolute and whether it is of concern • Persistent ED: 1st line - offer sildenafil 25-100mg • No response: assessment for contributing factors • Depression, anxiety, vascular disease, diabetes, medication S/Es etc • 2nd line - consider alprostadil or intracavernosal papaverine NICE MS Guidelines. National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care 2004

19. Women with MSNICE Recommendations • Should be asked whether they experience sexual dysfunction • Failure or arousal, lubrication or anorgasmia and whether this is of concern • Assess for general and specific (treatable) contributing factors • Depression, anxiety, vascular disease, diabetes, medication S/Es etc NICE MS Guidelines. National Clinical Guideline for Diagnosis and Management in Primary and Secondary Care 2004

20. Professional input Multidisciplinary Including: • Specialist Nurse - MS and/or Continence • Psychosexual Health Advisor • Psychologist • GP • Occupational therapists • Physiotherapists

21. Assessments and reviews

22. Assessment of sexual function • MDT assessment of primary, secondary and tertiary precipitating factors • Sexual history • Psychosocial history • Evaluation / review current medication regimes • Specific sexual assessment tools

23. Medication review • Many medicines used in MS interfere with sexual function • Anticholinergics • can reduce vaginal lubrication • Antidepressants - tricyclics and SSRIs • can inhibit libido and orgasm • Antiepileptics used for tremor and pain and antispasticity medications • can affect desire and can cause significant fatigue

24. Medication review • Benzodiazepines and psychoactive stimulants • can affect orgasm • Antihypertensives and antihistamines • are implicated in arousal disorders • Timing of doses may have to be reviewed to minimise effect on sexual activity

25. Assessment Tools

26. Guys Assessment Sexual Disabilities (may be called UK Neurological assessment) • Do you have any problems in relation to your sexual function? • Do you have any problems satisfying or finding a sexual partner? • Is your sexual drive reduced? • Is your sexual function affected by any physical problems such as loss of sensation, pain, weakness, spasticity, catheterisation or incontinence? • Do you have any difficulty: • women: vaginal lubrication/orgasm • men: erection/orgasm Sharrack B & Hughes RAC. 1999 Multiple Sclerosis. 5(4):223-33

27. MSISQ 19 Multiple Sclerosis Intimacy and Sexuality Questionnaire

28. Sexual Satisfaction Scale (SSS) Sexual Health Inventory for Men Pfizer

29. P-LI-SS-IT model • Permission: to discuss concerns • Limited information: non-expert information • Specific Suggestions: training at specialist practitioner level. • Intensive therapy: complex interpersonal & psychological issues. Anon 1976. Journal of Sex Education Therapy. 2:1-15

30. Strategies for Women with Sexual Dysfunction

31. Symptomatic treatment Secondary sexual dysfunction • Fatigue • timing, energy conservation techniques, cooling • medication review • Bladder • anticholinergics, timing of drinks, bladder emptying • catheter management strategies

32. ED management • Lifestyle: exercise, diet, smoking, drinking • Humour • Talking to partner • Psychosexual counselling • Education and sexual aids • Vacuum assisted devices • Surgically implanted penile prostheses • (inflatable or permanently rigid - last option)

33. ED management Medications: • Phosphodiesterase inhibitors (PDE-5 inhibitors) • Viagra (sildenafil citrate), Ciallis and Levitra • Intracavernosal injection (Caverjet, Viridal) • Intraurethral alprostadil (MUSE)

34. Vacuum erection pumps Advantages • Non-surgical treatment • Non-pharmaceutical • Economical Adapted from Erectile Dysfunction Institute website. www.erectile-dysfunction-impotence.org

35. Disadvantages May take time to learn to use Some side effects are possible: Not painful or serious Reddish pinpoint-size dots may appear on the surface Some bruising may occur if used too long A cold glans is common and uncomfortable Solved by not using the pump for a short period Cumbersome to use Interfere spontaneity So best suited for stable relationship with a supportive sexual partner May impair ejaculation May cause some discomfort and embarrassment Tension ring can be painful Vacuum erection pumps

36. Penile implantsMalleable type Advantages • Easy to use • Generally a simple surgical procedure • Medically economical Disadvantages • The penis always has some degree of rigidity and may be difficult to conceal under tighter-fitting clothes • Complications are rare but include infection and malfunction Adapted from Erectile Dysfunction Institute website. www.erectile-dysfunction-impotence.org

37. Three-piece inflatable penile implant Advantages • Most closely resembles the process and "feel" of a natural erection • Simple, fast inflation preserves sexual spontaneity • Erection feels full • When deflated, the penis feels soft and flaccid • Totally concealed Adapted from Erectile Dysfunction Institute website. www.erectile-dysfunction-impotence.org

38. Three-piece inflatable penile implant Disadvantages • Requires some manual dexterity to inflate • More mechanical parts than other penile implants • Complications can occur, including infection and device malfunction Adapted from Erectile Dysfunction Institutue website. www.erectile-dysfunction-impotence.org

39. CaverjectInjectable alprostadil Advantages • Fast-onset, high-quality erection • Long lasting erection • Partners have no reported side effects Adapted from Erectile Dysfunction Institute website. www.erectile-dysfunction-impotence.org

40. CaverjectInjectable alprostadil Disadvantages • Limits spontaneity • Invasive technique • Some men feel pain • Some develop nodules in their penis. Generally reversible although a small number of nodules may become permanent • Scarring can occur complicating erection process • Can turn into "priapism." Adapted from Erectile Dysfunction Institute website. www.erectile-dysfunction-impotence.org

41. MUSE intraurethral alprostadil Advantages • No needles • Less invasive than injection therapy Adapted from Erectile Dysfunction Institute website. www.erectile-dysfunction-impotence.org

42. MUSE Disadvantages • Irritation, or a burning sensation • Light-headedness, dizziness, fainting, and rapid pulse • Substantially less effective than Viagra • May interfere with spontaneity • Some female partners have reported itching and burning • Can fail: added stress and anxiety - works in about 30% of men • Does not work in men who self catheterise Adapted from Erectile Dysfunction Institute website. www.erectile-dysfunction-impotence.org

43. PDE-5-inhibitors Phosphodiesterase inhibitors • Viagra (sildenafil) • Cialis (tadalafil) • Levitra (vardenafil) • Mode of action: Delays the action of enzymes called phosphodiesterases that can interfere with erectile function thus increasing the capability for blood flow to the penis

44. PDE-5-inhibitors Erection physiology • Sexual stimulation causes the release of nitric oxide, which relaxes muscles in the penis to let more blood flow in and compresses the veins that normally carry blood away • The enzyme PDE-5 reduces the effect of nitric oxide in producing an erection. • A PDE-5 inhibitor limits the release of nitric oxide, which temporarily restores the body's natural sexual response. • PDE-5 inhibitors are unique because they only work when a man is sexually stimulated

45. PDE-5-inhibitors Advantages • Non-invasive • Easy to use • Generally well tolerated • Must incorporate sexual stimulation for predictable and long-lasting erections • Allows more spontaneity than penile injections, urethral suppositories, or vacuum erection devices • Second generation of drugs have longer effect

46. PDE-5-inhibitors Disadvantages • Erections may not be as rigid, predictable, or long lasting as desired • Takes time to work; a delay that can dampen spontaneity • High cost per dose • Prescribing can be restricted to one tablet per week • Side effects and contraindications • Available on internet - self prescribing may be a risk

47. PDE-5-inhibitors • Side effects • Headache, facial flushing, and altered or bluish vision • Should be used with caution in those with cardiovascular disease • Rarely: dizziness, abnormal vision (eg blurring, colour changes, sensitivity to light); bladder problems (pain, cloudy or bloody urine, increased frequency of urination; painful urination) • May be difficult to distinguish between certain common symptoms of MS and some side effects of PDE-5 inhibitors - monitor for abrupt change of this type

48. PDE-5-inhibitors Precautions • Severe heart or liver problems • Recent stroke, heart attack or low blood pressure. • Certain rare inherited eye diseases such as retinitis pigmentosa • Bleeding disorders or stomach ulcers • History of priaprism • Abnormalities of penis

49. Viagra (Sildenafil) Manufacturer says • Viagra works best when taken on an empty stomach about an hour before attempting an erection • Recommended that Viagra be taken only once every 24 hours • If a man takes Viagra but does not have sex, his body naturally eliminates the drug over a 6-10 hour period

50. Cialis (Tadalafil) • European label says Cialis can be taken without regard to food prior to sexual activity • Australian label states that efficacy may continue for up to 36 hours • Manufacturer claims trials indicate a response in less than 30 minutes • Most common side effects are headache, gastro intestinal disturbances, and back pain