J Chron Dis 1976, Vol. 29, pp. 643-647. Pergamon Press. Printed in Great Britain
SEXUAL PROBLEMS IN PATIENTS SUFFERING FROM MULTIPLE SCLEROSIS H. G. LILIUS, ERKKI J. VALT~NEN and JUHANI WIKSTB~M Departments of Physical Medicine and Neurology. University Central Hospital. Helsinki, Finland (Received
6 April 1975)
Abstract-A questionnaire which allowed anonymous answering and which included also a lot of other questions besides those dealing with sexual life was sent to 302 patients suffering from multiple sclerosis (MS). The sexual life was changed in 91% of males and in 72”/, of females. About half of the patients reported to have either an unsatisfied or ceased sexual life. The patients were as a rule in a relative poor physical condition. In males the disturbances in erection (62%) were the most common problems. Erection was normal only in 20% of the males. In females the essential figures were: loss of orgasm in 33%, loss of libido in 27x, and spasticity in 12%. There was no correlation between the incidence of sexual disturbances and the duration of MS. It seems that the neurological disturbances in sexual life appear together with symptoms of spinal origin. Some compensatory methods of maintaining the sexual intercourse are discussed.
disturbances are very common and early symptoms, although seldom complained of, by patients suffering from multiple sclerosis (MS). Ivera and Goldstein [l] found that 26% of the male patients were impotent and in 3% of the cases the impotence was a principal symptom of the disease. Vas [3] observed that 47% of his male patients had some impairment of erection in spite of the absence of marked neurological disability. He suggested the impotence to be caused by a lesion of the spinal cord in its lateral horn or in the connecting pathways in the dorsolumbal area. He also found a decrease in the amount of circulating testosterone in patients suffering from the impotence. The concept of the impotence generally includes among other things, weak erection or inability to gain erection, premature ejaculation, loss of sensation in spite of the normal ejaculation, and loss of libido. Various degrees of impotence are quite common. Kinsey et al. [2] suggested that 6.7% of normal men up to 54 yr were impotent. Very seldom is there any organic cause of the impotence to be found. Therefore, in most cases, it must be considered psychogenic and based on guilt, anxiety, strained physical condition, jealousy, or frigidity of the wife. In literature there is a lack of detailed reports dealing with the sexual problems of patients suffering from MS. Because only the exact knowledge about the troubles SEXUAL
643
H. G. LILIUS, ERKKI J. VALTONEN and JUHANI WIKSTRBM
644
caused by this
to understand of investigation.
A questionnaire lot of
which allowed anonymous
answering and which included also to 302 of the in every of of Neurology, of Helsinki.
MS association of Helsinki. in the
I. DISTRIBUTION BY AGE AND SEX
Age (Yr)
Total
Males
Cases
(%)
Cases
Females Cases (%)
(%I
17720
2
0.7
0
0.0
2
1.5
21-30 3140 41-50 51-60
48 74 111 14
19.3 29.8 44.6 5.6
13 36 54 12
11.3 31.3 47.0 10.4
35 38 57 2
26.1 28.4 42.5 1.5
Total
249
100.0
115
100.0
134
100.0
TABLE 2. DURATION OF THE DISEASE Duration of the disease
I-2 yr 3-5 6-9 IO-20 over 20 Total
Cases
Per cent
15 36 54 113 31
5.9 14.2 21.4 45.9 12.6
249
100.0
TABLE 3. NEUROLOGICAL CHARACTERIZATION OF THE PATIENTS.THE PERCENTAGEOCCURRENCEOF SOME SYMPTOMS AND DISTURBANCES
Symptom
or disturbance
Pyramidal tract disturbances -upper extremities -lower extremities Incontinence Visual disturbances Sensory disturbances Vertigo Diplopia Dysarthria Intention tremor Locomotion: -cane or crutches -wheelchair -no walking aids needed
Percentage in 81 94 78 73 67 66 47 46 41 30 27 33
645
Sexual Problems in Patients Suffering from Multiple Sclerosis
Two hundred and forty-nine patients answered all the questions in the questionnaire. Fifty-three patients (nine men and 44 women) (17.5%) did not answer the questions dealing with sexual life. Nine of the women were unmarried, twelve were 61-70 yr old, and 29 of the women as well as the nine male patients were in a very poor physical condition. In this group of patients there were also 27 divorcees, and in every case the divorce had occurred during the disease. The age and sex distribution of the 249 patients (115 males and 134 females) is presented in Table 1 and the duration of the disease is presented in Table 2. On the basis of the numerous questions, also the neurological condition of the patients could be clarified to a large extent. The most essential neurological data of the patients are presented in Table 3. RESULTS
sexes. The sexual life in general as shown in Table 4 was changed in 91% of the male patients. The figures of the females were somewhat better. Sexual life in general was changed in 72% of female patients. About half (52x, 128 cases) of the 249 patients of this series reported to have either an unsatisfied or finished sexual life. The figure was 64% in males and 39% in females. On the other hand, the patients with unsatisfied or finished sexual life were as a rule in relatively poor physical condition. One fifth of them (19x, 25 cases) were bedridden, and 60% (76 cases) had various grave disturbances, e.g. 35 of them could walk only by the aid of crutches. The duration of the disease in this group had lasted for 4-14 yr. The remaining 21% (27 cases, 14 males and 13 females) were, however, in relatively good physical condition. Nevertheless the Both
TABLET. SEXUAI. LIFE IN GENERAL OF 115 MALES AND 134 FEMALES SUFFERING FROM
MS
Unchanged Fairly good Unsatisfied Finished Total
TABLE
5. THE
Males percentage
Females percentage
9 27 34 30
28 33 20 19
too
100
PRESENT SITUATION OF THE SEXUAL LIFE OF 115 MALES SUFFERING FROM MS. PERCENTAGE DISTRIBUTION OF SOME DETAILS
Interest in sexual intercourse
Satisfaction with sexual intercourse
Frequency of sexual intercourse
Unchanged Increased Decreased Finished
41 3 34 22
34 1 35 30
19 I 50 30
20 0 50 30
Total
100
100
100
100
Erection
H. G. LILIUS, ERKKI J. VALTONEN and JUHANI WIKSTR~~M
646
males had disturbances in erection and the females in orgasm and libido. In this group a third of the patients had suffered from MS 6-9 yr and the remainder, a shorter time. Males. The present situation of the sexual life of 115 males suffering from MS is shown in Table 5. As can be seen, sexual life in general was changed in 91% of the cases. It was unsatisfied or finished in 64%. The interest in sexual intercourse was unchanged in 41’/& decreased in 34’/& and finished in 22%. Erection was unchanged only in 20% and ejaculation in 23%. The percentage distribution of the main problems of 75 males with unsatisfied or extinct sexual life are presented in Table 7. Disturbance in erection is the most common problem, being 62% of the total. TABLE 6. THE PRESENTSITUATION OF THE SEXUAL LIFE OF 134 FEMALESSUFFERINGFROM MS. PERCENTAGE DISTRIBUTION OF SOME DETAILS Interest in sexual intercourse
Satisfaction with sexual intercourse
Frequency of sexual intercourse
Sensitivity of the clitoris
Achieving of the orgasm
Unchanged Increased Decreased Finished
52 6 25 17
44 6 31 19
34 4 43 19
45 6 30 19
37 6 28 29
Total
100
100
100
100
100
TABLE 7. PERCENTAGE DISTRIBUTTONOF THE MAIN PROBLEM OF 75 MALES WITH UNSATISFIED OR FINISHED SEXUAL LIFE Loss of erection Weak erection Weakness of the body muscles Spasticity Frigidity of the wife Periodical loss of erection Premature ejaculation The wife’s incapability to understand the reduced potence Insensitivity of the glans penis The wife must act as the active partner Lack of partner Total
48 9 9 8 6 5 4 4 3 3
1 100
TABLE 8. PERCENTAGE DISTRIBUTION OF THE MAIN PROBLEM OF 53 FEMALESWITH UNSATISFIED OR FINISHED SEXUAL LIFE Loss of orgasm Loss of libido Spasticity The husband’s refusal from sexual intercourse Weakness of the body muscles Lack of sexual partner Dryness of the vagina Total
33 27 12 9 9 5 5 loo
Sexual Problems in Patients Suffering from Multiple Sclerosis
647
Females. The present situation of sexual life of the 134 females suffering from MS is presented in Table 6. The figures are somewhat better than those of males. Sexual life in general was changed in 72% of the cases. The interest in sexual intercourse and satisfaction with sexual intercourse were unchanged in 52 and 44% respectively. The percentage distribution of the main problems of 53 females with unsatisfied or finished sexual life are shown in Table 8. Loss of orgasm (33%) loss of libido (27x), and spasticity (12%) are the most common problems. DISCUSSION
The members of the MS society of Helsinki are as a rule in an advanced stage of the disease. Patients with mild symptoms take an awaiting attitude to the membership of the society. Therefore, in this series patients with severe symptoms dominate. A successful sexual life is of great importance for everybody. The results obtained in this study show that this part of life is greatly changed in patients suffering from MS. The most important cause of impotence in MS is, according to Vas [3] a lesion of the lateral horns in the lumbar cord and perhaps in some cases deficiency of circulating testosterone. In normal population the cause of impotence and loss of libido will be found in psychogenic factors. These, of course, also play a certain role in the sexual disturbances of MS patients. The occurrence of pyramidal tract symptoms (94%) and bladder dysfunction (78%) were of equal frequency as the sexual disturbances (91%) as shown in Tables 3 and 4. There was no correlation between the incidence of sexual disturbances and the duration of the disease. It seems that the sexual disturbances advance with other neurological symptoms of spinal origin. In about 40% of the cases with difficulties in sexual life, we can help the patients in some detail. This includes, as shown in Tables 7 and 8, decreasing of spasticity with drugs, muscle training, and information of the healthy consort of the disease. The most important problem is loss of erection. In these cases it is possible to instruct the patients in some compensatory methods of sexual intercourse. These include the use of a penis-prosthesis and in some cases a plastic prosthesis can be implanted operatively in the penis in order to afford a continuous erection. In about half of the cases, the interest in sexual intercourse was decreased or finished. On the other hand, it was increased in 3% of the males and in 6% of the females. Of these reasons it is obvious that in many cases the other partner suffers more from the disturbances in sexual life than the patient does. Therefore, it is important to inform also the healthy partner of compensatory methods in sexual intercourse. This can in some cases help in overcoming the difficulties. REFERENCES 1. Ivers RR, Goldstein NP: Multiple sclerosis: A current appraisal of symptoms and signs, Proc Mayo Clinic 38: 457-466, 1963 2. Kinsey AC, Pomerey WB, Martin CE: Sexual Behaviour in the Human Male. Philadelphia: Saunders, 1948 3. Vas CJ: Sexual impotence and some autonomic disturbances in men with multiple sclerosis. Acta Neural Stand 45
: 166-l 82, 1969
SEXUAL PROBLEMS IN PATIENTS SUFFERING FROM MULTIPLE SCLEROSIS H. G. LILIUS, ERKKI J. VALT~NEN and JUHANI WIKSTB~M Departments of Physical Medicine and Neurology. University Central Hospital. Helsinki, Finland (Received
6 April 1975)
Abstract-A questionnaire which allowed anonymous answering and which included also a lot of other questions besides those dealing with sexual life was sent to 302 patients suffering from multiple sclerosis (MS). The sexual life was changed in 91% of males and in 72”/, of females. About half of the patients reported to have either an unsatisfied or ceased sexual life. The patients were as a rule in a relative poor physical condition. In males the disturbances in erection (62%) were the most common problems. Erection was normal only in 20% of the males. In females the essential figures were: loss of orgasm in 33%, loss of libido in 27x, and spasticity in 12%. There was no correlation between the incidence of sexual disturbances and the duration of MS. It seems that the neurological disturbances in sexual life appear together with symptoms of spinal origin. Some compensatory methods of maintaining the sexual intercourse are discussed.
disturbances are very common and early symptoms, although seldom complained of, by patients suffering from multiple sclerosis (MS). Ivera and Goldstein [l] found that 26% of the male patients were impotent and in 3% of the cases the impotence was a principal symptom of the disease. Vas [3] observed that 47% of his male patients had some impairment of erection in spite of the absence of marked neurological disability. He suggested the impotence to be caused by a lesion of the spinal cord in its lateral horn or in the connecting pathways in the dorsolumbal area. He also found a decrease in the amount of circulating testosterone in patients suffering from the impotence. The concept of the impotence generally includes among other things, weak erection or inability to gain erection, premature ejaculation, loss of sensation in spite of the normal ejaculation, and loss of libido. Various degrees of impotence are quite common. Kinsey et al. [2] suggested that 6.7% of normal men up to 54 yr were impotent. Very seldom is there any organic cause of the impotence to be found. Therefore, in most cases, it must be considered psychogenic and based on guilt, anxiety, strained physical condition, jealousy, or frigidity of the wife. In literature there is a lack of detailed reports dealing with the sexual problems of patients suffering from MS. Because only the exact knowledge about the troubles SEXUAL
643
H. G. LILIUS, ERKKI J. VALTONEN and JUHANI WIKSTRBM
644
caused by this
to understand of investigation.
A questionnaire lot of
which allowed anonymous
answering and which included also to 302 of the in every of of Neurology, of Helsinki.
MS association of Helsinki. in the
I. DISTRIBUTION BY AGE AND SEX
Age (Yr)
Total
Males
Cases
(%)
Cases
Females Cases (%)
(%I
17720
2
0.7
0
0.0
2
1.5
21-30 3140 41-50 51-60
48 74 111 14
19.3 29.8 44.6 5.6
13 36 54 12
11.3 31.3 47.0 10.4
35 38 57 2
26.1 28.4 42.5 1.5
Total
249
100.0
115
100.0
134
100.0
TABLE 2. DURATION OF THE DISEASE Duration of the disease
I-2 yr 3-5 6-9 IO-20 over 20 Total
Cases
Per cent
15 36 54 113 31
5.9 14.2 21.4 45.9 12.6
249
100.0
TABLE 3. NEUROLOGICAL CHARACTERIZATION OF THE PATIENTS.THE PERCENTAGEOCCURRENCEOF SOME SYMPTOMS AND DISTURBANCES
Symptom
or disturbance
Pyramidal tract disturbances -upper extremities -lower extremities Incontinence Visual disturbances Sensory disturbances Vertigo Diplopia Dysarthria Intention tremor Locomotion: -cane or crutches -wheelchair -no walking aids needed
Percentage in 81 94 78 73 67 66 47 46 41 30 27 33
645
Sexual Problems in Patients Suffering from Multiple Sclerosis
Two hundred and forty-nine patients answered all the questions in the questionnaire. Fifty-three patients (nine men and 44 women) (17.5%) did not answer the questions dealing with sexual life. Nine of the women were unmarried, twelve were 61-70 yr old, and 29 of the women as well as the nine male patients were in a very poor physical condition. In this group of patients there were also 27 divorcees, and in every case the divorce had occurred during the disease. The age and sex distribution of the 249 patients (115 males and 134 females) is presented in Table 1 and the duration of the disease is presented in Table 2. On the basis of the numerous questions, also the neurological condition of the patients could be clarified to a large extent. The most essential neurological data of the patients are presented in Table 3. RESULTS
sexes. The sexual life in general as shown in Table 4 was changed in 91% of the male patients. The figures of the females were somewhat better. Sexual life in general was changed in 72% of female patients. About half (52x, 128 cases) of the 249 patients of this series reported to have either an unsatisfied or finished sexual life. The figure was 64% in males and 39% in females. On the other hand, the patients with unsatisfied or finished sexual life were as a rule in relatively poor physical condition. One fifth of them (19x, 25 cases) were bedridden, and 60% (76 cases) had various grave disturbances, e.g. 35 of them could walk only by the aid of crutches. The duration of the disease in this group had lasted for 4-14 yr. The remaining 21% (27 cases, 14 males and 13 females) were, however, in relatively good physical condition. Nevertheless the Both
TABLET. SEXUAI. LIFE IN GENERAL OF 115 MALES AND 134 FEMALES SUFFERING FROM
MS
Unchanged Fairly good Unsatisfied Finished Total
TABLE
5. THE
Males percentage
Females percentage
9 27 34 30
28 33 20 19
too
100
PRESENT SITUATION OF THE SEXUAL LIFE OF 115 MALES SUFFERING FROM MS. PERCENTAGE DISTRIBUTION OF SOME DETAILS
Interest in sexual intercourse
Satisfaction with sexual intercourse
Frequency of sexual intercourse
Unchanged Increased Decreased Finished
41 3 34 22
34 1 35 30
19 I 50 30
20 0 50 30
Total
100
100
100
100
Erection
H. G. LILIUS, ERKKI J. VALTONEN and JUHANI WIKSTR~~M
646
males had disturbances in erection and the females in orgasm and libido. In this group a third of the patients had suffered from MS 6-9 yr and the remainder, a shorter time. Males. The present situation of the sexual life of 115 males suffering from MS is shown in Table 5. As can be seen, sexual life in general was changed in 91% of the cases. It was unsatisfied or finished in 64%. The interest in sexual intercourse was unchanged in 41’/& decreased in 34’/& and finished in 22%. Erection was unchanged only in 20% and ejaculation in 23%. The percentage distribution of the main problems of 75 males with unsatisfied or extinct sexual life are presented in Table 7. Disturbance in erection is the most common problem, being 62% of the total. TABLE 6. THE PRESENTSITUATION OF THE SEXUAL LIFE OF 134 FEMALESSUFFERINGFROM MS. PERCENTAGE DISTRIBUTION OF SOME DETAILS Interest in sexual intercourse
Satisfaction with sexual intercourse
Frequency of sexual intercourse
Sensitivity of the clitoris
Achieving of the orgasm
Unchanged Increased Decreased Finished
52 6 25 17
44 6 31 19
34 4 43 19
45 6 30 19
37 6 28 29
Total
100
100
100
100
100
TABLE 7. PERCENTAGE DISTRIBUTTONOF THE MAIN PROBLEM OF 75 MALES WITH UNSATISFIED OR FINISHED SEXUAL LIFE Loss of erection Weak erection Weakness of the body muscles Spasticity Frigidity of the wife Periodical loss of erection Premature ejaculation The wife’s incapability to understand the reduced potence Insensitivity of the glans penis The wife must act as the active partner Lack of partner Total
48 9 9 8 6 5 4 4 3 3
1 100
TABLE 8. PERCENTAGE DISTRIBUTION OF THE MAIN PROBLEM OF 53 FEMALESWITH UNSATISFIED OR FINISHED SEXUAL LIFE Loss of orgasm Loss of libido Spasticity The husband’s refusal from sexual intercourse Weakness of the body muscles Lack of sexual partner Dryness of the vagina Total
33 27 12 9 9 5 5 loo
Sexual Problems in Patients Suffering from Multiple Sclerosis
647
Females. The present situation of sexual life of the 134 females suffering from MS is presented in Table 6. The figures are somewhat better than those of males. Sexual life in general was changed in 72% of the cases. The interest in sexual intercourse and satisfaction with sexual intercourse were unchanged in 52 and 44% respectively. The percentage distribution of the main problems of 53 females with unsatisfied or finished sexual life are shown in Table 8. Loss of orgasm (33%) loss of libido (27x), and spasticity (12%) are the most common problems. DISCUSSION
The members of the MS society of Helsinki are as a rule in an advanced stage of the disease. Patients with mild symptoms take an awaiting attitude to the membership of the society. Therefore, in this series patients with severe symptoms dominate. A successful sexual life is of great importance for everybody. The results obtained in this study show that this part of life is greatly changed in patients suffering from MS. The most important cause of impotence in MS is, according to Vas [3] a lesion of the lateral horns in the lumbar cord and perhaps in some cases deficiency of circulating testosterone. In normal population the cause of impotence and loss of libido will be found in psychogenic factors. These, of course, also play a certain role in the sexual disturbances of MS patients. The occurrence of pyramidal tract symptoms (94%) and bladder dysfunction (78%) were of equal frequency as the sexual disturbances (91%) as shown in Tables 3 and 4. There was no correlation between the incidence of sexual disturbances and the duration of the disease. It seems that the sexual disturbances advance with other neurological symptoms of spinal origin. In about 40% of the cases with difficulties in sexual life, we can help the patients in some detail. This includes, as shown in Tables 7 and 8, decreasing of spasticity with drugs, muscle training, and information of the healthy consort of the disease. The most important problem is loss of erection. In these cases it is possible to instruct the patients in some compensatory methods of sexual intercourse. These include the use of a penis-prosthesis and in some cases a plastic prosthesis can be implanted operatively in the penis in order to afford a continuous erection. In about half of the cases, the interest in sexual intercourse was decreased or finished. On the other hand, it was increased in 3% of the males and in 6% of the females. Of these reasons it is obvious that in many cases the other partner suffers more from the disturbances in sexual life than the patient does. Therefore, it is important to inform also the healthy partner of compensatory methods in sexual intercourse. This can in some cases help in overcoming the difficulties. REFERENCES 1. Ivers RR, Goldstein NP: Multiple sclerosis: A current appraisal of symptoms and signs, Proc Mayo Clinic 38: 457-466, 1963 2. Kinsey AC, Pomerey WB, Martin CE: Sexual Behaviour in the Human Male. Philadelphia: Saunders, 1948 3. Vas CJ: Sexual impotence and some autonomic disturbances in men with multiple sclerosis. Acta Neural Stand 45
: 166-l 82, 1969
