1294
ORIGINAL RESEARCH—MEN’S SEXUAL HEALTH Sexual Dysfunctions and Sexual Quality of Life in Men with Multiple Sclerosis Michal Lew-Starowicz, MD, PhD* and Rafal Rola, MD, PhD†‡ *III Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland; †I Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland; ‡Department of Human Physiology and Pathophysiology, The Medical University of Warsaw, Warsaw, Poland DOI: 10.1111/jsm.12474
ABSTRACT
Introduction. Multiple sclerosis (MS) is one of the most frequent diseases of the central nervous system and usually occurs at the age when people would be expected to be in the prime of their sexual lives. Clinicians working in this field commonly concentrate on the classical neurological deficits and often overlook symptoms that seriously affect the quality of life, such as sexual dysfunction (SD). Sexual functioning of MS patients remains poorly understood. Aim. The aim of this study was to assess the prevalence of SDs, their relationship with demographic factors, and sexual quality of life in men with multiple sclerosis (MS). Methods. Sixty-seven patients from the National Multiple Sclerosis Center were interviewed, completed the questionnaires, and underwent neurological assessment. Main Outcome Measures. Primary outcome measures included the International Index of Erectile Function (IIEF), the Sexual Quality of Life Questionnaire (SQoL), and the Expanded Disability Status Scale (EDSS). Results. The most common complaints were erectile dysfunction (52.9%), decreased sexual desire (26.8%), and difficulties in reaching orgasm (23.1%) or ejaculation (17.9%). The severity of SD had a clear impact on sexual quality of life, especially in the domains of erectile function and intercourse satisfaction. However, neither IIEF nor SQoL scores were correlated with age, time since onset of MS symptoms, or EDSS scores. Only 6% of the patients had ever discussed their concerns with a medical professional or undergone sexual therapy. Conclusions. SD is highly prevalent but commonly overlooked in MS patients and has a significant impact on their sexual quality of life. The data support a multifactorial etiology of SD in MS. More focus on SD and use of appropriate screening tools in clinical practice with MS patients are recommended. Lew-Starowicz M and Rola R. Sexual dysfunctions and sexual quality of life in men with multiple sclerosis. J Sex Med 2014;11:1294–1301. Key Words. Multiple Sclerosis; Male Sexual Health; Sexual Dysfunction; Quality of Life
Introduction
M
ultiple sclerosis (MS) is one of the most frequent diseases of the central nervous system and often leads to chronic disability [1]. It usually occurs in people between 20 and 50 years of age, that is, those who would be expected to be in the prime of sexual and reproductive life [2,3]. The traditional therapeutic approach among neurologists concentrates on the classical neurological deficits. Other symptoms interfering with quality of life are often ignored in routine clinical J Sex Med 2014;11:1294–1301
work. Such symptoms include sexual dysfunction (SD), a very important but often overlooked symptom of multiple sclerosis [4]. Although SD is not life-threatening, its occurrence can seriously affect the quality of life in these patients [5–7]. The causes of SD in MS are commonly divided into primary (disease-specific brain and spinal cord lesions), secondary (indirect physical impact, effect of fatigue, bladder and bowel dysfunction, spasticity, muscle weakness, and other physical disability), and tertiary (psychosocial aspects of chronic © 2014 International Society for Sexual Medicine
1295
Sexual Dysfunction in Men with Multiple Sclerosis disease, especially depression and couple issues) [8–11]. The literature on the prevalence of distinct types of SD in MS patients and their influence on the sexual quality of life as measured by validated clinimetric assessment methods remains scant. Most studies rely on very small groups of patients. According to a review article by Schmidt et al. [12], SDs are estimated to occur in between 64% and 91% of men with MS, erectile dysfunction (ED) being the most commonly reported (19–62%). Other, frequent complaints include decreased sexual desire, decreased sensation during sexual stimulation, and ejaculatory and orgasm dysfunction. Diagnosing SDs in MS men seems to be increasingly important, as effective methods to treat these conditions are available. Chao et al. found that intracavernosal therapy with trimix could be effective for neurogenic ED, including in MS patients [13]. More recently, studies on the promising efficacy of sildenafil and tadalafil have been published [14,15]. However, the efficacy of new treatments needs to be further investigated in this particular population [16]. According to Mattson et al., corticosteroid treatments that were started for problems other than SD resulted in improved sexual functioning in many MS patients. They also found that 43 of 60 patients who discussed sexual problems with their spouses and four of six who tried formal counseling found these courses of action helpful. This further supports the significance of nonpharmacological interventions for sexual problems in this particular group of patients [17]. The impact of level of disability and duration of illness on sexual function in men with MS remains unclear. Likewise, it is not known whether existing literature on the occurrence of SD in MS has had a sufficient impact among medical professionals working with this particular group to change the probability of the patient’s being properly diagnosed and treated. In a previous study, we assessed the prevalence of SD in women with MS [18]. We found that only 2.2% of the female patients had ever discussed their sexual or couple problems with a clinician. The aims of this study were to (i) evaluate the frequencies of particular types of SD in MS men and compare them with those in the general population, (ii) assess the relationships of SD with demographic factors and sexual quality of life, and (iii) investigate what proportion of patients had ever been checked or treated for SD.
Methods
All of the subjects were patients at the National Multiple Sclerosis Center in Dabek, Poland. The design of the study was approved by the local ethics committee. Only adult men with a definite diagnosis of MS who gave written informed consent were included in the study. Subsequently, patients were interviewed, completed the questionnaires, and underwent neurological assessment. MS diagnosis was established according to the McDonald diagnostic criteria for MS. These criteria require evidence for at least two episodes of neurological dysfunction with the involvement of two different brain regions and MRI confirmation of substantial numbers of demyelination foci in the central nervous system [19]. Sexual activity was defined as any activity that might lead to sexual arousal or sexual enjoyment that occurred during a 1-month period before admission to the rehabilitation center. It included sexual intercourse, caressing, and masturbation.
Demographics and Disease- and Treatment-Specific Variables Demographic data were obtained from semistructured interviews and medical chart reviews. Information was collected regarding age, onset of symptoms of MS, comorbidities, concomitant medications, and history of depression and how it had been treated if present. Sexual Functioning and Quality of Life Patients completed the International Index of Erectile Function (IIEF) and the Sexual Quality of Life Questionnaire—Male Version (SQoL-M). The IIEF is a commonly used multidimensional self-report instrument for the evaluation of male sexual function; it is the most widely used questionnaire worldwide for evaluation of erectile dysfunction (ED). A high degree of internal consistency and test–retest reliability has been demonstrated for the five domains separately and for the scale as a whole in validation studies [20–22]. The questionnaire is composed of 15 items, each graded on a 5- or 6-point Likert-type response scale, investigating five domains: erection, orgasm, desire, intercourse satisfaction, and overall satisfaction. For the erectile function domain, there are reference range scores: 1–10 indicates severe ED, 11–16 moderate ED, 17–21 mild to moderate ED, 22–25 mild ED, and 26–30 no ED. For the other domains, higher scores mean less SD (no standard reference cutoffs). J Sex Med 2014;11:1294–1301
1296 The SQoL-M is the men’s version of a questionnaire designed to measure the sexual quality of life. It contains 11 items, each graded on a 6-point Likert-type response scale with possible responses ranging from “completely agree” to “completely disagree.” Items are scored 1–6 (worst to best). The total raw score is further transformed according to a standardized scale of 0 to 100. Higher scores imply better quality of life. The questionnaire has very good internal consistency, as well as good test–retest reliability and convergent validity [23]. Data on the frequency of sexual activity and the prevalence of SD in MS patients were compared to those for the general population of Poles at the same age [24].
Neurological Assessment A neurological assessment using the Expanded Disability Status Scale (EDSS) was performed by an independent rater (neurologist) who did not have any knowledge of patients’ medical charts or the results of their sexual function evaluations. The assessment was performed according to the method originally described by Kurtzke [25]. The EDSS is the most frequently used scale when it comes to the assessment and quantification of symptom severity and physical functioning of patients with MS. The final score may range from 0 to 10, where 0 stands for normal functioning without any neurological deficits, and 10 represents “death due to MS” [25]. Statistical Analyses Statistical analysis was performed using Microsoft Excel 2010 for Windows and GraphPad InStat 3.06 for Windows. Frequencies were calculated for each variable. Data are presented as means and standard deviation. Measured values with normal (Gaussian) distributions were compared using Student’s t-test and anova as appropriate, followed by Tukey post hoc tests. Values that were not normally distributed were compared by nonparametric tests—the Mann–Whitney U-test and Kruskal–Wallis test, followed by a Dunn post hoc test. Correlations were performed using a linear regression model with a runs test for departure from linearity. Statistical significance was determined based on P values 0.05). Physical comorbidities were found in 38.8% of patients; the most common were arterial hypertension (13.4%), osteoarthritis (6.0%), and urinary incontinence (4.5%). More than one-fourth of patients (26.9%) were receiving immunomodulative therapy (interferon, glatiramer acetate, natalizumab, or azathioprine). Depression had previously been diagnosed in 18%, and 15% had been treated with antidepressants. Only 6% of patients had ever been diagnosed with or treated for SD. Nearly all men (98.5%) were heterosexual, and 71.2% were living in stable relationships. Typical frequency of sexual intercourse is presented in Figure 1. Masturbation was reported by 23.9% of patients.
Sexual Function IIEF domain scores and selected items are presented in Tables 1 and 2. ED was found in 52.9% of patients; 11.8% had mild ED, 11.8% mild to moderate ED, 17.6% moderate ED, and 11.8% severe ED. For 40.5% of men, erections were not hard enough for penetration during at least half of intercourse attempts, and 54.6% experienced difficulties in maintaining an erection to the com-
Results
Sixty-seven men completed the study. Mean age was 49.9 years (range 29–72, median 51.0), and J Sex Med 2014;11:1294–1301
Figure 1 Frequency of intercourse in men with MS.
1297
Sexual Dysfunction in Men with Multiple Sclerosis Table 1
Sexual function in men with MS measured by IIEF score IIEF dimension
Measure
Erectile function
Orgasmic function
Sexual desire
Intercourse satisfaction
Overall satisfaction
Total score
Mean SD SE 95% CI Median n
21.7 7.6 1.3 19.0–24.3 24.5 34
7.9 2.6 0.4 7.0–8.7 9.0 39
6.2 2.2 0.26 5.6–6.7 6.0 67
9.7 2.9 0.51 8.7–10.8 10.0 32
6.3 2.8 0.44 5.4–7.2 7.0 41
56.5 11.8 2.15 52.1–60.9 60.0 30
pletion of intercourse. Hypoactive sexual desire (defined as feeling sexual desire on few occasions, almost never, or never) was reported by 26.8% of patients. Inability to ejaculate was reported by 17.9%, and 23.1% had not had an orgasm during sexual stimulation on the majority of occasions during the past 4 weeks. About equal proportions of patients were dissatisfied (43.1%) and satisfied (41.6%) about their overall sexual life, 15.4%
Table 2
being neutral. There was no correlation between scores in particular IIEF domains and time since the onset of MS or EDSS score. Only in the overall satisfaction domain of the IIEF did patients with disease duration of 10 years or fewer score significantly higher than the others (7.5 vs. 5.6, respectively; P < 0.05, Mann–Whitney Test). Of the IIEF domains, only the desire domain was correlated with age (r = –0.25, P = 0.038; linear
Responses to selected IIEF questions by men with MS
Question
Response options
Percentage (n)
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
No sexual stimulation Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always/always
9.5% (4) 11.9% (5) 14.3% (6) 14.3% (6) 9.5% (4) 40.5% (17)
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
Did not attempt intercourse Extremely difficult Very difficult Difficult Slightly difficult Not difficult
16.6% (7) 14.3% (6) 7.1% (3) 16.6% (7) 16.6% (7) 28.6% (12)
Over the past 4 weeks, when you had sexual stimulation or intercourse how often did you ejaculate?
Did not attempt intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (more than half the time) Almost always or always
11.4% (5) 9.1% (4) 6.8% (3) 9.1% (4) 11.4% (5) 52.3% (23)
Over the past 4 weeks, when you had sexual stimulation or intercourse how often did you have the feeling of orgasm or climax (with or without ejaculation)?
No sexual stimulation or intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always
11.4% (5) 6.8% (3) 13.6% (6) 13.6% (6) 4.5% (2) 50.0% (22)
Over the past 4 weeks, how often have you felt sexual desire?
Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always
11.9% (8) 14.9% (10) 28.4% (19) 29.9% (20) 14.9% (10)
Over the past 4 weeks, how satisfied have you been with you overall sex life?
Very dissatisfied Moderately dissatisfied About equally satisfied and dissatisfied Moderately satisfied Very satisfied
35.4% (23) 7.7% (5) 15.4% (10) 26.2% (17) 15.4% (10)
J Sex Med 2014;11:1294–1301
1298
J Sex Med 2014;11:1294–1301
17.2% (11) 15.4% (10) 15.6% (10) 20.0% (13) 12.5% (8) 16.9% (11) 9.4% (6) 20.0% (13) 18.5% (12) 23.4% (15) 13.8% (9) 7.8% (5) 12.3% (8) 7.8% (5) 6.2% (4) 7.8% (5) 6.2% (4) 7.8% (5) 7.7% (5) 10.8% (7) 12.5% (8) 6.2% (4) 23.4% (15) 13.8% (9) 17.2% (11) 16.9% (11) 17.2% (11) 13.8% (9) 20.3% (13) 12.3% (8) 9.2% (6) 7.8% (5) 13.8% (9) 17.2% (11) 15.4% (10) 23.4% (15) 23.1% (15) 17.2% (11) 21.5% (14) 26.6% (17) 18.5% (12) 15.4% (10) 15.6% (10) 27.7% (18) When I think about my sexual life, I feel frustrated When I think about my sexual life, I feel depressed When I think about my sexual life, I feel like less of a man I have lost confidence in myself as a sexual partner When I think about my sexual life, I feel anxious When I think about my sexual life, I feel angry I worry about the future of my sexual life When I think about my sexual life, I am embarrassed When I think about my sexual life, I feel guilty When I think about my sexual life, I worry that my partner feels hurt or rejected When I think about my sexual life, I feel like I have lost something
Data are given as percentage (n).
Completely agree
Table 3
Multiple sclerosis leads to a significant deterioration in the sexual lives of men. Our study contributes to the field, understudied in the literature, of the prevalence of SDs and their impact on the sexual quality of life in men with MS. Twenty percent of men with MS had had more than one sexual intercourse per week in the previous month, and the most common frequency was from once a month to once a week (55%). In comparison, 35% of men in Poland (general population) have sexual intercourse more than once a week, and 52% have it from once a month to once a week [24]. The prevalence of particular SDs was significantly higher in our group than in the general population [24]: 52.9% vs. 8.0% for ED (33.3% vs. 2.9% in patients
ORIGINAL RESEARCH—MEN’S SEXUAL HEALTH Sexual Dysfunctions and Sexual Quality of Life in Men with Multiple Sclerosis Michal Lew-Starowicz, MD, PhD* and Rafal Rola, MD, PhD†‡ *III Department of Psychiatry, Institute of Psychiatry and Neurology, Warsaw, Poland; †I Department of Neurology, Institute of Psychiatry and Neurology, Warsaw, Poland; ‡Department of Human Physiology and Pathophysiology, The Medical University of Warsaw, Warsaw, Poland DOI: 10.1111/jsm.12474
ABSTRACT
Introduction. Multiple sclerosis (MS) is one of the most frequent diseases of the central nervous system and usually occurs at the age when people would be expected to be in the prime of their sexual lives. Clinicians working in this field commonly concentrate on the classical neurological deficits and often overlook symptoms that seriously affect the quality of life, such as sexual dysfunction (SD). Sexual functioning of MS patients remains poorly understood. Aim. The aim of this study was to assess the prevalence of SDs, their relationship with demographic factors, and sexual quality of life in men with multiple sclerosis (MS). Methods. Sixty-seven patients from the National Multiple Sclerosis Center were interviewed, completed the questionnaires, and underwent neurological assessment. Main Outcome Measures. Primary outcome measures included the International Index of Erectile Function (IIEF), the Sexual Quality of Life Questionnaire (SQoL), and the Expanded Disability Status Scale (EDSS). Results. The most common complaints were erectile dysfunction (52.9%), decreased sexual desire (26.8%), and difficulties in reaching orgasm (23.1%) or ejaculation (17.9%). The severity of SD had a clear impact on sexual quality of life, especially in the domains of erectile function and intercourse satisfaction. However, neither IIEF nor SQoL scores were correlated with age, time since onset of MS symptoms, or EDSS scores. Only 6% of the patients had ever discussed their concerns with a medical professional or undergone sexual therapy. Conclusions. SD is highly prevalent but commonly overlooked in MS patients and has a significant impact on their sexual quality of life. The data support a multifactorial etiology of SD in MS. More focus on SD and use of appropriate screening tools in clinical practice with MS patients are recommended. Lew-Starowicz M and Rola R. Sexual dysfunctions and sexual quality of life in men with multiple sclerosis. J Sex Med 2014;11:1294–1301. Key Words. Multiple Sclerosis; Male Sexual Health; Sexual Dysfunction; Quality of Life
Introduction
M
ultiple sclerosis (MS) is one of the most frequent diseases of the central nervous system and often leads to chronic disability [1]. It usually occurs in people between 20 and 50 years of age, that is, those who would be expected to be in the prime of sexual and reproductive life [2,3]. The traditional therapeutic approach among neurologists concentrates on the classical neurological deficits. Other symptoms interfering with quality of life are often ignored in routine clinical J Sex Med 2014;11:1294–1301
work. Such symptoms include sexual dysfunction (SD), a very important but often overlooked symptom of multiple sclerosis [4]. Although SD is not life-threatening, its occurrence can seriously affect the quality of life in these patients [5–7]. The causes of SD in MS are commonly divided into primary (disease-specific brain and spinal cord lesions), secondary (indirect physical impact, effect of fatigue, bladder and bowel dysfunction, spasticity, muscle weakness, and other physical disability), and tertiary (psychosocial aspects of chronic © 2014 International Society for Sexual Medicine
1295
Sexual Dysfunction in Men with Multiple Sclerosis disease, especially depression and couple issues) [8–11]. The literature on the prevalence of distinct types of SD in MS patients and their influence on the sexual quality of life as measured by validated clinimetric assessment methods remains scant. Most studies rely on very small groups of patients. According to a review article by Schmidt et al. [12], SDs are estimated to occur in between 64% and 91% of men with MS, erectile dysfunction (ED) being the most commonly reported (19–62%). Other, frequent complaints include decreased sexual desire, decreased sensation during sexual stimulation, and ejaculatory and orgasm dysfunction. Diagnosing SDs in MS men seems to be increasingly important, as effective methods to treat these conditions are available. Chao et al. found that intracavernosal therapy with trimix could be effective for neurogenic ED, including in MS patients [13]. More recently, studies on the promising efficacy of sildenafil and tadalafil have been published [14,15]. However, the efficacy of new treatments needs to be further investigated in this particular population [16]. According to Mattson et al., corticosteroid treatments that were started for problems other than SD resulted in improved sexual functioning in many MS patients. They also found that 43 of 60 patients who discussed sexual problems with their spouses and four of six who tried formal counseling found these courses of action helpful. This further supports the significance of nonpharmacological interventions for sexual problems in this particular group of patients [17]. The impact of level of disability and duration of illness on sexual function in men with MS remains unclear. Likewise, it is not known whether existing literature on the occurrence of SD in MS has had a sufficient impact among medical professionals working with this particular group to change the probability of the patient’s being properly diagnosed and treated. In a previous study, we assessed the prevalence of SD in women with MS [18]. We found that only 2.2% of the female patients had ever discussed their sexual or couple problems with a clinician. The aims of this study were to (i) evaluate the frequencies of particular types of SD in MS men and compare them with those in the general population, (ii) assess the relationships of SD with demographic factors and sexual quality of life, and (iii) investigate what proportion of patients had ever been checked or treated for SD.
Methods
All of the subjects were patients at the National Multiple Sclerosis Center in Dabek, Poland. The design of the study was approved by the local ethics committee. Only adult men with a definite diagnosis of MS who gave written informed consent were included in the study. Subsequently, patients were interviewed, completed the questionnaires, and underwent neurological assessment. MS diagnosis was established according to the McDonald diagnostic criteria for MS. These criteria require evidence for at least two episodes of neurological dysfunction with the involvement of two different brain regions and MRI confirmation of substantial numbers of demyelination foci in the central nervous system [19]. Sexual activity was defined as any activity that might lead to sexual arousal or sexual enjoyment that occurred during a 1-month period before admission to the rehabilitation center. It included sexual intercourse, caressing, and masturbation.
Demographics and Disease- and Treatment-Specific Variables Demographic data were obtained from semistructured interviews and medical chart reviews. Information was collected regarding age, onset of symptoms of MS, comorbidities, concomitant medications, and history of depression and how it had been treated if present. Sexual Functioning and Quality of Life Patients completed the International Index of Erectile Function (IIEF) and the Sexual Quality of Life Questionnaire—Male Version (SQoL-M). The IIEF is a commonly used multidimensional self-report instrument for the evaluation of male sexual function; it is the most widely used questionnaire worldwide for evaluation of erectile dysfunction (ED). A high degree of internal consistency and test–retest reliability has been demonstrated for the five domains separately and for the scale as a whole in validation studies [20–22]. The questionnaire is composed of 15 items, each graded on a 5- or 6-point Likert-type response scale, investigating five domains: erection, orgasm, desire, intercourse satisfaction, and overall satisfaction. For the erectile function domain, there are reference range scores: 1–10 indicates severe ED, 11–16 moderate ED, 17–21 mild to moderate ED, 22–25 mild ED, and 26–30 no ED. For the other domains, higher scores mean less SD (no standard reference cutoffs). J Sex Med 2014;11:1294–1301
1296 The SQoL-M is the men’s version of a questionnaire designed to measure the sexual quality of life. It contains 11 items, each graded on a 6-point Likert-type response scale with possible responses ranging from “completely agree” to “completely disagree.” Items are scored 1–6 (worst to best). The total raw score is further transformed according to a standardized scale of 0 to 100. Higher scores imply better quality of life. The questionnaire has very good internal consistency, as well as good test–retest reliability and convergent validity [23]. Data on the frequency of sexual activity and the prevalence of SD in MS patients were compared to those for the general population of Poles at the same age [24].
Neurological Assessment A neurological assessment using the Expanded Disability Status Scale (EDSS) was performed by an independent rater (neurologist) who did not have any knowledge of patients’ medical charts or the results of their sexual function evaluations. The assessment was performed according to the method originally described by Kurtzke [25]. The EDSS is the most frequently used scale when it comes to the assessment and quantification of symptom severity and physical functioning of patients with MS. The final score may range from 0 to 10, where 0 stands for normal functioning without any neurological deficits, and 10 represents “death due to MS” [25]. Statistical Analyses Statistical analysis was performed using Microsoft Excel 2010 for Windows and GraphPad InStat 3.06 for Windows. Frequencies were calculated for each variable. Data are presented as means and standard deviation. Measured values with normal (Gaussian) distributions were compared using Student’s t-test and anova as appropriate, followed by Tukey post hoc tests. Values that were not normally distributed were compared by nonparametric tests—the Mann–Whitney U-test and Kruskal–Wallis test, followed by a Dunn post hoc test. Correlations were performed using a linear regression model with a runs test for departure from linearity. Statistical significance was determined based on P values 0.05). Physical comorbidities were found in 38.8% of patients; the most common were arterial hypertension (13.4%), osteoarthritis (6.0%), and urinary incontinence (4.5%). More than one-fourth of patients (26.9%) were receiving immunomodulative therapy (interferon, glatiramer acetate, natalizumab, or azathioprine). Depression had previously been diagnosed in 18%, and 15% had been treated with antidepressants. Only 6% of patients had ever been diagnosed with or treated for SD. Nearly all men (98.5%) were heterosexual, and 71.2% were living in stable relationships. Typical frequency of sexual intercourse is presented in Figure 1. Masturbation was reported by 23.9% of patients.
Sexual Function IIEF domain scores and selected items are presented in Tables 1 and 2. ED was found in 52.9% of patients; 11.8% had mild ED, 11.8% mild to moderate ED, 17.6% moderate ED, and 11.8% severe ED. For 40.5% of men, erections were not hard enough for penetration during at least half of intercourse attempts, and 54.6% experienced difficulties in maintaining an erection to the com-
Results
Sixty-seven men completed the study. Mean age was 49.9 years (range 29–72, median 51.0), and J Sex Med 2014;11:1294–1301
Figure 1 Frequency of intercourse in men with MS.
1297
Sexual Dysfunction in Men with Multiple Sclerosis Table 1
Sexual function in men with MS measured by IIEF score IIEF dimension
Measure
Erectile function
Orgasmic function
Sexual desire
Intercourse satisfaction
Overall satisfaction
Total score
Mean SD SE 95% CI Median n
21.7 7.6 1.3 19.0–24.3 24.5 34
7.9 2.6 0.4 7.0–8.7 9.0 39
6.2 2.2 0.26 5.6–6.7 6.0 67
9.7 2.9 0.51 8.7–10.8 10.0 32
6.3 2.8 0.44 5.4–7.2 7.0 41
56.5 11.8 2.15 52.1–60.9 60.0 30
pletion of intercourse. Hypoactive sexual desire (defined as feeling sexual desire on few occasions, almost never, or never) was reported by 26.8% of patients. Inability to ejaculate was reported by 17.9%, and 23.1% had not had an orgasm during sexual stimulation on the majority of occasions during the past 4 weeks. About equal proportions of patients were dissatisfied (43.1%) and satisfied (41.6%) about their overall sexual life, 15.4%
Table 2
being neutral. There was no correlation between scores in particular IIEF domains and time since the onset of MS or EDSS score. Only in the overall satisfaction domain of the IIEF did patients with disease duration of 10 years or fewer score significantly higher than the others (7.5 vs. 5.6, respectively; P < 0.05, Mann–Whitney Test). Of the IIEF domains, only the desire domain was correlated with age (r = –0.25, P = 0.038; linear
Responses to selected IIEF questions by men with MS
Question
Response options
Percentage (n)
When you had erections with sexual stimulation, how often were your erections hard enough for penetration?
No sexual stimulation Almost never/never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always/always
9.5% (4) 11.9% (5) 14.3% (6) 14.3% (6) 9.5% (4) 40.5% (17)
During sexual intercourse, how difficult was it to maintain your erection to completion of intercourse?
Did not attempt intercourse Extremely difficult Very difficult Difficult Slightly difficult Not difficult
16.6% (7) 14.3% (6) 7.1% (3) 16.6% (7) 16.6% (7) 28.6% (12)
Over the past 4 weeks, when you had sexual stimulation or intercourse how often did you ejaculate?
Did not attempt intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (more than half the time) Almost always or always
11.4% (5) 9.1% (4) 6.8% (3) 9.1% (4) 11.4% (5) 52.3% (23)
Over the past 4 weeks, when you had sexual stimulation or intercourse how often did you have the feeling of orgasm or climax (with or without ejaculation)?
No sexual stimulation or intercourse Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always
11.4% (5) 6.8% (3) 13.6% (6) 13.6% (6) 4.5% (2) 50.0% (22)
Over the past 4 weeks, how often have you felt sexual desire?
Almost never or never A few times (much less than half the time) Sometimes (about half the time) Most times (much more than half the time) Almost always or always
11.9% (8) 14.9% (10) 28.4% (19) 29.9% (20) 14.9% (10)
Over the past 4 weeks, how satisfied have you been with you overall sex life?
Very dissatisfied Moderately dissatisfied About equally satisfied and dissatisfied Moderately satisfied Very satisfied
35.4% (23) 7.7% (5) 15.4% (10) 26.2% (17) 15.4% (10)
J Sex Med 2014;11:1294–1301
1298
J Sex Med 2014;11:1294–1301
17.2% (11) 15.4% (10) 15.6% (10) 20.0% (13) 12.5% (8) 16.9% (11) 9.4% (6) 20.0% (13) 18.5% (12) 23.4% (15) 13.8% (9) 7.8% (5) 12.3% (8) 7.8% (5) 6.2% (4) 7.8% (5) 6.2% (4) 7.8% (5) 7.7% (5) 10.8% (7) 12.5% (8) 6.2% (4) 23.4% (15) 13.8% (9) 17.2% (11) 16.9% (11) 17.2% (11) 13.8% (9) 20.3% (13) 12.3% (8) 9.2% (6) 7.8% (5) 13.8% (9) 17.2% (11) 15.4% (10) 23.4% (15) 23.1% (15) 17.2% (11) 21.5% (14) 26.6% (17) 18.5% (12) 15.4% (10) 15.6% (10) 27.7% (18) When I think about my sexual life, I feel frustrated When I think about my sexual life, I feel depressed When I think about my sexual life, I feel like less of a man I have lost confidence in myself as a sexual partner When I think about my sexual life, I feel anxious When I think about my sexual life, I feel angry I worry about the future of my sexual life When I think about my sexual life, I am embarrassed When I think about my sexual life, I feel guilty When I think about my sexual life, I worry that my partner feels hurt or rejected When I think about my sexual life, I feel like I have lost something
Data are given as percentage (n).
Completely agree
Table 3
Multiple sclerosis leads to a significant deterioration in the sexual lives of men. Our study contributes to the field, understudied in the literature, of the prevalence of SDs and their impact on the sexual quality of life in men with MS. Twenty percent of men with MS had had more than one sexual intercourse per week in the previous month, and the most common frequency was from once a month to once a week (55%). In comparison, 35% of men in Poland (general population) have sexual intercourse more than once a week, and 52% have it from once a month to once a week [24]. The prevalence of particular SDs was significantly higher in our group than in the general population [24]: 52.9% vs. 8.0% for ED (33.3% vs. 2.9% in patients
