International Journal of Impotence Research (1998) 10, 233±237 ß 1998 Stockton Press All rights reserved 0955-9930/98 $12.00 http://www.stockton-press.co.uk/ijir Ð A comprehensive pilot-study into etiology PEM Lottman 1, PJH Jongen 2,3, PFWM Rosier 1 and EJH Meuleman 1 1 Department of Urology; 2 Department of Neurology, University Hospital Nijmegen, PO Box 9101, 6500 HB, Nijmegen; and 3 Multiple Sclerosis Centre Nijmegen, Snelliusstraat 6, 6533 NV Nijmegen, The Netherlands Ideally, the etiological diagnosis of sexual dysfunction in patients with multiple sclerosis is established on the basis of both objective and subjective tests. Accordingly, we assessed sexual function in 16 male patients with multiple sclerosis and complaints of sexual dysfunction by means of subjective data from interviews and questionnaires and objective data, obtained from (psycho)physiological tests. Psychophysiological investigation consisted of measurement of sleep erections and of erectile response to visual erotic stimulation and penile vibration. Urodynamic investigation was used to assess the neurological status of the genital tract. Sixteen male patients with clinically de nite multiple sclerosis, complaints of sexual dysfunction and a steady heterosexual relationship participated in the study. The majority of patients had no abnormalities in the objective tests. Only one (1 out of 15) patient showed disturbed sleep-erections, and four (4 out of 12) other patients showed signs of neurological dysfunction of the genital tract. Conclusion: in our patient-group, disturbed sleep erections and abnormal ndings on urodynamic investigation appeared unrelated to the complaint of erectile dysfunction. Sexual function was related to psychological factors, decreased general sensitivity, and motor impairment. Keywords: etiology; sexual dysfunction; multiple sclerosis Introduction Multiple sclerosis may affect sexual functioning in many different ways through interference with physiological and psychological mechanisms involved in sexual function. 1 Lesions in the spinal cord may affect the genital neurological pathways and cause erectileand ejaculatory dysfunction, whereas lesions in the brain may cause disorders of sexual desire and alter the sensation of orgasm. Furthermore, decreased sensitivity and pain may interfere with the capacity to achieve or maintain erection and orgasm through tactile stimulation. In addition, patients with muscular weakness or spasticity may experience motor limitations during sexual activity. Finally, multiple sclerosis may affect sexual life through psychological and social factors: loss of personal identity, anxiety, depression, dependency, and dif culty to cope with invisible symptoms, such as fatigue and sensory changes. 2 Traditionally, sexual dysfunction in patients with multiple sclerosis has been classi ed on subjective data from interviews and questionnaires. 2±4 Only a Correspondence: Dr PEM Lottman. Received 2 August 1997; accepted in revised form 7 April 1998 few studies used objective data based on neurophysiological tests and measurement of sleep-erections to identify the etiology of sexual dysfunction. Staerman et al 5 found abnormal pudendal evoked potentials in 14 out of 16 patients with multiple sclerosis and erectile dysfunction, and abnormal bulbo-cavernosus re ex in four patients. He reported normal sleep-erections in more than half of the patients with neurophysiological abnormalities. In addition, Kirkeby et al 6 found neurophysiological abnormalities in 90% of the patients with multiple sclerosis and erectile dysfunction, and normal sleep-erections in 42% of these patients. However, due to the scarcity of objective data on physiological and psychological factors that are associated with sexual dysfunction in patients with multiple sclerosis, it is dif cult to draw conclusions on their relative contribution to the occurrence and maintenance of sexual dysfunction. In this pilot-study we investigated the etiology of sexual dysfunction in 16 patients with clinically de nite multiple sclerosis 7 and complaints of sexual dysfunction by means of psychological, psychophysiological, and physiological tests. Psychological tests included interviews and questionnaires about psychosexual functioning and marital satisfaction. Psychophysiological investigation consisted of measurement of sleep-erections and erectile
234 response to visual erotic stimulation and penile vibration. Physiological assessment included urodynamic investigation to evaluate the sensory and motoric neurological status of the genital tract indirectly. Material and methods Patients were recruited on the department of Neurology where they were treated for multiple sclerosis. The median age of the patients was 41.0 y (range 31 ± 54). The age at onset of multiple sclerosis varied between 18 and 49 y (median 31.5) and the duration of the disease varied between 2 and 26 y (median 10.5). Four patients were able to walk without restrictions, whereas eight patients used walking-aids and four patients were wheelchairbound. Nine patients were employed and seven patients were retired due to their illness. Fifteen patients had a steady heterosexual relationship and were married or in committed relationships for 13.0 y (median, range 2 ± 29). At the moment of the interview, one patient had recently divorced his wife. Before investigation, written informed consent was obtained from patients. Patients underwent a psychosexological assessment by means of interviews and questionnaires. Following psychosexological assessment, erectile responses to visual erotic stimulation with and without vibration were measured. Sleep erections were measured on three consecutive nights. Urodynamic investigation was performed within the period between six months before and after the psychophysiological assessment in 12 patients. Motor function of the pelvic oor muscles, re exes in the sacral segments, and sensitivity of the genital area were tested in respectively seven, nine and six patients within the aforementioned period. The nature of the sexual problem, psychological factors (depression, anxiety, fear of failure), relationship issues, physiological factors (decreased sensitivity, pain, motor impairment) and sexual performance status were assessed in a semi-structured interview and by means of three questionnaires: the Questionnaire for screening Sexual Dysfunctions, 8 the Maudsley Marital Questionnaire, 9 and the Symptom Checklist 90. 10 The Questionnaire for screening Sexual Dysfunctions consists of 76 questions to assess sexual problems. We focussed in this study on six of the 12 subscales, frequency of (score 1 ˆ almost never; 3 ˆ frequently; 5 ˆ always) and trouble with (score 1 ˆ no trouble; 3 ˆ trouble; 5 ˆ very much trouble) the following sexual problems: erectile problems (6 items), sexual excitement problems (6 items), ejaculation problems (4 items), orgasm problems (6 items), genital pain (2 items), and genital insensitivity (4 items). 11 We compared scores on these subscales between our group of patients and 16 men of similar age selected from a normal healthy population. 12 The Maudsley Marital Questionnaire consists of twenty Likertscale questions that evaluate marital, social satisfaction, and sexual satisfaction. We focussed on the subscale for marital satisfaction (5 items; score 0 ± 40). Marital satisfaction is considered normal if the score for marital items is < 20. 13 The Symptom Checklist 90 is a self-report inventory that consists of ninety questions to assess psychological symptoms. We focussed in this study on scores for depression and anxiety. The score for depression and anxiety is considered to be within normal range if the Symptom Checklist 90-score is < 23 and < 15, respectively (namely, according to the criteria for the normal healthy population, Derogatis et al 14 ). Quality of erectile response to visual erotic stimulation with and without vibration was measured with Rigiscan 1. The Rigiscan device provides simultaneous, continuous measurement of both tumescence and rigidity. Vibration was administered with a ring-shaped vibrator at a frequency of 50 Hz. Visual erotic stimulation consisted of two heterosexual erotic lms showing various types of sexual activities. After placing the two wire loops of the Rigiscan at the penile base and tip, the vibrator was positioned at the penile shaft between the wire loops. The subject viewed two erotic lms, each of 10 min length, sitting in a comfortable chair in front of a video monitor. The rst lm was presented without vibration and the second lm with vibration. After each lm the subject was asked to ll in a form containing questions about subjective arousal, genital and extragenital sensations, together with the maximal degree of erection he experienced during the lm. We considered an increase 15 mm of tumescence as a cut-off value of erectile response. 15,16 Sleep erections were measured on three consecutive nights using the Erectiometer. 17 The Erectiometer consists of a 2 cm-wide felt band with a sliding collar fastened to one end. The band requires a force of about 250 g to initiate expansion. For this reason, the device responds when penile tumescence involves increases in both circumference and rigidity. All patients were instructed in the use and interpretation of the Erectiometer. The patients were requested to ll in the results of the Erectiometer in a diary at home and to return this together with the Erectiometer. It is well documented that sleep erections are suppressed by depression, anxiety and disturbed sleep. 18,19 Therefore, we explicitly investigated these items and asked patients to report their sleep performance during the nights of the measurement of sleep erections. The relevant parameters of urodynamic investigation consisted of cystometry and pressure- ow study together with electromyography registration of the pelvic oor muscles. Early or late rst
sensations during storage, hypoactivity, overactivity and dyssynergia were considered to be indicative of the presence of neurological lesions. Results Data obtained from interviews indicated that 15 patients experienced sexual dysfunction following the diagnosis of multiple sclerosis, whereas in one patient the sexual dysfunction preceded the diagnosis. Fourteen men attributed sexual dysfunction to multiple sclerosis and two men to marital problems or fatigue. The majority of patients reported that their sexual dysfunction had a gradual onset, only three patients reported it started abruptly. Six patients responded with performance-anxiety and feelings of disappointment. Although the majority of men reported a satisfactory sexual relationship (10 out of 15), most of these patients (9 out of 10) said to be dissatis ed with their sexual functioning. The scores on the Questionnaire for screening Sexual Dysfunctions showed that: seven patients experienced erectile problems, four patients orgasm problems, three patients ejaculation problems (remarkable only one patient was troubled by this problem), and three patients genital insensitivity; genital pain was only experienced by one patient. Table 1 shows the mean scores on six subscales of the Questionnaire for screening Sexual Dysfunctions in our group of patients in comparison to a population of normal healthy males of similar age. 12 Note that patients with multiple sclerosis showed a higher frequency and were more troubled with erectile problems, orgasm problems and genital insensitivity. In the majority of patients sexual function was impaired by motor limitations and decreased general sensitivity. Twelve patients reported impaired mobility during sexual activity due to muscular weakness and spasticity. Ten patients reported diminished genital- and extragenital response to sexual stimulation. The scores on the Maudsley Marital Questionnaire showed that the majority of patients (15 out of 16) reported normal marital satisfaction (score < 20). The scores on the Symptom Checklist-90 indicated that four patients experienced anxiety and three patients depression. Table 2 shows the mean scores of the Symptom Checklist-90 in our group of patients in comparison with a normal healthy male population and a outpatient psychiatric population. Note that depression and anxiety scores in our group of patients is comparable with the healthy population. Maximal increases in penile circumference in response to visual erotic stimulation (VES), VES and vibration (VES VIB) and during sleep (NPT) of every individual patient are shown in Figure 1. Note that only ve patients responded to visual erotic stimulation with an increase of circumference of more than 15 mm. Furthermore, it is remarkable that visual erotic stimulation in combination with vibration did not enhance erectile response (Two patients showed even a signi cant ( < 15 mm) lower response), and that there was no correlation between sleep-erections (as measured with NPT) 235 Table 1 Mean (s.d.) scores on six subscales of the Questionnaire for screening Sexual Dysfunctions. Both frequency- and trouble-scores are given for 16 patients with multiple sclerosis (MS) and sexual problems (SP) and 16 normal healthy men of similar age 12 MS patients with SP Normal healthy men Item Frequency of a Trouble with b Frequency of a Trouble with b Erectile problems c 2.8 (1.4) 2.8 (1.2) 1.4 (0.4) 1.4 (0.6) Excitement problems 1.4 (0.5) 1.6 (0.8) 1.3 (0.3) 1.3 (0.5) Orgasm problems d 1.9 (1.1) 2.0 (1.1) 1.3 (0.4) 1.2 (0.4) Ejaculation problems 1.5 (1.0) 1.5 (0.9) 1.3 (0.2) 1.1 (0.2) Genital pain 1.2 (0.4) 1.3 (0.6) 1.0 (0.0) 1.0 (0.0) Genital insensitivity d 1.5 (0.6) 1.6 (0.9) 1.0 (0.1) 1.1 (0.1) a Frequency: 1 ˆ (almost) never; 3 ˆ frequently; 5 ˆ always. b Troubled by: 1 ˆ no trouble; 3 ˆ trouble; 5 ˆ very much trouble. c P < 0.01 for difference in both frequency of and trouble with sexual problems between groups. d P < 0.05 for difference in both frequency of and trouble with sexual problems between groups. Table 2 Mean (s.d.) scores on the depression and anxiety scale of the Symptom Checklist-90 in 16 patients with multiple sclerosis (MS) and sexual problems (SP) together with those of a normal healthy male population and an outpatient psychiatric population 14 Variable Normal healthy population MS patients with SP Psychiatric population Depression 20.7 (6.3) 17.8 (5.9) 39.3 (14.4) Anxiety 13.0 (4.3) 12.9 (5.3) 24.5 (9.5)
236 Figure 1 Erectile response to visual erotic stimulation (VES), VES and vibration (VES VIB), and nocturnal penile tumescence (NPT). and stimulated erectile response. Only one patient showed an abnormal sleep-erection, which was not associated with sleeping disorders nor with abnormal psychological functioning in terms of anxiety and depression. Six patients experienced bladder dysfunction. Abnormal ndings on urodynamic investigation were found in four out of twelve patients: two patients with overactivity and dyssynergia and two patients with late sensation and hypoactivity. All patients with abnormal ndings on urodynamic investigation had normal sleep erections. Motor dysfunction of the pelvic oor muscles was found in two out of seven patients. No abnormalities were found in the re exes in the sacral segments (n ˆ 9) and in the sensitivity of the genital area (n ˆ 6). Discussion Sexual problems in our patient-group consisted of erectile-, orgasm-, and ejaculation problems, genital insensitivity and pain. Erectile problems were most often reported. Our patient-group showed a higher frequency and were more troubled by erectile and orgasm problems and genital insensitivity than normal healthy men of similar age. Although the majority of patients was dissatis ed with sexual functioning, they reported a satisfactory sexual relationship. It is remarkable that only one patient with erectile problems appeared to have abnormal sleep-erection. This nding is consistent with the study of Staerman et al. 5 One reasonable explanation for this nding is that in the majority of patients with multiple sclerosis the efferent part of the genital nervous system, through which sleep-erections are generated is intact or consists of suf ent alternative pathways. Consequently, abnormal sleep-erections indicate lesions in the efferent nervous system, after other causes for disturbed sleep-erection such as anxiety, depression, disturbed sleep patterns or drug use are excluded. Abnormal ndings on urodynamic investigation were found in four patients. No relation could be established between the ndings on urodynamic investigation and the quality of sleep-erections: all patients with signs of dysfunction as assessed with urodynamic investigation had normal sleep-erections. There are two possible explanations for this on rst sight remarkable nding. Firstly, erection which mainly relies on central excitatory mechanisms is less susceptive to disturbances in the central nervous system than bladder function, that relies mainly on central inhibitory mechanisms. Secondly, erection is more dependent on the autonomic system than bladder function that is more dependent on the somatosensoric system, which is relatively more susceptible for multiple sclerosis lesions. It may therefore be hypothesized that sexual function in our patients was not primarily related to lesions in the spinal cord, but to supraspinal lesions or psychological factors such as fear of failure, decreased sexual arousal, and secondary erectile- and orgasm problems. Although this hypothesis is supported by the results of the interviews and psychometric tests and the study of Mattson et al, 2 it has to be con rmed in future research consisting of detailed radiological studies of the central nervous system. The predominant physiological factors in our study are loss of genital and extragenital sensation and motor impairment. The average erectile response to visual erotic stimulation is comparable to that in men with nonneurogenic erectile dysfunction in other studies. 18,20 However, in contrast to men with non-neurogenic erectile dysfunction, erectile response was not enhanced by vibration. This nding suggests a decreased sensitivity of the penis to vibration probably due to lesions in the sensory limb of the genital re ex pathway. Although the majority of patients were troubled by sexual problems, professional help was sought by
only a few patients: one patient was treated by a psychologist, and three patients were on intracavernous injection therapy. However, it is noteworthy that the patients in this study reported to appreciate the discussion of their sexual problems. Patients indicated that they were helped by receiving information on possible alternations in their sexual function, and on the different treatment options eventually available for their sexual problems. It appeared to us that quality of life of patients with multiple sclerosis can be improved by sexual counseling only. Conclusion In our patient-group, sleep erections and abnormal ndings on urodynamic investigation appeared unrelated to the complaint of erectile dysfunction. Sexual function was related to psychological factors, decreased general sensitivity, and motor impairment. Acknowledgements The authors would like to thank Professor OR Hommes and Dr PA Vruggink for reading the manuscript and their valuable contributions. References 1 Minderhoud JM et al. Sexual disturbances arising from multiple sclerosis. Acta Neurol Scand 1984; 70: 299 ± 306. 2 Mattson D, Petrie M, Srivastava DK, McDermott M. Multiple sclerosis: sexual dysfunction and its response to medications. Arch Neurol 1995; 52: 862 ± 868. 3 Vas CJ. Sexual impotence and some autonomic disturbances in men with multiple sclerosis. Acta Neurol Scand 1969; 45: 166 ± 182. 4 Lilius HG, Valtonen EJ, WikstroÈm J. Sexual problems in patients suffering from multiple sclerosis. J Chron Dis 1976; 29: 643 ± 647. 5 Staerman F et al. Value of nocturnal penile tumescence and rigidity (NPTR) recording in impotent patients with multiple sclerosis. Int J Impot Res 1996; 8: 241 ± 245. 6 Kirkeby HJ, Poulsen EU, Petersen T, Dorup J. Erectile dysfunction in multiple sclerosis. Neurology 1988; 38: 1366 ± 1371. 7 Poser CM et al. New diagnostic criteria for multiple sclerosis: guidelines for research protocols. Ann Neurol 1983; 13: 227 ± 231. 8 Vroege JA. Vragenlijst voor het signaleren van Seksuele Dysfuncties (VSD), 5de versie. [Questionnaire for screening Sexual Dysfunctions (QSD), 5th version]. AZU=NISSO: Utrecht, The Netherlands, 1994. 9 Arrindell WA, Schaap C. The Maudsley Marital Questionnaire (MMQ): an extension of its construct validity. Br J Psychiat 1985; 147: 295 ± 299. 10 Arrindell WA, Ettema JHM. Symptom Checklist-90: Manual (in Dutch). Swets & Zeitlinger: Lisse, 1986. 11 Vroege JA. Vragenlijst voor het signaleren van Seksuele Dysfuncties (VSD). Codeboek 5de versie. [Questionnaire for screening Sexual Dysfunctions (QSD). Manual 5th version]. AZU=NISSO: Utrecht, The Netherlands, 1995. 12 Vroege JA. Normgegevens VSD. Versie voor mannen met een vrouwelijke partner. Maart 1997. (Data normgroup QSD. Version for men with a female partner. March 1997). [SPSS- 'system le']. Leiden, The Netherlands, Vakgroep Psychiatrie, Rijks Universiteit Leiden, 1997. 13 Arrindell WA. Marital Con ict and Agoraphobia: Fact or Fantasy? Eburon: Delft, 1987. 14 Derogatis LR. SCL-90 Administration, Scoring and Procedures Manual-I. Johns Hopkins: Baltimore, 1977. 15 Rowland DL, Den Ouden AH, Slob AK. The use of vibrotactile stimulation for determining sexual potency in the laboratory in men with erectile problems: methodological considerations. Int J Impot Res 1994; 6: 153 ± 161. 16 Bancroft J, Smith G, Munoz M, Ronald P. Erectile response to visual erotic stimuli before and after intracavernosal papaverine, and its relationship to nocturnal penile tumescence and psychometric assessment. Br J Urol 1991; 68: 629 ± 638. 17 Slob AK, Blom JHM, van der Werff ten Bosch JJ. Erection problems in medical practice: Differential diagnosis with relatively simple method. J Urol 1990; 143: 46 ± 50. 18 Thase ME et al. Diagnostic performance of nocturnal penile tumescence studies in healthy, dysfunctional (impotent), and depressed men. Psychiat Res 1988; 26: 79 ± 87. 19 Pressman MR et al. Problems in the interpretation of nocturnal penile tumescence studies: Disruption of sleep by occult sleep disorders. J Urol 1986; 136: 595 ± 598. 20 Incrocci L, Hop WCJ, Slob AK. Visual erotic and vibrotactile stimulation and intracavernous injection in screening men with erectile dysfunction: a 3 year experience with 406 cases. Int J Impot Res 1996; 8: 227 ± 232. 237