Managing sexual dysfunction

1. Managing sexual dysfunction

2. 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

3. Sexual difficulties and MS • Plaques within spinal cord can profoundly influence sexual function • Atrophy of the pons may affect erections, orgasm, lubrication and changes in vaginal sensation • Lesions in cerebral white matter of the parietal lobe can play a part • Brain stem abnormalities • Side effects of medication are major players

4. 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

5. Sexual Dysfunction in MEN • Inability to acquire or maintain an erection satisfactory for sexual intercourse (impotence or erectile dysfunction (ED); a lack of interest in sex (diminished libido); premature ejaculation; and delayed or inhibited ejaculation. • Erectile dysfunction is the most common physiological sexual disorder for men experienced by 22% of 40-year-old men and up to 49% of 70-year-old men. • Estimated that three-hundred and twenty two million men world wide are affected.

6. Cause of ED • Psychogenic Causes such as anxiety, depression, fatigue, guilt, marital discord, excessive alcohol and smoking • Organic causes: Cardiovascular disease, Diabetes mellitus, Surgery on colon, bladder, prostate, Neurologic causes (lumbar disc, MS, CVA), Hormonal deficiency. Even when treated (ED): heart disease (39%), Diabetes (28%), hypertension (15%) Feldman Ha, J Urol 1994; 151:54-61 • Medications may be responsible for 25% of cases of ED such as anticholinergics, antidepressants, antihypertensives

7. 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

8. Sexual Dysfunction in FEMALES • Up to 40% of women experience SD, the highest proportion occurs 18 - 29. • Most women can only orgasm with clitoral stimulation • Only half of women regularly reach orgasm during sexual intercourse. About 1 of 10 women never reaches orgasm. • Arousal and orgasmic disorders can be caused by a lack of blood circulation to the clitoris and genital area and may be related to medical conditions such as menopause, vascular disease, hypertension, diabetes, pelvic trauma or some pelvic surgery

9. Fluctuations in the levels of oestrogen and testosterone hormones, which occur monthly and during pregnancy, can affect sex drive. • In postmenopausal women, sex drive may be reduced because oestrogen levels decrease. • A reduction in sex drive may result from depression, anxiety, stress, or problems in a relationship.

10. 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

11. 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

12. 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

13. 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

14. 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

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

16. 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

17. ‘Normal’ sexual response cycle • Excitement • Plateau • Orgasm • Resolution • Masters and Johnson 1960

18. All stages are complex ... • Excitement: starts with arousal, influenced by physical contact, thoughts, cognition, emotions. There is increased muscular tension, heart rate, and BP • Plateau: vasodilation to penis and clitoris. More increased muscle tension, respiratory rate. Testes/vagina swell due to engorgement. Excitement builds steadily • Orgasm: Shortest phase, rhythmic pulsing and a release of sexual tension. Pelvic floor muscles are integral, areas of the brain are significant • Resolution: emergence of oxytocin (f) and vasopressin(m) – the ‘satisfaction hormones’, relaxation of muscles, reflection on the experience may increase desire

19. Management

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. Professional input Multidisciplinary- including: • Specialist Nurse - MS and/or Continence • Psychosexual Health Advisor • Erectile Dysfunction Nurse • Psychologist • GP • Occupational therapists • GUM clinic • Urologist • Physiotherapists

27. Assessments and reviews

28. 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

29. 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

30. 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

31. Assessment Tools

32. Guy’s 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

33. MSISQ 19 Multiple Sclerosis Intimacy and Sexuality Questionnaire

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

35. 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

36. BETTER Model to assess sexuality(Hughes and Cohen 2004-Clin J Oncology. 11(5) 671-675) B ringing up the topic of sexuality. E xplaining to the patient or partner that sexuality is a part of quality of life. T elling the patient about resources available to them and the team's ability and willingness to help address concerns and questions. T iming the discussion to when the patient prefers, not only when it's convenient for the health care practitioner. R ecording in the patient's notes that the conversation took place and any follow-ups to further address the person's concerns or questions.

37. Strategies for Men with Sexual Dysfunction

38. The male sexual response -with a focus on erection

39. 3 Mechanisms of erection • Central psychogenic: in response to auditory,visual and/or olfactory sexual stimuli • Reflexogenic : tactile sexual stimulation • Nocturnal : involuntary response An erection generally begins with either central psychogenic sexual stimulation (mental stimulation) and/or reflexogenic (tactile or sensory) sexual stimulation. 1. Male and Female Sexual Dysfunction. Seftel. 2004. Page 20

40. How Does an Erection Occur? • Stimulation of penile shaft sends signals to the nervous system • This leads to the secretion of nitric oxide (NO), and guanosine monophosphate (cGMP) both cause vasodilatation • Erectile tissues in the corpus cavernosa engorge with blood, and subsequently cause a penile erection. • Venous occlusion • Engorgement and erection

41. 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)

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

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

44. PDE5 Inhibitors • Blocking the enzyme that allows relaxation of the smooth muscles, resulting in erection • Only work if there is sexual stimulation 8. Culley C. Carson and Tom F. Lue. Phosphodiesterase type 5 inhibitors for erectile dysfunction. BJU International. 2005:96;257-280

45. 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

46. sildenafil (VIAGRA) • Viagra is the most popular of the PDE5 inhibitors. • Estimated it has worked for 20 million men worldwide. • Administered in 25, 50 and 100mg doses. • Taken 1 hour before sexual intercourse • Maximum dose is once daily • Window of opportunity: 30 minutes to 4-5 hrs. • But can be effective for up to 12 hrs. • side effects, such as: headache, facial flushing, dyspepsia, dizziness, rhinitis and abnormal vision.

47. Tadalafil (Cialis) • Oral dose can be administered daily either 10mg and 20mg doses • Take Tadalafil two hours before sexual intercourse • Its efficacy is maintained for at least 36 hours • Improved erections reported by 82.8% of treated men. • Side effects: headache, flushing, rhinitis and back pain/myalagia. • Safety concern: it also serves as an inhibitor of PDE11, an enzyme in the testes, so there is concern on the effect that it has on sperm and spermatogenesis

48. vardenafil (Levitra) • Administered orally in 5, 10 and 20mg doses • Maximum dose administration frequency is once daily. • There is a window of opportunity from 30 minutes to 4-5 hours after administration. Can work in just 10 minutes! • 75% success rate • Treatment with vardenafil in patients with erectile dysfunction that were previously unresponsive to sildenafil produced significant improvements in erectile function domain score and maintenance of an erection. • Side effects: headache, flushing and rhinitis

49. Eligibility criteria-1 dose per week (DoH 1998)

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