Although Inga is quite able bodied, she is having sexual problems. Sexual dysfunction, which may occur early or late in the course of MS, does not always correlate to the degree of physical disability. Often it is under-recognized and goes untreated. It is present in up to 90 percent of men and in nearly as many women. In women, the most common problems are low libido and altered genital sensation. For men, the major problem is erectile dysfunction.
Sexual dysfunction can be a direct result of demyelination in the central nervous system. Secondary changes are related to poor bladder control or muscle weakness, and psychological, social or cultural issues that interfere with sexual feelings or responses. Examples of the latter include alterations in body image and low self esteem.
Regardless of the cause, sexual dysfunction can adversely affect quality of life and contribute to additional problems. For Inga, it has led to embarrassment, depression and avoidance of intimate relationships. Marital problems are present in more than two-thirds of patients with sexual issues.
Most patients, like Inga, are embarrassed to reveal they are having sexual difficulty.
Health-care providers often omit the assessment of sexual dysfunction because of embarrassment, assumptions the patient is too disabled to engage in sexual activity, the subject is outside the provider’s scope of practice or the problems are considered untreatable. It is, however, the responsibility of the health-care team to routinely, but sensitively, ask about sexual function. Inga’s description of urinary incontinence provided an opportunity to discuss how this might contribute to sexual dysfunction and to inform her that treatments are available.
Inga can reduce her fluid intake, avoid the bladder-irritating effects of caffeine and void before engaging in sex. Overflow incontinence and bladder infection can be easily excluded, and an anticholinergic can regulate an overactive bladder. Physical therapists could address positioning techniques that enhance physical comfort. Psychologists can work with individuals or couples to enable difficult conversations. The goal is to help her return to the most normal life possible.
Ed.Note: This case study is presented for educational purposes and does not relate to a specific patient.
