Sex and MS: a guide for menErectile dysfunction
Erectile dysfunction, sometimes called impotence or ED, is the inability to achieve or maintain an erection. It is estimated that nearly one in five men in the general population is affected at some point, either every now and again or more consistently over a prolonged period of time. Erectile dysfunction is thought to be more prevalent amongst men with MS and research suggests anything from one quarter to two thirds of men with MS are affected.
There are a number of possible causes for erectile dysfunction in MS.
MS nerve damage
Arousal and erection require a complicated interaction of nerve messages. When MS damages these nerve pathways, messages from the brain can be delayed or prevented meaning that arousal is not maintained or, in some cases, may not occur at all.
What can be frustrating is that a nocturnal or waking erection, which is not triggered by the brain's response erotic stimuli, can still occur but doesn't last for long enough to be useful.
Other MS symptoms
Several MS symptoms can make it difficult to achieve or maintain an erection. If you experience pain or numbness in the genital area, potentially pleasurable sensations can become uncomfortable. Depression or reduced attention span or concentration can lead to distraction.
Fear of symptoms can also play a role, for example worry that sexual activity will provoke spasms or an episode of fatigue. Similarly being anxious about wetting or soiling yourself might inhibit anticipation and pleasure.
Emotional or psychological issues
As mentioned in the section on sexual desire, if MS has dented your self-confidence or self-image, or affected how you think partners see you, this may undermine your ability to enjoy sex and make erections harder to maintain.
Viagra solves half the problem but there is no treatment available to enhance feelings. If there were something, ejaculations would be easier
Managing erectile dysfunction
Although there are treatments available that can restore the ability to achieve an erection, the effective management of the symptom requires an assessment of the whole person, not merely their penis.
With this wider context in mind, the following treatments should be seen as part of the treatment of symptoms, not a complete solution in their own right.
Medication
Erectile dysfunction can be treated with a class of drugs known as PDE5inhibitors - Viagra, Levitra and Cialis. PDE5 (phosphodiesterase type 5) is an enzyme that regulates blood flow in the penis. Altering levels of this enzyme means that normal sexual stimulation leads to better erections. Contrary to the many jokes, the use of these tablets without sexual stimulation will not cause an erection.
Multiple sclerosis is listed in NHS guidelines as one of the conditions for which erectile dysfunction drugs can be prescribed. The guidance says 'one tablet per week is considered to be appropriate for the majority of patients, but when more is required the GP should prescribe that quantity at NHS cost'. You do not have to be in a relationship to be given a prescription.
How you use your medication most effectively needs careful thought. If the prescription allows for one chance of sex a week, the level of expectation can lead to stress that works against feelings of relaxation and sensuality and potentially lead to disappointment and frustration. Within a relationship, if taken without planning, the opportunity for the man with MS to have sex may occur when the partner isn't in the mood, making intercourse seem functional, imposed or unsatisfying. Whilst the drugs can provide the ability to have penetrative sex, they don't of themselves create the anticipation and pleasure of sex.
All of the drugs have similar side effects, which include headaches, flushing, upset stomach, visual disorders, nasal congestion and dizziness. None of these drugs should be taken by people receiving treatment with drugs containing nitrates, such as are used to treat angina. They must be used with caution by people with existing heart conditions or problems with liver or kidney function or low blood pressure.
I know that this is bold-printed on the info with the tablets, but some (such as myself) might be tempted to continue trying to increase dosage over time as effectiveness is reduced by the progression of MS. I stupidly did this for some months late last year, and suffered from diplopia and nystagmus for several months as a result. Don't do it, kids!!
Viagra (sildenafil citrate)
Viagra was the first drug to become available as a treatment for erectile dysfunction, being licensed in 1998. Originally tested as a treatment for heart problems, it has also been used in treating high blood pressure (under the name Revatio) and, more recently, altitude sickness.
Viagra is taken about 30 minutes to an hour before sexual activity and the effects last for about four hours. It will take longer for the drug to take effect if taken after eating fatty foods or alcohol.
Several studies have looked at the effect of Viagra on men with MS with differing results. In one study, researchers compared 104 men taking Viagra with 113 on an inactive placebo and found that almost all of the treatment group reported improved erections. A second study with 101 men receiving Viagra and 102 on a placebo showed a less clear cut result, with only a third of the treatment group reporting improved erections.
Levitra (vardenafil)
Levitra is taken an hour before sexual activity and no more than once a day. The effects last for about four hours. A soluble tablet version is also available. As with Viagra, it will take longer for Levitra to take effect if it is taken with food.
Although there have been more general studies, there has been no published research into the effects of Levitra in men with MS.
Cialis (tadalafil)
Cialis is taken at least half an hour before sexual activity, though is most effective about two hours after it is taken. People who anticipate needing treatment more than once a week can be prescribed a smaller daily dose. This continuous dose must be regularly reviewed.
Cialis lasts longer than the other drugs. Some people may still experience effects up to 36 hours after use, which allows greater scope for spontaneity in lovemaking. Unlike Viagra and Levitra, the effects of Cialis are not delayed if taken soon after a fatty meal.
There has been one study of Cialis in multiple sclerosis in which men took the drug for eight weeks. Results showed it to be an effective and safe treatment for erectile dysfunction.
Other treatments
If the first line drugs are not effective, there are other approaches that can be tried.
Alprostadil (Caverject, Viridal Duo) and MUSE
Alprostadil is a synthetic form of prostaglandin, a naturally occurring chemical in the body that increases blood flow by relaxing muscle cells.
Alprostadil is applied directly to the penis by injection (under the trade names Caverject or Viridal Duo). Alternatively, a pellet can be inserted with an applicator into the tip of the penis (known as MUSE - medicated urethral system for erections).
Unlike the previously mentioned drugs, both methods of application of alprostadil will cause an erection without sexual arousal, lasting for about 30 minutes to an hour. This happens almost immediately with Caverject or after a few minutes with Viridal Duo. With MUSE, once the pellet has been inserted, it is necessary to massage the penis for a few seconds to help distribute the drug. This process can involve a partner and be part of foreplay. Whilst waiting for the drug to have its effect, which happens in five to ten minutes, it is important to remain upright as this helps blood flow to the penis. Lying down in this period will mean the drug is less likely to be effective. MUSE is also less effective if you use a catheter.
Side effects of Caverject and Viridal Duo can include pain in the penis or groin and bleeding in the tissue around the injection site. Less frequently, the erection may not subside for several hours, known as priapism. This can be uncomfortable and without medical attention may result in tissue damage in the penis.
A side effect with MUSE is a burning feeling or irritation at the end of the penis. The partner may also experience similar pain after penetrative sex and oral sex should be avoided with a man using MUSE. MUSE shouldn't be used if the partner is pregnant.
Vacuum constriction devices (VCDs)
A vacuum constriction device works by trapping blood in the penis. The penis is inserted into a tube and the surrounding air pumped out. This draws blood into the penis causing an erection. A tight band is placed around the base of the penis, trapping the blood and maintaining the erection. The band can safely stay in place for up to 30 minutes.
On first using a vacuum pump, the penis can feel cold. This can be countered by applying a warm lubricant or using in the shower or bath. Some men can feel pain or numbness in the penis or find they have a delayed or unsatisfactory ejaculation.
Although effective, devices can be cumbersome to use and take five to ten minutes to operate. Some people might find this to be intrusive and work against spontaneity, particularly for men who are not in a stable relationship. But for some it can be sexy and incorporated into foreplay. There are no rules.
Apomorphine (Uprima, Ixense)
Apomorphine is an injected drug used in the treatment of Parkinson's disease. In the treatment of erectile dysfunction, it works by stimulating chemicals in the brain which are believed to enhance the sexual response and to initiate an erection. Although there is no specific research in MS, general studies have shown that apomorphine is less effective than Viagra.
Side effects can include thickening of the skin at the injection site, sleepiness, nausea and vomiting. The drug must not be used by people with respiratory problems or with liver problems, and must be used with caution by people with existing heart conditions or problems with kidney function. Unlike the three PDE5-inhibitor drugs, apomorphine can be used by people receiving nitrates to treat angina.
Prosthesis
If no other methods are effective, there are different types of surgical implant that can mechanically assist with erections. One uses pouches that are filled with fluid to stiffen the penis. Another involves flexible rods that can be adjusted into the desired position. As both devices artificially stiffen the penis the result may not be as firm as a natural erection. Prosthesis is usually only considered when other options have not been successful.