AUA 2016: Sexual Dysfunction in Neurogenic Disorders and their treatment
San Diego, CA USA (UroToday.com): Dr Elliott presented an informative lecture on sexual health in patients with neurogenic lower urinary tract dysfunction (NLUTD). The primary take away was the importance of sexual health in this population and methods (e.g. drugs, device aids) that can be used to promote satisfying sex in this population.
56-72% of women with MS report sexual problems compared to 41% in the general population. In men with MS, 75 – 91% report sexual problems compared to 34% in the general population.
According to Alexander (2011), who has reported on sexual problems in men with spinal cord injuries (SCI), 2/3 to 3/4 can attain an erection but not necessarily maintain it, ejaculatory difficulties is a common complaint with anejaculation reported as the “biggest problem.” Only 40-50% may experience orgasm and most men report that their priority is pleasure during sex, not fertility. Women with a SCI also report sexual issues. Since arousal is dependent on sensory preservation or visceral recognition, lubrication may be the problem. 50% of these women may experience orgasm, indistinguishable in description from non-SCI patients, but it takes longer and requires stronger stimulus for these women to attain an orgasm.
As the orgasmic threshold can be neurologically elevated, lack of genital sensation, a common problem in SCI patients, makes high arousal more difficult. Dr Elliott detailed treatment options for both men and women with NLUTD.
In men, oral phosphodiesterase5 inhibitors (PDE5I) are an indirect method as these drugs need release of nitric oxide (NO) from either sexual mental stimulus or physical touch. Those men with low and/or peripheral lesions vs central lesions respond less well (e.g., cauda equina vs quad) since there is less NO. Clinicians must prescribe a low dose in men with hypotension (i.e. SCI) and daily Cialis can be very useful in most NLUTD patients (less in quadriplegics). As intracavernosal delivery (injection therapy) is directed at the neurotransmitter, these injections can be very effective in the NLUTD population. But the patient must have good hand function so may need assistance from a partner. They must be taught and dosed carefully as there is a risk of priapism in this population. As to dosing, Dr Elliott recommended use of monotherapy first, before going adding papaverine/phentolamine. In a MS exacerbation, worsening symptoms may require lower dose. Low SCIs may not do well on intracavernosal injections because of a venous leak so the use of penile rings may be necessary. Dr Elliott teaches injection- therapy using saline and men do not get a prescription until they view a video on self-injection. She also recommends a vacuum erection device (VED) to male patients (e.g. Parkinson's). But in many of the NLUTD patients, combination therapy may be required and these patients should only be treated by experienced physicians/clinicians. Dr Elliott discussed all the vibrators for men with neurogenic ejaculatory dysfunction, noting that the “Viberect” is FDA approved. She cautioned that there is a risk autonomic dysreflexia in SCI patients who use these devices.
In women, treatments for neurogenic Female Sexual Dysfunction differ from men. Lubrication difficulties and dyspareunia are common. There are a wide variety of lubricants to help in this area. Vibrators are frequently used and there are devices that allow for adaptability for self and partner stimulation. Dr Elliott showed many devices and a good resource for these can be found at http://www.dhrn.ca/files/sexualhealthmanual_lowres_2010_0208.pdf from the Disability Health Research Network. Since PDE5Is only affect erectile tissue, the topical use of these in women may increase sensation due to vasocongestion. Topical use may help about 1/3 of women with MS and some women with incomplete SCI, but it does not directly influence sexual drive or orgasmic capacity. There is now an oral medication for female sexual dysfunction as Addyi (flibanserin) was FDA approved in 2015. Flibanserin is designed to help pre-menopausal women with Hypoactive Sexual Desire Disorder. But this medication has not been tested in the neurogenic population and according to Dr Elliott; it is unlikely to make a difference in this population. The most commonly reported adverse events included dizziness, nausea, feeling tired, sleepiness, and trouble sleeping, but most were mild to moderate.
Dr Elliott discussed other problems that can affect sexual health and function, namely urinary and fecal incontinence that may occur during sexual acts. Urinary incontinence secondary to NLUTD is a top priority for sexuality in these women. Women are more likely to have leakage of either urine or stool with partner pressure of sexual activity (e.g. missionary position). Women with MS report a major fear and embarrassment of incontinence during sex, they find this “mortifying.” Incontinence causes these women to withdraw from sexual activity or the urine or bowel leakage can take away the pleasure, as they have to do elaborate preparation to prevent it. They worry about having an odor and would dread or avoid oral sex. Many fake pleasure and disguise the urine leakage.
This was a very informative leakage for clinicians who treat men and women with NLUTD. The information on devices that can aid sexual pleasure can be used in all populations.
Presented by: Stacy Elliott, MD. Director, BC Center for Sexual Medicine, Co-Director Vancouver Sperm Retrieval Clinic, Clinical Professor, Departments of Psychiatry & Urologic Sciences, University of British Columbia
Written by:
Diane K. Newman, DNP, Adjunct Professor of Urology in Surgery, Research Investigator Senior Co-Director, Penn Center for Continence and Pelvic Health
University of Pennsylvania, Division of Urology, 3400 Spruce Street, 3rd Floor Perelman Bldg, Philadelphia, PA. 19104
References:
Alexander MS, Biering-Sørensen F, Elliott S, Kreuter M, Sønksen J. International spinal cord injury female sexual and reproductive function basic data set. Spinal Cord. 2011 Jul;49(7):787-90.
Alexander MS, Biering-Sørensen F, Elliott S, Kreuter M, Sønksen J. International spinal cord injury male sexual function basic data set. Spinal Cord. 2011 Jul;49(7):795-8
Sipski ML, Arenas A. Female sexual function after spinal cord injury. Prog Brain Res. 2006;152:441-7