The majority of signs and synq)toms in MS are attributable to involvement
of the brain stem and spinal cord (Matthews 1991). Several systems may be
affected and result in visual, cerebellar (incoordination), sensory
(paresthaesia) and motor disturbances. Additionally, there may be
significant disturbance of the autonomic nervous system causing bladder and
sexual dysfimction.
In men and women with MS, sexual health may be affected by a number of
influences. These have been defined as either organic or psycho-social. The
organic causes may be neurophysiological changes or problems associated
with fatigue, adductor spasm and disorders of elimination. Psycho-social
factors may encompass anxiety about sexual performance, depression,
change in role identity, low mood/self-esteem and loss of independence.
Adjustment to sexual dysfimction has been described as incorporating a
similar process as adjustment to disabihty (Berkman et al 1978) or coping
with disabihty (Barrett 1982). Despite extensive hterature examining many
different aspects of MS, the issue of sexual disturbances has not been
addressed to the same extent as other inq)airments or disabihties arising
fiomthis disease.
Literature is sparse even in the area of sexual dysfimction in males with MS.
It has been attributed to disease of the spinal cord and more specificahy the
thoracic spine and autonomic nerves (Kirkeby et al 1988). Sexual problems
reported include decreased hbido, changes in erectile fimction and
ejaculatory difficulties (Vas 1969, Lihus et al 1976 and Kirkeby et al 1988).
Before 1960 the incidence of impotence or erectile dysfimction in this group
was thought to be rare possibly due to under reporting. Ivers and Goldstein
males, 43% were partially or totally impotent (Vas 1969). Interestingly, the
men in the latter study were only mildly disabled in that all were able to walk
without aids or assistance and this suggests that sexual dysfunction is not
necessarily associated with severe physical disability. However a reduction
in sexual interest and response may become more evident as the disease
progresses and synq)toms worsen generally (Lihus et al 1976). Kirkeby et al
(1988) investigated 29 males reporting sexual dysfunction, by measuring
penile arterial inflow and venous outflow, pudendal evoked potentials and
the bulbocavemosus reflex. They demonstrated that 26 (89%) had a
neurogenic cause for their erectile dysfunction.
The changes in sexual functioning in females that have been identified are
altered sensation in the genitaha, weakness of the pelvic musculature and
hyperreflexic contractions of the bladder during intercourse (Lihus et al
1976, Lundberg 1978, Minderhoud et al 1984b, VaUeroy and Kraft 1984).
Two early studies with samples of females with MS are by Lhius et al (1976)
and Lundberg (1978). The first of these include 115 males and 134
females. The subjects ah had advanced forms of MS and 50% had had the
disease for ten years or longer. Of these 72% of females reported a change
in sexual fimction. Lihus agreed with Vas (1969) in that individuals who
complained of sexual dysfunction also had signs of pyramidal and bladder
disturbance. No correlation was found to exist between sexual disturbance
and the duration of the disease. However sexual dysfunction did appear to
be dependent on the location of plaques in the central nervous system and
this argument was later supported by Goldstein et al (1982).
Lundberg (1978) was interested in studying those females who had a mild
include disturbances in bladder and bowel function in addition to that of
sexual function - and in fact serve to confound it - attention was paid to
both bladder and bowel syn^tomatology.
Two cohorts of females were investigated. Twenty-five females with MS,
aged between 20 and 42 (mean 31. lyears) were matched for sex, parity and
age with a control group of twenty-five subjects with migraine. Thirteen
women with MS declared that they had some sexual problems. These
included the following conq)laints: reduction in libido (9), difficulty in
achieving orgasm (9), external dysaethesiae (3), vaginal dyspareunia (5),
poor vaginal lubrication and one incidence of vaginismus.
It is worth emphasising that these females had relatively mild forms of the
disease, that they had not experienced any sexual problems prior to the onset
of the disease and that the afore-mentioned complaints commenced
suddenly. Bladder and bowel disorders were evident in 68% (17) females
with MS and it was reported that urinary incontinence created difficulties in
sexual activity.
In contrast, the control group suffering from migraine did not report
disorders in sexual function. There were no problems respecting loss of
hbido, general paraesthesia or incontinence. AdditionaUy the neurological
examinations for this group were normal whilst those with MS had evidence
of sensory signs and loss of sacral cord reflex associated with syn^toms of
sexual dysfimction. From this study, the author deduced that anatomical
lesions in the central nervous system correlated with syn^toms of sexual
disturbance and this was so even in females with a mild form of MS,
Goldstein et al (1982) demonstrated that an abnormal sacral evoked
response exists in patients with sexual disturbance and functional
disturbances of the bladder and suggested that the causative factor was
damage to the lower part of the spinal cord. The location of the lesion is
said to dictate the type of dysfunction (Strasburg and Brady 1988), The
authors stated that the aim of treatment strategies must be to maintain a
level of sexual intimacy during the phases of the sexual response cycle.
An attençt was made by Szasz et al (1984) to investigate the history of
sexual problems in this patient group. A sexual functioning scale, taken
from the Minimal Record of Disabihty (1985) was utihsed. The aim of using
this scale was to identify the level of sexual activity and the degree of
concern expressed about the level of sexual functioning. The sangle
consisted of 73 patients with MS. Although 43% of the sample are
described as being sexually less active or inactive since the onset of their
MS, and 27% expressed a concern, no differentiation was made between
male and female patients. The scale was helpful in determining at what stage
sexual activity was affected but it was not possible to identify the nature and
severity of the sexual difi&culties.
Minderhoud et al (1984b) focused on the frequency and nature of sexual
disturbances amongst those who were only shghtly disabled by MS, that is
they were ah able to walk a few steps. A questionnaire consisting of sixty
items covered the foUowing areas: sexual function, bladder function, bowel
function, temperature in the lower extremities and the patient's level of
handicap. Seventy-four questionnaires were completed. Of these, 39 of the
respondents were female, ah with chnicahy dehnite multiple sclerosis.
Reported changes in sexual function were reduced hbido, decreased
in sexual activity, fatigue and dyspareunia corresponded with scores on an
"ambulation index" which was derived from responses to questions on
mobihty. There was a significant correlation between sexual dysfimction
and bladder disturbance (p = < 0.01 Mann Whitney test). Minderhoud et al's
(1984b) results concur with other studies and he argues that sexual
dysfimction often co-exists with disturbances in bladder and sphincter
ftmction due to disease in the lower part of the spinal cord.
The question of sexual dysftmction in women with MS has also been
addressed by VaUeroy and Kraft (1984). A questionnaire was developed to
determine the extent and type of sexual dysfimction and consisted of
multiple choice questions and short written answers for major problem areas
of sexual fimction. Two hundred and seventeen volunteers were included in
the study, of which 149 were females and 68 were males. The length of
time that had elapsed since diagnosis ranged from 2 to 13 years, with a mean
of 12 and 13 years respectively. Fifty-three per cent of the total sample
were described as ambulant without the assistance of aids and 75% did not
use a wheelchair. However the level of disabihty between the sexes was not
distinguishable. As the subjects were volunteers, the sample may have been
biased rather than random and this was acknowledged by the authors.
The major disabihties found in the female group (n=149) were described as
reduced mobihty, fatigue, weakness/paralysis, balance problems, poor
manual dexterity, pain and sensory disturbance. The commonly reported
sexual symptoms included fatigue (97%), decreased sensation (68%),
decreased hbido (58%), decreased orgasm (53%), anorgasmia (52%) and
difficulty with arousal (50%). Overah a higher proportion of women
reported sexual dysfimction in this study than in that conducted by Lihus
by VaUeroy and Kraft (1984) study were more mobUe. This may have been
because there is an increasing wiUingness amongst individuals to discuss
sexuaUy related problems in recent years. Sexual dysfunction was found to
be significantly associated with spasticity in the lower Umbs as weU as
bladder symptomatology. WhUst this supports the findings in other studies
(Lundberg 1978), the authors did ercphasise that some subjects who did not
have either disordered bladder function or spasticity stiU reported some
change in sexual function. They concluded that the data suggested one
could expect approximately 50% of females with MS to note an alteration in
their sex Ufe.
CONCLUSION
The unpredictable nature of the disease and the initial uncertainty that often
surrounds the diagnosis of MS can create enormous pressures for females
at a time when they are having to contend with a number of disabilities and
handicaps. Many factors may be involved in sexual dysfunction and it is
often difficult to distinguish between neurophysiological changes leading to
in^aired fimction and specific disabilities, such as poor mobility, which can
compromise 'normal ' sexual activity. In addition to this, emotional and
psychological factors are important contributors to sexual dysfunction.
Difficulties exist in describing causal relationships between sexual
dysfunction, and a number of variables such as functional limitations arising
from various disabilities and psychological responses.
MS can affect the sex life of individuals through the feeling of being
disabled, a loss of self respect, a sense of uncertainty over the prognosis,
dependency on others to con^lete activities of daily living and changes in
1980). As such, all of these factors - and not least the specific neurological
impairments - may negatively influence the opportunity for a fidfiUed sex
life.
Sexual fimctioning in MS is a corq)lex and incompletely addressed issue.
The studies that have been conducted indicate that sexual dysfimction
occurs in a large number of people with MS, in both sexes and in those with
mild as well as advanced forms of the disease. Practitioners working with
this chent group, should therefore expect a sizeable proportion of their
patients to have sexual dysfimction. Unless this aspect is addressed by
health care professionals, the sexual health needs of this group will go
unmet.
The hypotheses for testing were as follows:
1. There will be a positive correlation between reduced sexual activity and
incontinence.
2. There will be a positive correlation between sexual dysfimction and poor
SECTION n i: PSYCHOLOGICAL ASPECTS CHAPTERS