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Sexual problems are very common in multiple sclerosis, yet they remain among the symptoms least often discussed during neurological appointments. Patients may feel embarrassed to bring them up, and physicians do not always ask.
From a medical perspective, there is nothing inappropriate about this subject. Sexual desire, sexual intercourse, orgasm, masturbation, the use of vibrators, clitoral stimulators or other sexual devices are normal aspects of human sexuality.
If MS interferes with arousal, erection, lubrication, genital sensation or the ability to reach orgasm, this is a medical problem in the same way as pain, spasticity or bladder dysfunction. In many cases, the mechanism can be identified and practical treatment or adaptation is possible.
Historically, clinical research on sexual dysfunction in neurological disease, including multiple sclerosis, focused disproportionately on men and especially on erectile dysfunction. Female sexual dysfunction received much less attention.
There were obvious reasons for this. Erectile and ejaculatory dysfunction can be identified as relatively clear functional problems: they may directly interfere with penetrative intercourse, make conception more difficult and affect a couple's ability to plan a family.
Because MS is often diagnosed in young and middle-aged adults, sexual dysfunction can appear during a period of active sexual life, partnership and family planning. Persistent problems with erection, ejaculation or sexual performance may lead to avoidance of intimacy, loss of sexual confidence, conflict within a couple and, in some cases, serious relationship breakdown.
Sexual function should therefore be regarded as a legitimate part of neurological care for both men and women.
Estimates vary depending on age, disease characteristics, the questionnaires used and the populations studied, but the overall conclusion is consistent: sexual dysfunction is highly prevalent in MS.
In a meta-analysis of 56 studies, the pooled prevalence of sexual dysfunction among women with MS was approximately 61%.
In the same analysis, an estimated 29% of women with MS reported an inability to reach orgasm.
A meta-analysis in men with MS estimated the prevalence of overall sexual dysfunction at approximately 66%, with erectile dysfunction at approximately 49%.
Clinical literature traditionally distinguishes three groups of mechanisms: primary, secondary and tertiary sexual dysfunction. More than one mechanism is often present in the same person.
Lesions in the brain and spinal cord may disrupt sensory and autonomic pathways involved in genital sensation, arousal, erection, lubrication and orgasm.
Sexual activity may be limited by fatigue, pain, spasticity, weakness, mobility problems, bladder dysfunction or bowel symptoms.
Depression, anxiety, changes in body image, fear of sexual failure, changes in roles within a couple and relationship conflict may further impair sexual function.
Libido may decrease because of neurological changes, depression, fatigue, medications or relationship difficulties.
Sensation in the clitoris, vagina, penis, perineum or other erogenous areas may become reduced or altered.
Sexual desire may remain intact, while the physiological response becomes weaker or takes longer to develop.
Men may have difficulty developing or maintaining an erection, even when libido is preserved.
Orgasm may become less intense, take much longer to reach or become temporarily impossible.
Vaginal dryness, spasticity, neuropathic pain, pelvic-floor dysfunction or another medical condition may make sexual activity painful.
Changes in genital sensation are an important cause of sexual dysfunction in MS. A person may still have sexual desire and feel psychologically aroused, but the usual genital stimulation may no longer produce the same sensory response.
For example, a woman may still feel touch but notice that clitoral sensation is much less intense. A man may experience reduced penile sensation.
This does not necessarily mean that the ability to experience pleasure or orgasm has been lost. What may have changed is the amount and type of sensory stimulation required to produce a sexual response.
A sexual routine that worked well before neurological symptoms developed may no longer be optimal.
This does not mean that sexual function has disappeared. It may need to be adapted to the altered functioning of the nervous system.
When genital sensation is reduced, vibration can provide a stronger and more repetitive sensory signal than manual stimulation alone.
Genital vibratory stimulation has been studied in sexual medicine for conditions including orgasmic dysfunction, arousal disorders, erectile dysfunction and ejaculatory problems. The quality of evidence differs between conditions, but vibration is a legitimate tool in sexual medicine.
When orgasm is difficult to reach, adequate clitoral stimulation is particularly important. For many women, clitoral stimulation is necessary for orgasm regardless of whether they have MS.
If sensation has become reduced, a stronger vibrator or longer vibratory stimulation may provide an intensity that is difficult to achieve manually.
Penile vibratory stimulation may be used when penile sensation is reduced or when orgasm or ejaculation is difficult.
The strongest evidence for penile vibratory stimulation comes from some other neurological conditions, particularly spinal cord disorders. These results cannot automatically be extrapolated to every man with MS.
Masturbation does not need a medical justification. It is a normal form of sexual activity, whether or not a person has a partner.
In the context of sexual dysfunction, masturbation can also help a person understand how the body's sexual response has changed: which areas retain sensation, what kind of stimulation works best, whether vibration helps, how long arousal takes and whether orgasm remains possible.
Female sexual dysfunction in MS cannot be reduced to a single symptom. Preserved desire does not guarantee a normal physiological arousal response, and difficulty reaching orgasm does not necessarily mean that libido is reduced.
Sensation in the clitoris, vulva or vagina may become reduced. Some women experience numbness, tingling or unpleasant sensory changes.
Insufficient vaginal lubrication may be part of impaired arousal, but menopause, hormonal changes, medications and gynecological conditions should also be considered.
Orgasm may require longer and more intense stimulation. It is useful to determine whether orgasm is possible during masturbation, with vibration or with direct clitoral stimulation.
Possible causes include vaginal dryness, spasticity, pelvic-floor dysfunction, neuropathic pain or gynecological disease. Pain should not simply be accepted as a normal consequence of MS.
When lubrication is insufficient, an appropriate lubricant is often the simplest first step to reduce discomfort and improve sensation.
Persistent dryness, burning or pain should be discussed with a gynecologist, particularly during peri- and postmenopause.
Medical devices exist that apply gentle negative pressure around the clitoral area to increase blood flow and potentially improve sensation. One historically well-known example is the EROS Clitoral Therapy Device.
The FDA recognizes clitoral engorgement devices as a category of medical devices. Small studies have suggested possible improvements in arousal, lubrication and orgasmic function.
Erectile dysfunction is one of the most visible sexual problems in men with MS, but male sexual dysfunction is not limited to erection.
A man may have difficulty developing an erection or maintaining it until sexual activity is complete.
Ejaculation may be delayed, difficult or absent, even when erection is preserved.
Orgasm may become less intense, markedly delayed or absent.
For erectile dysfunction in men with MS, phosphodiesterase-5 inhibitors such as sildenafil and tadalafil may be used when there are no contraindications.
A randomized, double-blind, placebo-controlled trial of sildenafil in men with multiple sclerosis demonstrated significant improvement in erectile function and quality-of-life measures.
If oral treatment is insufficient, a urologist or sexual-medicine specialist may consider vacuum erection devices, intracavernosal therapy or other treatments.
Erectile or ejaculatory dysfunction may make natural conception difficult, even when reproductive function itself is preserved.
It is important to distinguish sexual dysfunction from infertility. Having MS, erectile dysfunction or difficulty reaching orgasm does not automatically mean that a person is infertile.
Pelvic-floor muscles are involved not only in bladder and bowel control, but also in sexual function. Dysfunction of this system may therefore affect urinary symptoms, pain and sexual response at the same time.
In a randomized study, a 12-week supervised pelvic floor muscle training program in women with relapsing-remitting MS improved several measures of sexual function and reduced sexual distress.
Targeted pelvic-floor training may be used to improve strength, coordination and functional control.
Additional “Kegel exercises” may not be the right solution. Some people instead need training in relaxation, coordination and pain reduction.
Specialized pelvic-floor physiotherapy may include:
With severe MS fatigue, sexual activity late in the evening may be extremely difficult.
A simple but effective adaptation may be to choose morning, daytime or a period after rest.
Spasticity may limit leg abduction, make certain positions difficult or cause painful spasms.
Positioning, physiotherapy, medication and, in selected patterns, botulinum toxin may help.
Fear of urgency or urinary leakage may markedly suppress sexual arousal.
Treating neurogenic bladder dysfunction may sometimes improve sexual life more than direct sexual treatment.
Musculoskeletal, neuropathic or pelvic pain may restrict sexual activity and requires its own treatment.
Physical activity and an increase in body temperature may transiently worsen MS symptoms through Uhthoff phenomenon.
Constipation, fear of incontinence and other bowel symptoms may also have a substantial effect on sexual activity.
Not every sexual problem in a person with MS is caused by multiple sclerosis itself. Some medications can reduce sexual desire, impair arousal or make orgasm more difficult.
This is particularly well recognized with some antidepressants, including several SSRIs.
A psychological component does not mean that the sexual problem is “all in the mind.” Psychological reactions very often develop as a consequence of a genuine neurological problem.
For example, after several episodes of erectile failure or inability to reach orgasm, a person may begin to expect the next attempt to fail. Instead of becoming absorbed in arousal, they start monitoring themselves, checking whether they are “performing correctly” and anticipating disappointment.
A cycle can develop:
| Main problem | What should be assessed? | What may help? |
|---|---|---|
| Reduced sexual desire | Depression, fatigue, medications, pain, hormonal factors, relationship issues | Treatment of the cause, medication review, psychological therapy, couples work |
| Desire is present but arousal is difficult | Genital sensation, lubrication, erection, medications, anxiety | More intense stimulation, lubricants, ED treatment, sex therapy |
| Difficulty reaching orgasm | Sensation, medications, pain, spasticity, whether orgasm is possible during masturbation | Clitoral or penile stimulation, vibration, directed masturbation, treatment of contributing factors |
| Erectile dysfunction | Neurological, vascular, medication-related and psychological factors | PDE-5 inhibitors, urological assessment, other ED treatments when needed |
| Pain during sex | Dryness, pelvic floor, spasticity, neuropathic pain, gynecological or urological causes | Lubricants, treatment of the cause, pelvic-floor physiotherapy, gynecological/urological assessment |
| Fear of urinary leakage | Bladder and bowel function | Treatment of neurogenic dysfunction, emptying the bladder before sex, neuro-urological management |
If MS means that a person now needs a different position, more time, a lubricant, a vibrator, a different form of stimulation or medication to maintain a satisfying sexual life, this does not make that sexual life less normal or less complete.
There is no need to wait for a neurologist to ask about sexual function. A patient can simply describe what has changed: desire, sensation, arousal, erection, lubrication, orgasm or pain.
The examination and history may help determine whether the problem is related to neurological impairment or another cause.
Genital sensation, type of stimulation, medications and other MS symptoms should be reviewed.
Neurological, vascular, medication-related and psychological factors should all be considered.
Possible causes include spasticity, pain, bladder dysfunction, pelvic-floor problems and other treatable conditions.