Multiple sclerosis (MS) is a chronic autoimmune disease affecting the central nervous system, disrupting the flow of information between the brain and the body. While commonly known for its physical symptoms such as muscle weakness and coordination issues, MS can also impact sexual function, particularly in men.

Sexual dysfunction in men with MS can manifest in various ways, including erectile dysfunction, decreased libido, difficulties with ejaculation, and decreased sensation.

Open communication with doctor is crucial to address these concerns effectively and improve the overall quality of life for individuals living with MS.

Types of sexual dysfunctions in patients with multiple sclerosis

Several types of sexual dysfunction can occur in men with multiple sclerosis (MS) as a secondary effect of the disease. These may include:

• Erectile Dysfunction (ED): MS can interfere with the nerve signals involved in achieving and maintaining an erection, leading to difficulties in achieving or sustaining erections firm enough for sexual intercourse.
• Decreased Libido: MS-related fatigue, depression, and changes in hormone levels can contribute to a decrease in sexual desire or interest.
• Ejaculatory Dysfunction: MS can disrupt the nerves that control the timing and coordination of ejaculation, leading to difficulties such as delayed ejaculation, premature ejaculation, or retrograde ejaculation (where semen enters the bladder instead of exiting through the penis).
• Altered Sensation: MS-related nerve damage can affect sensation in the genital area, potentially leading to decreased sensitivity or altered perceptions of touch, temperature, or pleasure during sexual activity.
• Painful Intercourse: Some men with MS may experience pain during sexual intercourse (dyspareunia) due to nerve-related issues, muscle spasms, or other MS-related symptoms.

Causes

Multiple sclerosis (MS) can cause sexual dysfunction in men through various mechanisms related to the nature of the disease. Here are some key factors contributing to sexual dysfunction in men with MS:

• Nerve Damage: MS is characterized by damage to the myelin sheath, the protective covering of nerve fibers in the central nervous system. This damage disrupts nerve signals, including those involved in sexual function, leading to issues such as erectile dysfunction, altered sensation, and ejaculatory problems.
• Lesion Location: The location of MS lesions within the central nervous system can affect specific functions related to sexual arousal, performance, and genital sensation. Lesions in areas of the brain or spinal cord responsible for sexual response can directly impact sexual function in men.
• Autonomic Dysfunction: MS can affect the autonomic nervous system, which regulates involuntary bodily functions, including sexual response. Dysfunction in this system can contribute to erectile dysfunction, problems with ejaculation, and alterations in sexual arousal.
• Fatigue and Weakness: MS-related fatigue and weakness can interfere with sexual desire, stamina, and the ability to engage in sexual activity. Fatigue may also exacerbate other symptoms of sexual dysfunction.
• Psychological Factors: Living with a chronic condition like MS can lead to psychological stress, anxiety, depression, and changes in body image, all of which can affect sexual desire and performance in men.
• Medications and Treatment Side Effects: Some medications used to manage MS symptoms, such as antidepressants or muscle relaxants, can have side effects that impact sexual function. Additionally, treatments like bladder medications or steroid therapies may contribute to sexual dysfunction.
• Hormonal Changes: MS-related damage to the hypothalamus or pituitary gland can disrupt hormonal regulation, potentially leading to changes in libido, erectile function, and other aspects of sexual health.
• Secondary Health Conditions: MS can increase the risk of other health conditions that contribute to sexual dysfunction in men, such as urinary tract infections, bowel dysfunction, or cardiovascular issues.

Diagnosis

Diagnosing sexual dysfunction in men secondary to multiple sclerosis (MS) involves a comprehensive evaluation by healthcare professionals, including neurologists, urologists, and sexual health specialists. Here are the key steps in the diagnosis process:

• Patient History: Healthcare providers will conduct a thorough medical history, including questions about the onset and nature of sexual symptoms, any changes in libido or sexual function, and any underlying medical conditions or medications that may contribute to sexual dysfunction.
• Physical Examination: A physical examination may be performed to assess neurological function, genital anatomy, and signs of any underlying conditions that could affect sexual function.
• Neurological Evaluation: Given the neurological nature of MS, a neurological assessment is crucial. This may involve assessing motor function, sensory function, and reflexes, as well as evaluating for signs of MS-related lesions or damage in the spinal cord or brain.
• Laboratory Tests: Blood tests may be ordered to assess hormone levels, such as testosterone, which can impact sexual function. Additionally, tests may be conducted to evaluate for other underlying medical conditions, such as diabetes or cardiovascular disease, which can contribute to sexual dysfunction.
• Imaging Studies: Imaging studies, such as magnetic resonance imaging (MRI) of the brain and spinal cord, may be performed to assess for MS-related lesions or structural abnormalities that could affect sexual function.
• Questionnaires and Assessments: Patients may be asked to complete standardized questionnaires or assessments to evaluate sexual function, satisfaction, and quality of life. These tools help healthcare providers understand the extent and impact of sexual dysfunction on the individual.
• Specialized Testing: In some cases, specialized tests may be recommended to further evaluate specific aspects of sexual function, such as erectile function tests, penile Doppler ultrasound, or nerve conduction studies.
• Psychosocial Assessment: Given the potential psychological impact of sexual dysfunction, a psychosocial assessment may be conducted to evaluate for factors such as depression, anxiety, relationship issues, or body image concerns that could contribute to sexual difficulties.

• Collaborative Care Planning: Based on the findings of the evaluation, healthcare providers will collaborate to develop a tailored treatment plan that addresses both the physical and psychological aspects of sexual dysfunction.

Treatment

The treatment of sexual dysfunction in men with multiple sclerosis (MS) typically involves a multidisciplinary approach aimed at addressing both the physical and psychological aspects of the condition. Here are some common strategies used to manage sexual dysfunction in men with MS:

Medications:

• Erectile Dysfunction (ED): Oral medications such as sildenafil (Viagra), tadalafil (Cialis), or vardenafil (Levitra) may be prescribed to improve erectile function by increasing blood flow to the penis. In some cases, injections or suppositories containing medications like alprostadil may be recommended.
  • Ejaculatory Dysfunction: Medications such as selective serotonin reuptake inhibitors (SSRIs) or tricyclic antidepressants may be prescribed to manage ejaculatory problems, particularly premature ejaculation or delayed ejaculation.

Hormone Therapy:

• Hormone replacement therapy (e.g., testosterone replacement) may be considered if hormonal imbalances contribute to sexual dysfunction.

Counseling and Psychotherapy:

• Individual or couples counseling can help address psychological factors such as anxiety, depression, stress, or relationship issues that may impact sexual function.
  • Cognitive-behavioral therapy (CBT) techniques may be used to address negative thought patterns or performance anxiety related to sexual activity.

Education and Support:

• Providing information and education about sexual function and MS to both patients and their partners can help alleviate concerns and improve communication.
  • Support groups or peer counseling may offer valuable emotional support and practical advice for coping with sexual dysfunction and managing MS-related challenges.

Lifestyle Modifications:

• Adopting a healthy lifestyle, including regular exercise, a balanced diet, stress management techniques, and adequate sleep, can help improve overall well-being and may positively impact sexual function.
  • Avoiding alcohol, tobacco, and recreational drugs, which can exacerbate sexual dysfunction and other MS symptoms.

Assistive Devices:

• Devices such as vacuum erection devices or penile implants may be considered for men with severe or refractory erectile dysfunction.
  • Vibratory stimulation devices or penile rings may also be used to improve erectile function or ejaculation.

Alternative Therapies:

• ESWT, PRP, stem cell and exosome therapy

Penil prosthesis:

• Penile prosthesis implantation is a viable option for men with ED secondary to multiple sclerosis who have not responded to other treatments.

Summary

Sexual dysfunction is a common issue among men with MS, a chronic neurological condition. MS can affect various bodily functions, including those involved in sexual arousal and performance. Men with MS may experience difficulties such as erectile dysfunction, decreased libido, and problems with ejaculation. These sexual dysfunctions can significantly impact quality of life and intimate relationships. Treatment options may include medications, counseling, and lifestyle changes, but management can be challenging due to the complex nature of MS and its effects on the nervous system.

Prof. Dr. Emin ÖZBEK

Urologist

Istanbul- TURKIYE