Rate, burden, and treatment of sexual dysfunction in multiple sclerosis: The case for exercise training as a new treatment approach

doi:10.1016/j.msard.2021.102878

Multiple Sclerosis and Related Disorders

Volume 51, June 2021, 102878

https://doi.org/10.1016/j.msard.2021.102878 Get rights and content

Highlights

•
Prevalence, burden, and management of sexual dysfunction, in persons with MS.
•
Predictors of sexual dysfunction, in persons with MS.
•
Providing a research agenda for a deeper and broader understanding of exercise training and sexual function in MS.

Abstract

Multiple sclerosis (MS) is a prevalent immune-mediated and neurodegenerative disease of the central nervous system (CNS) among adults in the United States and worldwide. This disease results in impairments of physical, psychological, and social functions that compromise quality of life. This review focuses on sexual dysfunction, including its prevalence, burden, and management, in persons with MS. Sexual dysfunction is defined as sexual behaviors and experiences characterized as insufficient in quality, duration and frequency. Sexual dysfunction occurs in 40–80% percent of women and 50–90% percent of men with MS. The presence of sexual dysfunction is seemingly predicted by psychological and psychiatric issues such as depression and anxiety; sociodemographic dimensions such as older age, unemployment and lower socioeconomic status; and MS-related issues such as fatigue, higher degree of disability and motor impairments. Sexual dysfunction in persons with MS is further associated with decreased psychological and psychosocial wellbeing and impaired quality of life. There is limited research supporting pharmacological and other approaches for managing sexual dysfunction in MS, and we make the case for exercise training based on recent evidence from randomized controlled trials in MS and putative mechanisms of action targeted by exercise training in MS. This paper concludes by providing a research agenda for a deeper and broader understanding of exercise training and sexual function in MS.

Introduction

Multiple sclerosis (MS) is an immune-mediated and neurodegenerative disease of the central nervous system (CNS) (Thompson et al., 2018) with a prevalence of 1 million adults in the United States (Wallin et al., 2019) and 2.5 million worldwide (Reich et al., 2018). This disease and its associated CNS damage result in impairments of physical, psychological, and social functions that compromise quality of life and independence. Some of the commonly noted deficits and outcomes of MS include motor and cognitive dysfunction (Amato, 2018; Brauers et al., 2019; Motl et al., 2017), depression (Boeschoten et al., 2017), sleep disturbances (Braley, 2018; Braley and Boudreau, 2016; Sadeghi Bahmani et al., 2020b; Veauthier, 2015), and symptoms of pain and fatigue (Braley and Chervin, 2010; Induruwa et al., 2012). Those manifestations of MS have typically been managed through a combination of pharmacological treatments and rehabilitation approaches, including exercise training (Motl and Pilutti, 2012; Motl et al., 2017).

There are other outcomes of MS that have received less research attention regarding prevalence, burden, and management. This paper provides a focal overview of sexual dysfunction and its management in MS, and it makes the case for exercise training as a potential novel approach for treatment. The review initially focuses on the definition, measurement, prevalence, predictors, and consequences of sexual dysfunction in MS. We then provide an overview of current approaches for the management and treatment of sexual dysfunction in MS. This provides the context for our novel proposition regarding the management of sexual dysfunction in MS via exercise training – the proposition is based on evidence from the general population of adults and recent results concerning MS. The paper concludes by setting out a research agenda for a deeper and broader understanding of exercise training and sexual function in MS.

Section snippets

Definition and diagnosis

The study of sexual disorders and sexual dysfunction in MS should be guided by clear and accepted definitions for identification and diagnosis. The 5th Edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-5), for example, defines a ‘sexual disorder’ as sexual behaviors and experiences characterized as insufficient in quality, duration or frequency. The definition is further qualified based on frequency of occurrence, namely 75–100% of sexual behaviors and

Current approaches for the management and treatment of sexual dysfunction in MS

Sexual dysfunction is common and burdensome, and this underscores the importance of its management in MS. The management may differ by gender, but generally includes a) pharmaceutical and b) educational/psychotherapeutic treatments (Bronner et al., 2010; Cordeau and Courtois, 2014; Drulovic et al., 2020).

Management of sexual dysfunction using exercise training – evidence from the general population

The prevalence, burden, and poor management of sexual dysfunction in MS supports the search for possible alternative or concomitant treatments such as exercise training. Exercise training, defined as planned, structured, and repetitive physical activity performed over time with the intention or goal of improved or maintained health-related fitness, has pleiotropic effects in the general population and MS (Motl and Pilutti, 2012; Motl et al., 2017). Exercise training is associated with benefits

Exercise training as a treatment for sexual dysfunction in MS

The evidence in the general population sets the stage for examination of exercise training and sexual dysfunction in MS. We identified and reviewed only two studies that have examined exercise and sexual dysfunction in MS. The first study investigated the impact of regular yoga on sexual dysfunction in females with MS who had sexual dysfunction (Najafidoulatabad et al., 2014). Sixty women with MS were randomly into either a yoga condition or a passive control condition (i.e., participants in

Exercise training and sexual function in individuals with MS – putative mechanisms

The initial evidence of benefits regarding exercise and physical activity for sexual dysfunction in MS (Najafidoulatabad et al., 2014; Sadeghi Bahmani et al., 2020b) supports consideration of the mechanisms underlying these putative benefits. The focus on mechanisms may inform our understanding of why these behaviors work and may further inform the design of future trials in this area by targeting the mechanisms of action.

Given that tertiary sexual dysfunction is associated with psychosocial

Research agenda

To date, there is limited, but promising, research on the benefits of exercise training for sexual dysfunction in healthy people, persons with psychiatric issues (e.g., major depressive disorders; anxiety disorders), and persons with MS. We therefore offer a research agenda that could guide future research on exercise and sexual dysfunction in MS. This includes eight focal research questions.

1
Is there a form of exercise (e.g., endurance training or resistance training) that might be particularly

Conclusion

There is growing interest in sexual dysfunction in MS, although a general methodological issue is that most data are provided from cross-sectional studies, often without a control or comparison group (Mohammadi et al., 2020; Nazari et al., 2020) and rough and coarse-grained items (Zhao et al., 2020). This is based on evidence that people with MS report higher rates of sexual dysfunction than do adults in the general population, and there is evidence of secondary consequences and poor management

Declaration of Competing Interest

All authors declare no conflicts of interest.

Funding/Support

This research was supported by a Mentor-based Postdoctoral Fellowship from the National Multiple Sclerosis Society (Grant MB 0029).

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Applying different MSISQ-19 cut-offs influences both the estimated prevalence and the identification of risk factors for SD, a finding that should be considered during study planning and data interpretation. Preserved cognition exerts a protective effect towards SD regardless from the specific study setting, representing a key point for the implementation of preventive and therapeutic strategies.
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Low sexual function and satisfaction are common problems among people with multiple sclerosis (PwMS), but the literature on which patient variables are associated with these issues is inconsistent.
To investigate the associations between sexual function and satisfaction in PwMS with clinical, demographic, and patient-reported quality of life (QOL) measures and determine if sex differences exist.
This analysis includes PwMS enrolled in the Comprehensive Longitudinal Investigation of Multiple Sclerosis at the Brigham and Women's Hospital (CLIMB), who completed patient-reported outcome measures: Multiple Sclerosis Quality of Life-54 (MSQOL-54), Modified Fatigue Impact Scale (MFIS), and Center for Epidemiologic Studies Depression Scale (CES-D). Regression models were used to analyze associations between patient variables and function and satisfaction. Results were stratified by sex. Cross-sectional and longitudinal data were used.
702 PwMS (526 females,176 males, mean age 42.2 +/-11.1, median EDSS 1.5) were included in the cross-sectional analysis. Data from 341 PwMS were used in the three-year longitudinal analysis. Increasing age, disease duration, and disability were associated with reduced sexual function and satisfaction to the same degree in males and females. However, sex differences existed in the strength of associations with QOL variables. There was no significant longitudinal change in females or males.
Age and disease duration were associated with reduced sexual function and satisfaction in males and females. In females, function was significantly associated with disability and satisfaction with fatigue. Males had stronger associations with sexual function in domains related to emotional well-being, health perceptions, and overall QOL. Males had stronger associations with satisfaction in emotional and social functioning and physical health domains. These findings can help better understand the multidimensional problems of sexual function and satisfaction in PwMS and better guide patient care.
Effects of Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Stress Reduction (MBSR) on symptoms and emotional competencies in individuals with multiple sclerosis
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Citation Excerpt :
MS imposes a heavy burden in terms of suffering and loss of function, and psychosocial treatments play a key role in maximizing quality of life for patients with MS. MS results in impairments in physical, psychological, and social functions that compromise quality of life and independence (Sadeghi Bahmani and Motl, 2021). Typically, compared to the general population, individuals with MS report higher levels of insomnia (Sadeghi Bahmani et al., 2020,2019), depression (Boeschoten et al., 2017), fatigue (Braley and Chervin, 2010; Induruwa et al., 2012), and paresthesia (Razazian et al., 2016; Sanders and Arts, 1986).
Compared to the general population, individuals with multiple sclerosis (MS) report higher levels of insomnia, depression, fatigue, and paresthesia, and lower levels of emotional competencies (understanding emotions in self and others). Available treatments are limited, and novel approaches to reducing symptoms and enhancing emotional competencies in MS are needed. Two potentially beneficial treatments are Acceptance and Commitment Therapy (ACT) and Mindfulness-Based Stress Reduction (MBSR). The aim of the present study was to investigate the impact of ACT and MBSR on symptoms and emotional competencies in patients with MS.
A total of 76 individuals with MS (81.6% females; mean age: 38.88 years; EDSS median: 2; range: 0–5) were randomly assigned to an 8-week ACT treatment, an 8-week MBSR treatment, or a wait-list control condition. At baseline and study-end (week 8), participants completed a series of questionnaires covering symptoms and emotional competencies. At mid-term (week 4), participants rated their insomnia and depression.
Over time, symptoms of MS decreased (medium effect size for insomnia, fatigue, and paresthesia, and large effect size for depression) and emotional competencies improved (large effect size), but more so in the MBSR and ACT conditions, compared with the control condition. At study-end, the outcome improvement did not differ between the ACT and MBSR conditions.
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Citation Excerpt :
To define sexual disorders, the DSM-5 (American Psychiatric Association, 2013) states that a ‘sexual disorder’ is understood as sexual behaviors and experiences characterized as insufficient in quality, duration or frequency. The frequency of occurrence of such unsatisfying sexual behaviors and experiences is between 75 and 100% of sexual behaviors and experiences (IsHak and Tobia, 2013), which further must be present for a minimum of six months, and which must also cause significant distress (see for comprehensive overview: Sadeghi Bahmani and Motl, 2021). If the duration of such unsatisfying sexual behaviors is less than six months or does not lead to serious distress, then this is labelled as a “dysfunction” (van Lankveld, 2018; American Psychiatric Association, 2013).
For men, early ejaculation is a serious health concern. Here, we tested the influence of modafinil (Profinil®) on early ejaculation. To this end, we performed a double-blind randomized clinical trial among men with early ejaculation.
A total of 46 men with early ejaculation (mean age: 37.35 years) and in stable marital relationships with regular weekly penile-vaginal intercourse were randomly assigned either to the modafinil (100 mg) or to the placebo condition. Compounds were taken about 4–6h before intended penile-vaginal intercourse. At baseline and four weeks later at the end of the study, participants completed a series of self-rating questionnaires covering early ejaculation. Female partners also rated their male partners’ early ejaculation profile.
Dimensions of early ejaculation improved over time, but only so in the modafinil condition, while no improvements were observed in the placebo condition.
Among male adults in stable marital relationships with regular weekly penile-vaginal intercourse modafinil improved dimensions of early ejaculation, always compared to placebo. Given the strong effect of modafinil on cognitive-executive processes, it is conceivable, that modafinil acted both via physiological and cognitive-executive pathways.
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Review articleRate, burden, and treatment of sexual dysfunction in multiple sclerosis: The case for exercise training as a new treatment approach

Highlights

Abstract

Introduction

Section snippets

Definition and diagnosis

Current approaches for the management and treatment of sexual dysfunction in MS

Management of sexual dysfunction using exercise training – evidence from the general population

Exercise training as a treatment for sexual dysfunction in MS

Exercise training and sexual function in individuals with MS – putative mechanisms

Research agenda

Conclusion

Declaration of Competing Interest

Funding/Support

Mult Scler Relat Disord

Best Pract Res Clin Rheumatol

J Neurol Sci

Taiwan J Obstet Gynecol

Biomed Pharmacother

Sleep Med Rev

Med Clin North Am

Ann Phys Rehabil Med

J Sex Med

Psychiatry Res

J Sex Med

J Neurol Sci

J Sex Med

J Sex Med

Lancet Neurol

J Neurol Sci

Mult Scler Relat Disord

Urology

Mult Scler Relat Disord

J Psychiatr Res

Sex Med Rev

Lancet

Sex Med Rev

J Sex Med

Flibanserin and its discontents

Arch Womens Ment Health

A decline in cognitive function should lead to a change in disease-modifying therapy - Commentary

Mult Scler

Diagnostic and Statistical Manual of Mental Disorders

Ospemifene for the treatment of menopausal vaginal dryness, a symptom of the genitourinary syndrome of menopause

Expert Rev Endocrinol Metab

Increased risk of erectile dysfunction in men with multiple sclerosis: an Italian cross-sectional study

Cent European J Urol

Improvements in partner support predict sexual satisfaction among individuals with multiple sclerosis

Rehabil Psychol

Lack of exercise is a major cause of chronic diseases

Compr Physiol

Bladder and sexual function among women with multiple sclerosis

Mult Scler

Sleep Disorders in patients with Multiple Sclerosis

Pract Neurol

Sleep Disorders in Multiple Sclerosis

Curr Neurol Neurosci Rep

Fatigue in multiple sclerosis: mechanisms, evaluation, and treatment

Sleep

Measuring Motor Fatigability in the Upper Limbs in Individuals With Neurologic Disorders: a Systematic Review

Arch Phys Med Rehabil

Female sexuality in multiple sclerosis: the multidimensional nature of the problem and the intervention

Acta Neurol Scand

Evolutionary Psychology. The new Science of the Mind

Sexual dysfunction in male patients with multiple sclerosis: a need for counseling!

Int J Neurosci

Sexual Function in Young Individuals With Multiple Sclerosis: does Disability Matter?

J Neurosci Nurs

Subjective Sexual Well-Being in Chilean Adults: evaluation of a Predictive Model

J Sex Marital Ther

Functional treatments in multiple sclerosis

Curr Opin Neurol

The evaluation and management of female sexual dysfunction

J Fam Pract

Multiple sclerosis and sexual dysfunction: a need for further education and interdisciplinary care

NeuroRehabilitation

Multiple sclerosis patients with and without sexual dysfunction: are there any differences?

Multiple Sclerosis Journal

Multiple sclerosis patients with and without sexual dysfunction: are there any differences?

Mult Scler

Review article
Rate, burden, and treatment of sexual dysfunction in multiple sclerosis: The case for exercise training as a new treatment approach