Scand J Soc Med 4: 41-44, 1976
Sexual Problems in Patients Suffering from Multiple Sclerosis H. G. Lilius, Erkki J. Valtonen and Juhani Wikstrom From the Departments ofPhysical Medicine and Neurology, University Central Hospital, Helsinki, Finland
Sexual problems in patients suffering from multiple sclerosis. Lilius, H. G., Valtonen, E. J. and Wikstrom, J. (Departments of Physical Medicine and Neurology, University Central Hospital, Helsinki, Finland). Scand J Soc Med 1976, 1 (41-44): A questionnaire which allowed anonymous answering and which also included many other questions besides those dealing with sexual life was sent to 302 patients suffering from multiple sclerosis (MS). Sexual life had changed for 91 % of males and 72% of females. About half of the patients replied that their sexual life was unsatisfactory or had ceased altogether. These patients were as a rule in a relative poor physical condition. In males, disturbances in erection (62 %) were the most common problem, erection was normal in only 20 %. In females the essential figures were: loss of orgasm in 33 %, loss of libido in 27 % and spasticity in 12 %. There was no correlation between the incidence of sexual disturbances and the duration of the MS. It seems that the neurological disturbances in sexual life depend simply on the location of the plaques in the central nervous system.
Sexual disturbances are very common in patients suffering from multiple sclerosis (MS). Ivers & Goldstein (1) found that 26% of their 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 despite 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 impotent patients. The concept of impotence generally includes weak or complete loss of erection, premature ejaculation, loss of sensation in spite of 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 years were impotent. Very seldom can any organic cause of the impotence be found. Therefore, in most cases, it must be considered psychogenic, based on guilt, anxiety, strained physical condition, jealousy, or frigidity of the wife. In the literature there is a lack of detailed reports dealing with the sexual problems of patients suffering from MS. As only a thorough knowledge con-
Table I. Distribution by age and sex Total
Females
Males
Cases
%
Age (y.)
Cases
%
17-20 21-30 31-40 41-50 51-60
2 48 74 111 14
0.7 19.3 29.8 44.6 5.6
13 36 54 12
11.3 31.3 47.0 10.4
2 35 38 57 2
1.5 26.1 28.4 42.5 1.5
Total
249
100.0
115
100.0
134
100.0
Cases
%
Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
42
H. G. Lilius et ale cerning the troubles caused by this disease enables the physician to understand his patients, this subject was considered worthy of investigation.
Table II. Duration of the disease Duration of the disease (y.)
Cases
1-2 3-5 6-9 10-20 over 20 Total
15 36 54 113 31 249
%
5.9 14.2 21.4 45.9 12.6 100.0
PATIENTS
Table III. Neurological characterization of patients suffering from MS 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
81 94 78 73 67 66 47 46 41 30 27 33
RESULTS
Table IV. Sexual life in general of 115 males and 134females suffering from MS Males
Females
9 27 34 30 100
28 33 20 19 100
(%)
Unchanged Fairly good Unsatisfied Finished
A questionnaire which allowed anonymous answering and which also included numerous other questions besides those dealing with sexual life was sent to 302 patients suffering from MS. The addresses of the patients were taken from the local MS association in Helsinki. In almost every case the diagnosis of MS had been confirmed in the Department of Neurology, University of Helsinki. Two hundred and forty-nine patients answered all questions in the questionnaire. Fifty-three patients (9 men, 44 women) (17.5%) did not answer those questions dealing with sexual life. Nine of the women were unmarried, 12 were 61-70 years old, and 29 of the women as well as the 9 male patients were in very poor physical condition. In this group of patients there was also 27 divorcees, and in every case the divorce had occurred during the course of disease. The age and sex distribution of the 249 patients (115 males, 134 females) is presented in Table 1 and the duration of the disease in Table II. On the basis of the numerous questions, the neurological condition of the patients could also be elucidated to a large extent. The most essential neurological data of the patients are presented in Table III.
(%)
Both sexes Sexual life in general (Table IV) had changed for 91 % of the male patients. The figures' for the females were somewhat better. For them, sexual life in general had changed for 72 %. About half (52 %, 128 cases) of the 249 patients in this series reported that their sexual life was either unsatisfactory or had ceased entirely. The figures were 64% in males and 39% in females. On the other hand, these patients were as a rule in relatively poor physical condition. One-fifth of them
Table V. The present situation ofthe sexual life of 115 males suffering from MS. Percentage distribution of some details
Unchanged Increased Decreased Finished
Interest in sexual intercourse
Satisfaction with sexual intercourse
41 3 34 22 100
34 1 35 30 100
Frequency of sexual intercourse
Erection
1
50 30
20 0 50 30
100
100
19
Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
Sexual problems in MS patients
43
Table VI. The present situation of sexual life for 134 females suffering from MS. Percentage distribution of some details Interest in sexual intercourse Unchanged Increased Decreased Finished
Satisfaction with sexual intercourse
52
44
25 17 100
31 19 100
6
6
(19%,25 cases) were permanent invalids, and 60% (76 cases) had various serious afflictions, e.g. 35 of them could walk only with the aid of the crutches. The duration of the disease in this group varied between 4 and 14 years. The remaining 21 % (27 cases, 14 males and 13 females) were, however, in relatively good physical condition. Nevertheless the males had some difficulty in erection and the females in orgasm and libido. In this group a third of the patients had suffered from MS for 6-9 years and the remainder for a shorter time.
Males
The present situation in the sexual life of 115 male MS sufferers is presented in Table V. As can be seen, for 9 i % of the. cases, sexual life' in general had changed, whereas it had become unsatisfying or ceased completely in 64 %. Interest in sexual intercourse remained unchanged in 41 %, had waned in 34 % and ceased in 22 %. Erection function was unchanged in only 20 % and ejaculation in 23 %. The percentage distribution of the main probTable VII. Percentage distribution of the main problems of 75 males with unsatisfied or extinguished sexual life Problem Loss of erection Weak erection Weakness of the body muscles Spasticity Frigidity of the wife Periodic loss of erection Premature ejaculation Wife's inability to understand the reduced potency Insensitivity of the glans penis Wife must be the active partner Lack of partner
%
48
Frequency of sexual intercourse
34 4 43 19 100
Sensitivity of the clitoris
45
37
30 19 100
28 29 100
6
Females
The present situation of the sexual life of the 134 female MS sufferers is presented in Table VI. The figures are somewhat better than those of. males. Sexual life in general had changed in 72 % of cases. Interest in and satisfaction with sexual intercourse were unchanged in 52 % and 44 % respectively. The percentage distribution of the main problems of 53 females with unsatisfying or extinct sexual life is presented in Table VIII. Loss of orgasm (33 %), loss of libido' (27 %), and spasticity (12 %) are the most common problems. DISCUSSION The members of the local MS society of Helsinki are as a rule in an advanced stage of the disease. On the other hand, patients with mild symptoms hesitate to join the society. In this series, therefore, patients with severe symptoms dominate. Table VIII. Percentage distribution of the main problems of 53 females with unsatisfying or extinguished sexual life Problem
6
Loss of orgasm Loss of libido Spasticity Husband's refusal from sexual intercourse Weakness of the body muscles Lack of sexual partner Dryness of the vagina
5 4 4
3
3
1
6
lems of 75 males with unsatisfying or extinct sexual life are presented in Table VII. Disturbance in erection is the most common problem, being 62 % of all.
9 9
8
Orgasm achieved
%
33 27 12 9 9
5 5 Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
44
H. G. Lilius et al.
A satisfactory sexual life is of great importance for all human beings. The results obtained in this study show that this facet of life is greatly changed in patients suffering from MS. The most important cause of MS is, according to Vas (3), a lesion of the lateral horns in the lumbar cord and perhaps in some cases the deficiency of circulating testosterone. In the normal population the dominant causative factors in impotence and loss of libido are psychogenic. Psychogenic factors, of course, also play a certain role in the sexual disturbances of patients suffering from MS. The occurrence of pyramidal tract symptoms (94 %) and bladder disturbances (78 %), equalled the sexual disturbances (91 %) in frequency (Tables III and IV). There was no correlation between the incidence of sexual disturbances and the duration of the disease. It seems that the occurrence of sexual disturbances depends on the location of the plaques. Most patients in this series had severe lesions of the pyramidal tract and the occurrence of sexual disturbances was correspondingly high. In about 40 % of the patients with sexual difficulties we can help to a certain extent (Table IV and VIII). For instance we can assist by decreasing spasticity with drugs, providing muscle training for the patient and information for his healthy consort concerning the disease and the reasons for sexual disturbances. The most important problems is loss of erection. We are unable to help these patients in a direct way and must therefore instruct them in compensatory
methods of sexual intercourse. These include the use of a penisprosthesis and in some cases a plastic prosthesis can be surgically implanted in the penis in order to afford a lasting erection. In about half the cases the interest in sexual intercourse was diminished or absent, whereas it was increased in 3 ~ of the males and in 6lh in the females. For these reasons it is obvious that in many cases the partner suffers more from the patient's disturbances in sexual life than does the patient himself. Therefore it is also important to inform the healthy partner of compensatory methods of sexual intercourse. This can in some cases help in overcoming the difficulties.
REFERENCES I. Ivers, R. R. & Goldstein, N. P.: Multiple sclerosis: a· current appraisal of symptoms and signs. Proc Mayo Clin 38: 457, 1963. 2. Kinsey, A. C., Pomeroy, W. B. & Martin, C. E.: Sexual behaviour in human male. Saunders, Philadelphia, 1948. 3. Vas,C. J.: Sexual impotence and some autonomic disturbances in men with multiple sclerosis. Acta Neurolog Scand 45: 166, 1969.
Address for reprints: H. G. Lilius, M.D. Meilahti Hospital' Department of Physical Medicine 00290 Helsinki 29 Finland
Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
Sexual Problems in Patients Suffering from Multiple Sclerosis H. G. Lilius, Erkki J. Valtonen and Juhani Wikstrom From the Departments ofPhysical Medicine and Neurology, University Central Hospital, Helsinki, Finland
Sexual problems in patients suffering from multiple sclerosis. Lilius, H. G., Valtonen, E. J. and Wikstrom, J. (Departments of Physical Medicine and Neurology, University Central Hospital, Helsinki, Finland). Scand J Soc Med 1976, 1 (41-44): A questionnaire which allowed anonymous answering and which also included many other questions besides those dealing with sexual life was sent to 302 patients suffering from multiple sclerosis (MS). Sexual life had changed for 91 % of males and 72% of females. About half of the patients replied that their sexual life was unsatisfactory or had ceased altogether. These patients were as a rule in a relative poor physical condition. In males, disturbances in erection (62 %) were the most common problem, erection was normal in only 20 %. In females the essential figures were: loss of orgasm in 33 %, loss of libido in 27 % and spasticity in 12 %. There was no correlation between the incidence of sexual disturbances and the duration of the MS. It seems that the neurological disturbances in sexual life depend simply on the location of the plaques in the central nervous system.
Sexual disturbances are very common in patients suffering from multiple sclerosis (MS). Ivers & Goldstein (1) found that 26% of their 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 despite 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 impotent patients. The concept of impotence generally includes weak or complete loss of erection, premature ejaculation, loss of sensation in spite of 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 years were impotent. Very seldom can any organic cause of the impotence be found. Therefore, in most cases, it must be considered psychogenic, based on guilt, anxiety, strained physical condition, jealousy, or frigidity of the wife. In the literature there is a lack of detailed reports dealing with the sexual problems of patients suffering from MS. As only a thorough knowledge con-
Table I. Distribution by age and sex Total
Females
Males
Cases
%
Age (y.)
Cases
%
17-20 21-30 31-40 41-50 51-60
2 48 74 111 14
0.7 19.3 29.8 44.6 5.6
13 36 54 12
11.3 31.3 47.0 10.4
2 35 38 57 2
1.5 26.1 28.4 42.5 1.5
Total
249
100.0
115
100.0
134
100.0
Cases
%
Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
42
H. G. Lilius et ale cerning the troubles caused by this disease enables the physician to understand his patients, this subject was considered worthy of investigation.
Table II. Duration of the disease Duration of the disease (y.)
Cases
1-2 3-5 6-9 10-20 over 20 Total
15 36 54 113 31 249
%
5.9 14.2 21.4 45.9 12.6 100.0
PATIENTS
Table III. Neurological characterization of patients suffering from MS 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
81 94 78 73 67 66 47 46 41 30 27 33
RESULTS
Table IV. Sexual life in general of 115 males and 134females suffering from MS Males
Females
9 27 34 30 100
28 33 20 19 100
(%)
Unchanged Fairly good Unsatisfied Finished
A questionnaire which allowed anonymous answering and which also included numerous other questions besides those dealing with sexual life was sent to 302 patients suffering from MS. The addresses of the patients were taken from the local MS association in Helsinki. In almost every case the diagnosis of MS had been confirmed in the Department of Neurology, University of Helsinki. Two hundred and forty-nine patients answered all questions in the questionnaire. Fifty-three patients (9 men, 44 women) (17.5%) did not answer those questions dealing with sexual life. Nine of the women were unmarried, 12 were 61-70 years old, and 29 of the women as well as the 9 male patients were in very poor physical condition. In this group of patients there was also 27 divorcees, and in every case the divorce had occurred during the course of disease. The age and sex distribution of the 249 patients (115 males, 134 females) is presented in Table 1 and the duration of the disease in Table II. On the basis of the numerous questions, the neurological condition of the patients could also be elucidated to a large extent. The most essential neurological data of the patients are presented in Table III.
(%)
Both sexes Sexual life in general (Table IV) had changed for 91 % of the male patients. The figures' for the females were somewhat better. For them, sexual life in general had changed for 72 %. About half (52 %, 128 cases) of the 249 patients in this series reported that their sexual life was either unsatisfactory or had ceased entirely. The figures were 64% in males and 39% in females. On the other hand, these patients were as a rule in relatively poor physical condition. One-fifth of them
Table V. The present situation ofthe sexual life of 115 males suffering from MS. Percentage distribution of some details
Unchanged Increased Decreased Finished
Interest in sexual intercourse
Satisfaction with sexual intercourse
41 3 34 22 100
34 1 35 30 100
Frequency of sexual intercourse
Erection
1
50 30
20 0 50 30
100
100
19
Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
Sexual problems in MS patients
43
Table VI. The present situation of sexual life for 134 females suffering from MS. Percentage distribution of some details Interest in sexual intercourse Unchanged Increased Decreased Finished
Satisfaction with sexual intercourse
52
44
25 17 100
31 19 100
6
6
(19%,25 cases) were permanent invalids, and 60% (76 cases) had various serious afflictions, e.g. 35 of them could walk only with the aid of the crutches. The duration of the disease in this group varied between 4 and 14 years. The remaining 21 % (27 cases, 14 males and 13 females) were, however, in relatively good physical condition. Nevertheless the males had some difficulty in erection and the females in orgasm and libido. In this group a third of the patients had suffered from MS for 6-9 years and the remainder for a shorter time.
Males
The present situation in the sexual life of 115 male MS sufferers is presented in Table V. As can be seen, for 9 i % of the. cases, sexual life' in general had changed, whereas it had become unsatisfying or ceased completely in 64 %. Interest in sexual intercourse remained unchanged in 41 %, had waned in 34 % and ceased in 22 %. Erection function was unchanged in only 20 % and ejaculation in 23 %. The percentage distribution of the main probTable VII. Percentage distribution of the main problems of 75 males with unsatisfied or extinguished sexual life Problem Loss of erection Weak erection Weakness of the body muscles Spasticity Frigidity of the wife Periodic loss of erection Premature ejaculation Wife's inability to understand the reduced potency Insensitivity of the glans penis Wife must be the active partner Lack of partner
%
48
Frequency of sexual intercourse
34 4 43 19 100
Sensitivity of the clitoris
45
37
30 19 100
28 29 100
6
Females
The present situation of the sexual life of the 134 female MS sufferers is presented in Table VI. The figures are somewhat better than those of. males. Sexual life in general had changed in 72 % of cases. Interest in and satisfaction with sexual intercourse were unchanged in 52 % and 44 % respectively. The percentage distribution of the main problems of 53 females with unsatisfying or extinct sexual life is presented in Table VIII. Loss of orgasm (33 %), loss of libido' (27 %), and spasticity (12 %) are the most common problems. DISCUSSION The members of the local MS society of Helsinki are as a rule in an advanced stage of the disease. On the other hand, patients with mild symptoms hesitate to join the society. In this series, therefore, patients with severe symptoms dominate. Table VIII. Percentage distribution of the main problems of 53 females with unsatisfying or extinguished sexual life Problem
6
Loss of orgasm Loss of libido Spasticity Husband's refusal from sexual intercourse Weakness of the body muscles Lack of sexual partner Dryness of the vagina
5 4 4
3
3
1
6
lems of 75 males with unsatisfying or extinct sexual life are presented in Table VII. Disturbance in erection is the most common problem, being 62 % of all.
9 9
8
Orgasm achieved
%
33 27 12 9 9
5 5 Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
44
H. G. Lilius et al.
A satisfactory sexual life is of great importance for all human beings. The results obtained in this study show that this facet of life is greatly changed in patients suffering from MS. The most important cause of MS is, according to Vas (3), a lesion of the lateral horns in the lumbar cord and perhaps in some cases the deficiency of circulating testosterone. In the normal population the dominant causative factors in impotence and loss of libido are psychogenic. Psychogenic factors, of course, also play a certain role in the sexual disturbances of patients suffering from MS. The occurrence of pyramidal tract symptoms (94 %) and bladder disturbances (78 %), equalled the sexual disturbances (91 %) in frequency (Tables III and IV). There was no correlation between the incidence of sexual disturbances and the duration of the disease. It seems that the occurrence of sexual disturbances depends on the location of the plaques. Most patients in this series had severe lesions of the pyramidal tract and the occurrence of sexual disturbances was correspondingly high. In about 40 % of the patients with sexual difficulties we can help to a certain extent (Table IV and VIII). For instance we can assist by decreasing spasticity with drugs, providing muscle training for the patient and information for his healthy consort concerning the disease and the reasons for sexual disturbances. The most important problems is loss of erection. We are unable to help these patients in a direct way and must therefore instruct them in compensatory
methods of sexual intercourse. These include the use of a penisprosthesis and in some cases a plastic prosthesis can be surgically implanted in the penis in order to afford a lasting erection. In about half the cases the interest in sexual intercourse was diminished or absent, whereas it was increased in 3 ~ of the males and in 6lh in the females. For these reasons it is obvious that in many cases the partner suffers more from the patient's disturbances in sexual life than does the patient himself. Therefore it is also important to inform the healthy partner of compensatory methods of sexual intercourse. This can in some cases help in overcoming the difficulties.
REFERENCES I. Ivers, R. R. & Goldstein, N. P.: Multiple sclerosis: a· current appraisal of symptoms and signs. Proc Mayo Clin 38: 457, 1963. 2. Kinsey, A. C., Pomeroy, W. B. & Martin, C. E.: Sexual behaviour in human male. Saunders, Philadelphia, 1948. 3. Vas,C. J.: Sexual impotence and some autonomic disturbances in men with multiple sclerosis. Acta Neurolog Scand 45: 166, 1969.
Address for reprints: H. G. Lilius, M.D. Meilahti Hospital' Department of Physical Medicine 00290 Helsinki 29 Finland
Scand J Soc Med 4
Downloaded from sjp.sagepub.com at UCSF LIBRARY & CKM on March 22, 2015
