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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2745_Библиотеки_им_академика_М_И_Перельмана
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Male Female
Erectile Dysfunction
Inability to achieve and maintain erection
Able to achieve but not maintain an
erection
Ejaculatory Dysfunction
Premature ejaculation
Retrograde ejaculation
Anejaculation
Delayed ejaculation
Reduced libido
Anorgasmia
Dyspareunia
Loss of libido
Fatigue
Decreased tactile sensation
Decreased or absent orgasm
Arousal issues
Reduced enjoyment
Depression
Frequent urinary tract
infection
Vaginal dryness
Dyspareunia
In females, (Table 17.12) sexual dysfunction occurs in all
subtypes of MS. Sexual dysfunction occurs irrespective of the
type of MS. The most common symptom complaint of females
is impaired or absent genital sensations, vaginal dryness,
orgasmic dysfunction, loss of libido, and dyspareunia. Other
symptoms are present but to a lesser extent reported.
33
Time since the diagnosis of MS is not a predictor of sexual
dysfunction. The main difference between male and female
sexual dysfunction is the role the loss of libido plays in the
quality-of-life issues. In females, the loss of libido is
associated with relationship/intimacy issues, whereas in males,
libido is associated with sexual function. Libido is negatively
affected by increasing age equally in both sexes.
44
Case Study
A 47-year-old white male with relapsing remitting MS
presents with complaints of erectile dysfunction (ED).
Before his ED presentation, he complained of urge
incontinence, bladder pain from detrusor overactivity, and
bladder neck dysfunction manifested as incomplete bladder
emptying and a slow stream. These lower urinary tract
complaints distracted and interfered with his attempts at
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intimacy. These symptoms were being successfully managed
with an anticholinergic and an alpha blocker.
His erectile dysfunction is characterized by inconsistent
morning erections, intact libido, a “partial erection,” which
at times is “barely capable of vaginal penetration,” or as he
stated, “the erection was stuffable.” The clear majority of
time, the erection is not adequate for vaginal penetration.
When he can penetrate, he reaches orgasm quickly and loses
the erection. He is not able to satisfy not only himself but
more importantly to him, his partner. There is significant
performance anxiety, relationship fears, and depression. The
depression was managed with a selective serotonin reuptake
inhibitor. His medical history is significant for hypertension,
controlled with thiazide diuretics and beta blockers, and
hypertriglyceridemia managed by fenofibrate therapy. There
is no family history of urologic malignancy. He complains of
late day fatigue. He had a former tobacco use of one-half
pack per day for 10 years. He quit smoking 12 years ago.
Alcohol consumption is limited to 2 to 3 beers or 1 to 2
mixed cocktails on weekends. He is 20 pounds overweight.
Comorbid factors affecting his erectile function are obesity,
hypertriglyceridemia, antihypertensive medications, past
history of tobacco use, anxiety/depression, and psychotropic
medication.
Evaluation
In the patient with MS, sexual dysfunction can be the
presenting symptom of other shared comorbid diseases (Table
17.13).
37,65
It can occur because of patient exposures to
medications (Table 17.14),
66,67
medical therapy, radiotherapy,
or surgical therapies. A thorough history and focused physical
assessing medical, surgical, and psychosocial issues along
with requisite laboratory testing is initiated (Tables 17.15 and
17.16).
TABLE 17.13
Medical Conditions Associated With Erectile Dysfunction in Males and
Females
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Male Female
Male Female
Diabetes mellitus
Hypertension
Cardiovascular disease
Hypercholesterolemia
Benign prostate enlargement
Obstructive urinary symptoms
BMI > 30
Physical inactivity
Cigarette abuse
Antidepressant drug use
Antihypertensive medications
Psychosocial issues
Increasing age
Menopause
Age of partner
Partner sexual dysfunction
Bladder control issues
Depression
Tobacco use
HIV infection
Diabetes mellitus
Sleep panes
Hypothyroidism
Poor general health
BMI, body mass index; HIV, human immunodeficiency virus.
TABLE 17.14
Medications Associated With Sexual Dysfunction
Male Female
Antihypertensives
Diuretics
Beta blockers
Antiandrogens
5-alpha reductase inhibitors
LHRH agonists
Opiates
Alcohol
Tobacco use/abuse
Antiretroviral agents
Antipsychotics
SSRI
Baclofen
H-2 receptor antagonists
Antiandrogens: spironolactone
Anticonvulsants
Anticholinergics
Antiestrogens
Antihistamines
Corticosteroids
Antihypertensives
Diuretics
Beta blockers
Calcium channel blockers
Contraceptives
Metoclopramide
Metronidazole
Alcohol
Amphetamines
Opiates
LHRH, luteinizing hormone-releasing hormone; SSRI,
selective serotonin reuptake inhibitor.
TABLE 17.15
Specialized Testing for Sexual Dysfunction
66,67,75,76
Male Female
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Male Female
Specialist testing: Nocturnal penile
tumescence, sacral evoked potential,
intracavernosal injection separately or with
color duplex Doppler ultrasound, penile
brachial index, dynamic
cavernosometry/cavernosography, internal
pudendal arteriography, bulbocavernosus
reflex latency, biothesiometry-vibratory
thresholds
Specialist testing: sacral evoked
potential, pudendal evoked
potential, genital sensation:
vibration perception thresholds;
temperature perceptions, pressure
volume changes—vaginal
compliance/elasticity, vaginal
lubrication measurements, genital
blood flow
TABLE 17.16
Sexual Function/Quality of Life Questionnaires
68-74
Male Female
Questionnaires: International Index of
Erectile Function (IIEF), Multiple
Sclerosis Intimacy and Sexuality
Questionnaire (MSISQ-19), Sexual
Quality of Life Questionnaire-Male
Version (SQoL-M)
Questionnaires: Multiple Sclerosis
Intimacy and Sexuality Questionnaire
(MSISQ-19), Sexual Quality of Life
Questionnaire-Female Version
(SQoL-F), Female Sexual Function
Index (FSFI)
Case Study
Referral to a urologic specialist for sexual dysfunction
disease management was made. The patient’s hormonal
profile assessment was normal and neurourologic
examination was normal. The International Index of Erectile
Function was abnormal. The nerve conduction sacral evoked
potential study showed prolonged bulbocavernosus reflex
nerve responses bilaterally, indicating a neurological
etiology for his erectile dysfunction. Nocturnal penile
tumescence studies were abnormal.
Treatment
36,37,65-67,75
Patient education
Aggressive symptom management
a. Identify MS symptoms that interfere with intimacy
b. Assess MS therapies for unintended effect on sexual
function
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c. Planning for sexual activities
d. Altering medications and/or catheterization
schedules
Counseling with focus on communication skills
a. Body mapping exercise: identifies sensory patterns
that have been altered by MS, alters patterns of
thinking and behaving that contribute to sexual
problems
b. Cognitive behavioral therapy with focus on
communication skills training
i. Three phases
Educational: teaches the educational
framework for understanding sexual and
communicative problems
Rehearsal phase: teaches the patient with
MS skills that improve and correct
communication problems
Application phase: teaches applying those
learned communication skills in the affairs
of day-to-day life
Gender-specific therapies
a. Male
i. Psychotherapy
ii. PDE5 inhibitors: sildenafil, vardenafil,
tadalafil, avanafil
iii. Muse intraurethral alprostadil
iv. Intracavernosal injection therapies
PGE-1 (alprostadil)
Trimix: alprostadil + papaverine +
phentolamine
v. Vacuum erection device
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vi. Hormonal replacement: testosterone
replacement
vii. Vibratory stimulation
viii. Dopamine agonists, apomorphine
ix. Ejaculatory dysfunction: yohimbine and
midodrine
x. Penile prosthesis: semirigid, two-piece/three-
piece inflatable prosthesis
b. Female
i. Psychotherapy
ii. Lubricants
iii. Hormonal therapy: estrogen replacement;
testosterone therapy
iv. PDE5 inhibitor: sildenafil (limited benefit)
v. EROS-CTD vacuum device
vi. Vibratory stimulation
Case Study
The patient was treated with referral to a nutritionist to help
with weight loss, a change in antihypertensives with
angiotensin II receptor blockers added to the alpha blocker
prescribed for bladder neck dysfunction, and a selective
serotonin reuptake inhibitor with minimal sexual side
effects. Couple therapy and personal counseling were
recommended.
Therapeutic options for this patient were identified and
discussed in a shared decision-making format. Referral to a
urologic specialist for sexual dysfunction disease
management was made. Treatment options available were
vacuum erection device, 5-phosphodiesterase inhibitor
(5PDEi) therapy, intraurethral alprostadil intracavernosal
injection (ICI) therapy, and penile prosthesis implantation.
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He failed first-line 5PDEi therapy but responded to ICI
therapy, which he chose to reestablish his intimate life with.
Sexual dysfunction is a challenging part of the MS disease
process affecting both men and women. It exerts its primary
effect through identifiable and measurable lesions affecting
neural pathways (neurological primary sexual dysfunction),
identifiable physiologic impairments due to demyelinating
lesions in the spinal cord and/or brain, measurable physiologic
impairment involving the hypothalamic-pituitary-adrenal axis
and hypothalamic-pituitary-gonadal axis (neuroendocrine
primary sexual dysfunction), nonsexual physiological changes
affecting sexual response (secondary sexual dysfunction), and
psychosocial and cultural issues that interfere with sexual
satisfaction or performance (tertiary sexual dysfunction). An
integrated plan of treatment should include all respective care
stakeholders in the care and management of the patient with
MS.
33
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