Males and females in the general population may experience sexual dysfunction. Some studies suggest it affects between 40 and 80 percent of women, and 50 to 90 percent of men in people living with MS.  Other studies suggest sexual dysfunction increases over time in people with multiple sclerosis and may be associated with some of the other physical symptoms of the disease, including limited mobility, spasticity, and bowel and bladder dysfunction.

MS can directly affect your sexual response and function if it damages the nerves that carry messages from your brain to your sexual organs, says Nicholas LaRocca, PhD, vice president of health care delivery and policy research at the National Multiple Sclerosis Society.

Sexual problems may also stem from MS symptoms such as fatigue or spasticity and from psychological factors relating to self-esteem and mood changes and even medications.

Ignoring problems with sexual intimacy can lead to significant losses in quality of life. However, patients and healthcare professionals are often hesitant to bring up the subject.

Types of Sexual Dysfunction:
There are three categorizations of sexual dysfunction with multiple sclerosis. Primary, secondary and tertiary dysfunction help to recognize and present possible solutions should they exist to the complex sexual problems associated with MS.

Primary Sexual Dysfunction:

Primary sexual dysfunction is the result of damage to the central nervous system caused by MS. Motor and sensory pathways may be disrupted by damage to the neurons (nerve cells). This can result in a slowing or blockage of the impulses sent from the brain to the body and back. Symptoms that result can manifest as decreased sexual sensation, decreased vaginal lubrication, or erectile dysfunction.

MS can interfere directly or indirectly with orgasm. In women and men, orgasm depends on nervous system pathways in the brain (the center of emotion and fantasy during masturbation or intercourse), and pathways in the sacral, thoracic, and cervical parts of the spinal cord. If these pathways are disrupted by plaques, sensation and orgasmic response can be diminished or absent.

Orgasm and ejaculation are actually very complex processes and are near impossible to achieve if damage in the brain or spinal cord interferes with the process. Unfortunately, no existing treatments exist specifically targeted towards these problems in MS.

Some symptoms of primary sexual dysfunction include:

Decreased or absent sex drive.
Altered genital sensations such as numbness, pain, or hypersensitivity.
Decreased or absent genital sensations.
Decreased vaginal muscle tone.
Difficulty or inability to get an erection.
Decreased vaginal lubrication and clitoral engorgement.
Difficulty with or inability to ejaculate.
Decreased frequency and/or intensity of orgasms.

Secondary Sexual Dysfunction:

Secondary sexual dysfunction can be the result of other symptoms of the disease. Limited mobility may result in the inability of the person with MS to maintain certain positions to engage in sexual activity. Fatigue is also a major contributor to sexual dysfunction. Often the demands of daily life combined with fatigue in MS result in a decreased libido and a decreased willingness to attempt to engage in physical sexual activity.

Spasticity may limit the types and number of positions a person with MS can maintain during sexual activity. A sudden onset of painful spasms can certainly interrupt attempts at sexual activity. Bowel and bladder dysfunction are also known to contribute to sexual dysfunction. People with MS who have difficulty controlling their bowels or bladder often avoid intimate contact fearing an embarrassing accident.

Depression has also been found to have a significant effect on sexuality. Many of the medications used by people with MS can also contribute to sexual dysfunction, including antispasticity and antidepressant drugs.

Some symptoms of secondary sexual dysfunction include:

Fatigue can suppress desire or make sexual activity feel overwhelmingly exhausting and interfere with spontaneity.
Bladder and bowel dysfunction can anxiety and reduce interest in intercourse.
Decreased non-genital muscle tone. Muscle tension in the body helps build sexual excitement and contributes to orgasm in both men and women. The decrease in muscle tone sometimes caused by MS can interfere with both.
Sensory changes such as pain, tremor and others can feel very uncomfortable while trying be intimate.
Spasticity can interfere with sexual positioning or cause pain.
Cognitive dysfunctions can and often do result in loss of interest or focus during intimacy.

Tertiary Sexual Dysfunction:

Tertiary sexual dysfunction results from primary and secondary causes and includes psychological disturbances, cognitive dysfunction, and depression. People with MS often focus a significant amount of time and energy on the other physical symptoms of the disease. This may leave them simply too tired to consider sexual activity. They may also be embarrassed by the use of other devices such as urinary catheters or extremity splints.

Some people with MS experience a loss of self-esteem or an altered body image. For example, a man who is no longer able to work and needs physical care from his partner may not imagine himself to be a sexual being and will thus avoid sexual contact. This may be true for care partners also.

Providing intimate physical care for a person with MS such as catheterization and then engaging in sexual activity with that person may be overwhelming. Concerns about the possibility of pregnancy and having a child with MS can also impact sexual function.

There may be other possible causes that have nothing to do with MS yet should be considered. These problems may be associated with a normal aging process. Vaginal dryness and decreased libido may be the result of menopause in women. Lack of erectile function in men may be associated with aging or vascular disease, or medications such as anti-hypertension drugs.`

 

Managing Sexual Dysfunction:
Do not be afraid to seek professional help within your health care team in respect to addressing sexual dysfunction. Sexual function in humans is complex and professional guidance can make a significant difference. It is important to recognize that every person is different and there are many forms of sexual activity as well as mechanisms of showing desire, love and affection.

Orgasm and ejaculation are actually very complex processes and are near impossible to achieve if damage in the brain or spinal cord interferes with the process. Unfortunately, no existing treatments exist specifically targeted towards these problems in MS.

Minimizing Symptoms:

Multiple sclerosis symptoms may impact both intimacy directly or indirectly impacting intimacy and sex.

Pain can impact a person’s ability to be intimate, become aroused or enjoy sex. It is best to discuss pain management strategies with your health care provider team.
Spasticity can make sex difficult however you may find by testing differing positions some are more comfortable than others. Numerous mechanisms of treatment also exist for helping with spasticity including massage, exercise, medications and more.
Fatigue can impact all aspects of life and sex. You may find certain times of day are best in respect to your levels of fatigue and may decide that is a good time for intimacy and sex. Fatigue management is important with MS. Exercise, medications, sleep quality and more can impact energy levels.
Bladder and bowel dysfunction can induce fear, embarrassment and other emotions. Help from urologists and continence nurses can be quite helpful. Find out more about problems with the bladder and bowel.
Mood, Depression & Anxiety:

If someone is feeling depressed, anxiety or other forms of emotional distress they may lose interest in sex or they may ‘close off’ from other people around them. These emotional changes can be a reaction to the condition and a symptom of MS

It’s important that these emotional symptoms, like physical symptoms, are properly recognized and treated. If it’s affecting your sex life and your relationship, it can help to talk through your feelings with your partner. This may also bring you closer together – which might help with intimacy.

Psychological disorders in people with MS that often impacts sexual function. Decreased libido, difficulty with certain sexual positions, and fear of developing relationships are common. Men may also experience erectile dysfunction. Psychotherapy along with medication and exercise, strength in spiritual beliefs can help.

Anxiety can affect sexual function as well, and care partners are also at risk of anxiety impacting the relationship and intimacy. A great way to reduce your partner’s anxiety that they may “hurt” you in some way is to choose a “safe word”. Any word that you can say during intimacy that signals your partner to stop.

Medication Side Effects:

Changes in desire, performance and satisfaction can be a side effect of certain medications, such as some antidepressants. An important first step is to review medications. Many impact sexual performance. A discussion of these with your healthcare team may result in some changes that can improve sexual function. Doses may be changed or medications may be switched if necessary.

Some people who inject disease-modifying drugs may find the injection sites tender and sensitive to touch. If this is the case, you can ask your partner to avoid those places. You can also ask your MS nurse or the drug manufacturers about injection technique, to help minimize these problems.

Other Strategies:

Avoid beverages such as caffeinated drinks (coffee, tea, carbonated sodas) and spicy foods immediately prior to sexual intimacy
Emptying the bladder and bowels immediately prior to a sexual encounter may also reduce the risk of elimination dysfunction during intimacy.
Timing a sexual encounter is also important. Fatigue often worsens as the day progresses, so setting aside time early in the day may enhance the sexual experience.
Pelvic floor exercises taught by a physiotherapist can serve to strengthen the muscles used in many sexual encounters.
Hot or cold therapy, biofeedback, and electrical stimulation may also help with mobility limitations or spasticity.
Timing sexual encounters at least 30 minutes after a dose of antispasticity medications is important.
Personal lubricants may be useful for women with vaginal dryness.

General Tips on Managing Sexual Difficulties:

Communication is important between partners so both are aware of what multiple sclerosis is and how it impacts both of you. Avoid arguing, accusations, blame, and criticisms and negative connotations as these are blocks against understanding. Sometimes asking your partner questions .vs. making statements will yield forward progress.
Masturbation can assist you in locating what types of arousal and sexual stimulations work for you.
Writing how you feel is often preferable or easier to relate than saying things vocally that are difficult to relay.
Sexual toys can bring a new depth to sex and also help towards sexual gratification.
Appearance and taking care of yourself can be an important factor in sex and desire. Spending time on your physical appearance as well as diet, exercise and shared relaxation time not only shows you care and are trying but also happens to be good for mood and managing the disease.
Body mapping is a process by which you can touch portions of your body to locate what brings you or your partner pleasure. For more information on body mapping please follow this link: http://sexuality.about.com/od/humpdaysextips/a/sexual_anatomy.htm
Role reversal can be fun and fruitful. If a partner is the main caregiver a switch while engaging in intimacy can make a difference. While it is difficult to engage in switching roles if care activities are separated from intimacy it can be accomplished.
Massage can promote physical bonds and create a wonderful sense of intimacy especially is forms of penetrative contact are no longer possible. We recommend you seek out a massage therapist to help learn how massage can be used to promote and create intimacy, arousal and love in your relationship.
Education can be very important for both people in a relationship whether multiple sclerosis is in the picture or not. There are many many misconceptions about sexuality, sexual problems and sex related to disability. Education about MS and its symptoms is helpful but understanding depth and complexities of relationships is just as important.

Seeking Professional Help:
Speaking to your neurologist about sexual problems can feel quite difficult and this is perfectly normal. Under many circumstances, a health care provider will not bring up for discussion sexual related matters as they do no wish to be intrusive, appear insensitive or even inappropriate thus it is really up to you to begin a conversation. Once the subject has been opened for discussion most neurologists who are quite familiar with MS will have a great deal of information and options for you to consider.

If you do not feel comfortable discussing the topic with your provider ask that you be referred to someone else for a discussion. A man may feel uncomfortable discussing sexual issues with a female MS Nurse for example.

It is often a good idea to write down questions or particular problems you are experiencing prior to an appointment to both maximize your time and so you do not forget or neglect something you want have addressed or open discussion upon.

 

Emotional Aspects of MS in Men and Women:
People who endure life with multiple sclerosis often state in relation to sex that the disease creates both physical and emotional barriers that result in damage to their relationships. Depression, anxiety, loss of cognition or memories are a few aspects that can impact intimacy. Concerns over an uncertain future and even day to day feelings of rejection, isolation, anger can build similar to a stack of plates compromising the ability to openly express love verbally or intimately.

Several of these same types of problems exist in couples who are not experiencing a chronic disease and can be quite complex to navigate through and much dogma exists on the subject that can make for further confusion especially when MS is introduced into the conversation.

We all have emotional needs and contrary to most things you will read on the internet and even in books, intimacy, love, happiness, ffulfillment sex and love making do not fit in tidy boxes of categorizations. We are all as different as our fingerprints in respect to our emotional needs. We all know these words strike true and so we must examine what our needs are as an individual or if we are married or a couple what our partner’s needs are as well.

It can be very difficult to come forth openly to speak with a sex therapist, counselor, psychologist, psychiatrist, friend and even our significant other in discussing these needs. These discussions can be complex and exacerbated by MS in due to aspects and impacts of the disease. These conversations need to happen however whether they are moderated professionally or not.

One of the first places to start with couples is an understanding that the words “I am right” and “You are wrong” need be removed from the equation. These are instant blocks towards making progress in intimacy. People’s emotions are real and thus the two phrases essentially negate those emotions.

Start with open discussion and should frustration or arguing ensue stop the discussion and table it for another day. Arguing, negative emotions such as anger and frustration when speaking about love and intimacy push people apart when they become heated or hurtful. Remain calm and compassionate even if those feelings arise and table the discussion under the terms that both parties think more about the problem towards a solution.

If necessary albeit difficult reach out to seek some professional guidance or mediation. MS can only destroy relationships if a couple allows it, in fact, many relationships become more intimate when love is the primary emotion and kept cherished.

When considering love these words ring true and with MS ever so true:

“LOVE IS PATIENT, LOVE IS KIND. IT DOES NOT ENVY, IT DOES NOT BOAST, IT IS NOT PROUD. IT DOES NOT DISHONOR OTHERS, IT IS NOT SELF-SEEKING, IT IS NOT EASILY ANGERED, IT KEEPS NO RECORD OF WRONGS. LOVE DOES NOT DELIGHT IN EVIL BUT REJOICES WITH THE TRUTH. IT ALWAYS PROTECTS, ALWAYS TRUSTS, ALWAYS HOPES, ALWAYS PERSEVERES. LOVE NEVER FAILS.”

 

Sexual Dysfunction Male Specifics:
It has been stated some 70% of men living with MS experience erectile issues and they tend to begin several years after the initial symptoms of multiple sclerosis but this is not always the case. Medications or other conditions may also contribute to erectile dysfunction.

When related to multiple sclerosis directly nerve damage may result in a lack of sexual drive mentally or sense of actual sexual stimulation.

Erectile Dysfunction:

Erectile dysfunction can be a sign of a physical, psychological or neurological condition. The main symptom of erectile dysfunction is a males inability to get or keep an erection firm enough for sexual intercourse.
Drug treatments that a patient can discuss with their health care provider include:
Viagra (Sildenafil citrate)
Levitra (vardenafil)
Cialis (tadalafil)
These medications enhance blood flow to the penis thereby increasing erectile response but will not necessarily solve all male’s erectile dysfunction.

Other options include:

Prostaglandins which are a hormone-like substance naturally produced in the body. Synthetic versions of prostaglandins can be effective for treating erectile dysfunction. They work by enhancing blood flow into the penis, which leads to the penis becoming rigid and erect.

Extenze and other over the counter supplements are said to also work to increase blood flow to the penis.

Vacuum devices exist that fit over the penis and allow them to be pumped up creating pressure that results in blood flow into the penis. A ring is then placed around the base of the penis to maintain the erection created.

It is important to discuss all options with your health care team. Many of the medications and supplements can have side effects some of which are potentially dangerous. Patients with heart disease or vascular disease, for example, can have adverse events occur through medications and supplements.

Ejaculation and Orgasm:

It is estimated that between 35 and 50 percent of men with multiple sclerosis have problems with ejaculation including no ability to ejaculate at all or delayed ejaculation.

Orgasm and ejaculation are actually very complex processes and are near impossible to achieve if damage in the brain or spinal cord interferes with the process. Unfortunately, no existing treatments exist specifically targeted towards these problems in MS.

Sexual Dysfunction Female Specifics:
The most common sexual dysfunction problems with women include:

Decreased sexual desire
Diminished orgasm
Difficulty with vaginal lubrication
Fatigue

Sexual Desire:

Decreases in sexual desire are more common in women than in men living with MS. Several research studies are underway to try evaluate medications to enhance a womans desire. Devices such as vibrators, clitoral vacuum’s and other devices may help stimulate or enhance sexual desire.

Often Kegal exercises or pelvic floor exercises are prescribed to help enhance a female patient’s response towards sexual stimulation. Kegal exercises focus on the musculature around the vagina and sensations thereof towards sexual response.

Depression, mood, self-esteem, anger and other mood related issues impact sexual desire. Medications and therapy may help cope with these issues that impact many areas of quality of life including sex.

Diminished Orgasm:

As with males orgasm is a complex process and when and are near impossible to achieve if damage in the brain or spinal cord interferes with the process. Unfortunately, no existing treatments exist specifically targeted towards these problems at this time.

Vaginal Lubrication:

decreased vaginal lubrication can be treated with over the counter water-soluble lubricants. Dysesthesias (abnormal feelings when touched) may be relieved with medications in many instances.

Fatigue:

When loss of desire is due to secondary sexual dysfunction (for example, as a result of fatigue) or tertiary sexual dysfunction (for example, as a result of depression), treatment of the interfering secondary or tertiary symptoms frequently restores libido. When a person’s libido is diminished by MS, he or she may begin to avoid situations that were formerly associated with sex and intimacy. Sexual avoidance serves as a source of misunderstanding and emotional distress within a relationship. The partner may feel rejected, and the person with MS may experience anxiety, guilt, and reduced self-esteem. Misunderstandings arising from sexual avoidance tend to increase the loss of desire and diminish emotional intimacy in relationships.

Some men and women who have sustained loss of libido report that they continue to experience sexual enjoyment and orgasm even in the absence of sexual desire. They may initiate or be receptive to sexual activities without feeling sexually aroused, knowing that they will begin to experience sexual pleasure with sufficient emotional and physical stimulation. This adaptation requires developing new internal and external “signals” associated with wanting to participate in sexual activity. In other words, instead of experiencing libido or physical desire as an internal “signal” to initiate sexual behaviors, one can experience the anticipation of closeness or pleasure as an internal cue that may lead to initiating sexual behaviors and the subsequent enjoyment of sexual activity.

Sensory Changes

Uncomfortable genital sensory disturbances, including burning, pain, or tingling, can sometimes be relieved with gabapentin (Neurontin®), carbamazepine (Tegretol®), phenytoin (Dilantin®) or divalproex (Depakote®) or by a tricyclic antidepressant such as amitriptyline (Elavil®). Decreased genital sensation can sometimes be overcome by more vigorous stimulation, either manually, orally, or with the use of a vibrator. Exploring alternative sexual touches, positions, and behaviors, while searching for those that are the most pleasurable, is often very helpful. Masturbation with a partner observing or participating can provide important information about ways to enhance sexual interactions.

Orgasmic Dysfunction

MS can interfere directly or indirectly with orgasm. In women and men, orgasm depends on nervous system pathways in the brain (the center of emotion and fantasy during masturbation or intercourse), and pathways in the sacral, thoracic, and cervical parts of the spinal cord. If these pathways are disrupted by plaques, sensation and orgasmic response can be diminished or absent.

In addition, orgasm can be inhibited by secondary (indirect physical) symptoms, such as sensory changes, cognitive problems, and other MS symptoms. Tertiary (psychosocial or cultural) orgasmic dysfunction stems from anxiety, depression, and loss of sexual self-confidence or sexual self-esteem, each of which can inhibit orgasm.

Treatment of orgasmic loss in MS depends on understanding the factors that are contributing to the loss, and appropriate symptom management of the interfering problems.

Decreased Libido

Diminished libido is much more common in women with MS than men. To date, there are no published clinical trials of medications that restore libido in MS. Hormone replacement therapy has helped in some post-menopausal women without MS. Testosterone replacement in persons with abnormally low physiological levels has been tried in non-MS populations. However, there is research currently underway that is evaluating medicines that enhance sympathetic arousal, to see if this impacts libido in women with MS. Also, there is research evaluating clitoral vacuum devices and vibrators to see if blood flow, libido, and sensation are enhanced in women with MS.

Pelvic floor or Kegel exercises are sometimes prescribed to enhance female sexual responsiveness. However, in women with significantly reduced sensation, EMG biofeedback is required to help them identify and contract the appropriate pelvic floor muscles in the prescribed manner. The rationale for Kegel exercises is that sensation and contraction of the muscles around the vagina are important parts of the female sexual response.

When loss of desire is due to secondary sexual dysfunction (for example, as a result of fatigue) or tertiary sexual dysfunction (for example, as a result of depression), treatment of the interfering secondary or tertiary symptoms frequently restores libido. When a person’s libido is diminished by MS, he or she may begin to avoid situations that were formerly associated with sex and intimacy. Sexual avoidance serves as a source of misunderstanding and emotional distress within a relationship. The partner may feel rejected, and the person with MS may experience anxiety, guilt, and reduced self-esteem. Misunderstandings arising from sexual avoidance tend to increase the loss of desire and diminish emotional intimacy in relationships.

Some men and women who have sustained loss of libido report that they continue to experience sexual enjoyment and orgasm even in the absence of sexual desire. They may initiate or be receptive to sexual activities without feeling sexually aroused, knowing that they will begin to experience sexual pleasure with sufficient emotional and physical stimulation. This adaptation requires developing new internal and external “signals” associated with wanting to participate in sexual activity. In other words, instead of experiencing libido or physical desire as an internal “signal” to initiate sexual behaviors, one can experience the anticipation of closeness or pleasure as an internal cue that may lead to initiating sexual behaviors and the subsequent enjoyment of sexual activity.