How is sexual dysfunction managed in patients with Multiple Sclerosis (MS)?

Management of Sexual Dysfunction in Multiple Sclerosis

Sexual dysfunction in MS patients should be addressed through a structured, multidisciplinary approach that begins with proactive clinician-initiated discussion using the BETTER model, followed by systematic assessment with validated tools, and treatment targeting primary neurological symptoms (erectile dysfunction, orgasmic dysfunction), secondary symptoms (spasticity, fatigue, depression), and tertiary psychosocial factors through both pharmacological and non-pharmacological interventions. 1, 2

Prevalence and Clinical Significance

Sexual dysfunction affects 40-80% of women and 50-90% of men with MS, making it one of the most common yet underrecognized complications. 3 The most common manifestations include:

• Women: Lack of sexual interest (41.8%), reduced arousal, decreased lubrication, and orgasmic dysfunction 2
• Men: Erectile dysfunction (40.7%), ejaculatory problems, and reduced libido 2, 4

Sexual dysfunction is independently associated with depression risk, fatigue, older age, unemployment, higher disability levels, and motor impairments. 2, 3 Critically, 54.5% of MS patients report problems with sexual function, yet only 43.7% are satisfied with their sexual function, highlighting a substantial treatment gap. 2

Initiating the Conversation

Clinicians must proactively bring up sexual dysfunction at diagnosis and at regular intervals (suggested at 3,6,9, and 12 months), as patients rarely initiate these discussions despite wanting to address concerns. 5 Use the BETTER acronym as your framework: 5

• Bring up the topic of sexuality directly
• Explain concerns about quality of life impacts from MS
• Tell patients you can guide them to resources
• Timing: Reassure that discussion can occur when they're ready
• Educate about MS effects on sexual function
• Record the assessment and interventions in documentation

This approach is superior to the outdated PLISSIT model and ensures systematic coverage without relying on patient initiation. 5

Systematic Assessment

Validated Assessment Tools

Use standardized instruments to quantify dysfunction and guide treatment: 5, 6

• Female Sexual Function Index (FSFI): 19 items assessing desire, arousal, lubrication, orgasm, satisfaction (15-minute completion time)
• Changes in Sexual Functioning Questionnaire-Short Form (CSFQ-SF): 14 items for each sex, covering desire, arousal, orgasm phases (4-5 minute completion time, ideal for clinical settings)
• Index of Erectile Function-5 (IIEF-5): 5 items for men; scores <21 indicate ED with severity grading
• Arizona Sexual Experience Scale (ASEX): 5 items for both sexes; scores >19 or any item >5 indicates dysfunction

Identify Contributing Factors

Differentiate between three categories of sexual dysfunction in MS: 1, 4

Primary (neurological): Direct CNS demyelination affecting sexual response pathways

• Erectile dysfunction, decreased genital sensation, orgasmic dysfunction

Secondary (physical symptoms): MS-related symptoms interfering with sexual activity

• Spasticity, bladder/bowel dysfunction, fatigue, pain, motor weakness

Tertiary (psychosocial): Psychological and relationship factors

• Depression, anxiety, body image concerns, relationship strain, medication side effects

Treatment Algorithm

Step 1: Address Secondary Symptoms First

Optimize management of MS symptoms that directly impair sexual function: 1, 2

• Depression and anxiety: Screen and treat aggressively, as these are independently associated with sexual dysfunction 2
• Fatigue management: Critical target, as fatigue strongly predicts sexual dysfunction 2, 3
• Spasticity control: Consider antispasmodics or onabotulinumtoxinA for pelvic floor spasticity 1
• Medication review: Evaluate antidepressants and other medications for sexual side effects; adjust dosing or switch agents when possible 5

Step 2: Pharmacological Interventions for Primary Dysfunction

For erectile dysfunction in men: 1

• Sildenafil or tadalafil as first-line agents (evidence from MS-specific studies)
• Begin with conservative dosing and titrate for efficacy
• Screen for cardiovascular contraindications, particularly nitrate use 5

For orgasmic dysfunction and arousal: 1

• Limited pharmacological options; focus on non-pharmacological approaches below

Step 3: Non-Pharmacological Interventions

Pelvic floor rehabilitation shows the strongest evidence base: 1

• Pelvic floor muscle exercises alone
• Pelvic floor exercises combined with mindfulness techniques
• Pelvic floor exercises with electromuscular stimulation and EMG biofeedback

Exercise training programs: 3

• Aerobic exercise improves sexual function through multiple mechanisms: reducing fatigue, improving mood, enhancing cardiovascular fitness, and potentially modulating neuroinflammation
• Aquatic exercises specifically studied in MS populations 1
• Yoga techniques show preliminary benefit 1

Assistive devices: 1

• Clitoral vacuum suction devices for women
• Vibration devices to enhance arousal

Step 4: Psychosexual Counseling

Provide counseling through multiple sessions including partners when possible, using a psychosocial framework with cognitive behavioral therapy and social support. 5 This is particularly important given the strong associations between sexual dysfunction and depression/anxiety in MS. 2

Address specific concerns: 4

• Body image issues related to disability
• Communication strategies for couples
• Adaptation of sexual activities to accommodate physical limitations
• Timing of sexual activity when energy levels are optimal

Practical Positioning and Activity Modifications

Recommend position adaptations for motor weakness or spasticity: 5

• Side-lying positions reduce energy expenditure
• Use of pillows for support and comfort
• Non-coital sexual activities when intercourse is not feasible
• Timing sexual activity when well-rested and after bladder/bowel management

Documentation and Follow-Up

Document all assessments and interventions using the BETTER framework's "Record" component. 5 Schedule regular follow-up to reassess sexual function, as improvement can continue over time and needs may change with disease progression. 5

Critical Caveats

• Never assume age or relationship status precludes sexual concerns; assess all MS patients regardless of demographics 5
• Sexual dysfunction may worsen over time despite stable neurological status due to accumulating psychosocial factors 2
• Partner involvement is essential for optimal outcomes, as relationship dynamics significantly impact sexual satisfaction 5
• Multidisciplinary team approach involving neurology, urology, psychology, and physical therapy yields better outcomes than single-provider management 1, 4