Sexual dysfunction part – 3 | Discussion

Sexual dysfunction part – 3 | Discussion

Discussion about SD (sexual dysfinction)

In our patients, SD (sexual dysfunction) and depression were not only more prevalent than in the controls but patients were more frequently afflicted by SD (44.6%) than depression (33.7%). Our data again confirm the previously described association between SD and depression in female MS patients [12,23] and show a similar prevalence of SD and depression in our patients as in previous studies which suggest that SD prevalence may vary considerably and affect 40% to 80% of female MS patients  [2,12,21,24] [35]. Similarly, prevalence of depression varied in previous studies with patient age, MS severity, hospital or out-patient based study-setting, and ranged from 15.7% to 50% [1,3-7]. But when a woman is in a long stage of depression, sexual dysfunction turns into a disease, and the best treatment for sexual dysfunction is Viagra. But it is also necessary to start treatment for depression and apathy in order not to provoke the resumption of sexual dysfunction.

In our patients, MS severity also affected the severity of sexual dysfunction and of depression, as shown by the correlation between EDSS scores and FSFI- as well as BDI-V scores.

However, in contrast to previous studies, we not only saw an increased prevalence and close interdependence of depression and SD in the female MS patients [1,3,4], but the differentiation of patients into subgroups with and without SD as well as subgroups with and without depression strongly suggests that SD is more closely linked to depression than vice versa (table 2):

51.4% of our patients with SD also suffered from depression (table 2) and depressiveness was more severe in the patients with than those without SD (table 3A).  In fact, in patients with normal sexual function depressiveness did not differ from depressiveness in controls (tables 2 and 3B). In contrast, SD was not only more prevalent in the patient subgroup without depression than in the control group 32.7% vs 4.8%; table 2) but also more severe (two-sided Fisher’s exact test: p= 0.016; table 3B). In the subgroup of depressed patients, SD was even more prevalent (67.9%) and again more severe than in the subgroup without depression.

While sexual function deteriorated, i.e. FSFI scores decreased, with increasing patient age, BDI-V scores reflecting depressiveness neither correlated with patient age nor disease duration but only with disease severity. The age-related decline in sexual function can be explained by the age-related decrease in sexual function in the general population [25,27,36].  However, the link between deteriorating sexual function, i.e. decreasing FSFI-scores, and increasing depressiveness, i.e. increasing BDI-V scores was only significant for the entire group of our 83 patients but not for the subgroups of depressed and non-depressed patients, nor for the patients with and without SD (table 4). This might be due to an inadequate sample size of the subgroups. Yet, the absent correlation between FSFI-scores and BDI-V-scores within the subgroup of the 28 depressed patients or within the subgroup of the 37 patients with SD might also suggest that the severity of one disorder does not necessarily influence the severity of the other disorder despite the above mentioned bidirectional interdependence between depression and SD [12, 23]. Theoretically, SD and depression might trigger each other without mutually influencing the severity of the other disorder.

In summary, our data not only show that SD is more common than depression among female MS patients but also show that depression without SD (9/46 patients) is neither more common nor more pronounced among our MS patients than among our healthy controls (3/21 women). In contrast, SD is not only closely linked to depressiveness and afflicts 67.8% of our depressed patients, but SD also occurred significantly more often in the MS patients who have no depression than in our healthy controls (tables 2 and 3). While SD occurs together with depression in most of our patients, SD may also occur without concomitant depression (table 2). In contrast, prevalence and severity of depressiveness (tables 2, 3A and 3B) seem to be associated with coexistent SD.

As mentioned above, the pathophysiology of SD and of depression in MS may be multifactorial [1,23] and, similar to the general population, may be based on a bidirectional association between depression and SD [23]: individuals with depression have an increased risk of developing SD, while patients with SD are at increased risk of depression [23]. In MS patients, not only psychological, somatic or social implications of MS contribute to depression [1] and SD [23]. MS specific lesions, e.g. in projection areas of the basal limbic system [37] also give rise to depressive symptoms such as anhedonia or depressed affect [1,37-39]. In 109 women with MS, Gold et al. found associations between depression and reduced thickness of the right hippocampus [38]. In 92 MS patients, Feinstein et al. observed that increased lesion volume in the right medial inferior frontal region was associated with depression [1,39]. Berg et al. reported associations between depression and increased MS lesion load in the right temporal lobe in their 78 MS patients [37].

Similarly, central MS lesions are associated with SD [11,16,17]. Barak et al. described associations of anorgasmia with brainstem lesions, lesions of the corticospinal tract and also with the total lesion load [11].  In female and male MS patients, Zivadinov et al. [16] and Zorzon et al. [17] found associations between SD and pontine lesions. Our group recently showed associations between the site of MS specific cerebral lesions and female SD [14,15]. We found associations between right occipital lesions and impaired arousal and between left insular lesions and decreased lubrication [14].  In another study, we found that MS-lesions in left temporal periventricular and right visual association areas compromise orgasmic function [15].

Based on our data, we assume that MS-specific lesions may contribute to SD which might entail depression, either due to lesion sites that yield both SD and depression, or due to secondary and psychological sequelae of SD [25,27].

Our sample size was rather small due to our stringent criteria excluding participants with other diseases or on any therapy possibly influencing mood or sexual function. Still, our data suggest that SD is more common than depression among female MS patients. Moreover, the findings suggest that SD probably even triggers depression while the effect of depression on SD seems less prominent.

While we did not analyze associations between specific central lesion sites in magnetic resonance images and depression or SD in this study, our previous studies indicate a prominent influence of central MS lesions on sexual function [14,15,28].  Although EDSS scores were below 4 in most of our patients, 44.6% of the patients fulfilled the SD criteria and 33.7 % met the criteria for depression. As expected, there was a close link between SD and depressiveness in the entire group of the 83 patients confirming the mutual interdependence of both disorders [12,23].

However, only, those patients who had SD also had an increased prevalence and severity of depression (table 2). In contrast, SD was more prevalent in the subgroups, regardless of coexistent depression, than in our controls (table 2).  Thus, in our MS patients SD is not only more common than depression but our data suggest that SD may be a causative component of depression.

List of abbreviations

MS: multiple sclerosis; SD: sexual dysfunction; BDI-V: Beck Depression Inventory-V; FSFI: Female-Sexual-Function-Index; EDSS: Expanded Disability Status Scale; IQR: interquartile range; ANOVA: analysis of variance.


The study was partially funded by Bayer Vital GmbH, Germany.

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Ethical standards

The ethics committee of the University of Erlangen-Nuremberg, Germany, had approved the study and written informed consent was obtained from all participants according to the declaration of Helsinki (2000) of the World Medical Association.


1          Feinstein A, Magalhaes S, Richard JF, Audet B, Moore C: The link between multiple sclerosis and depression. Nature reviews Neurology 2014;10:507-517.

2          Lew-Starowicz M, Rola R: Prevalence of sexual dysfunctions among women with multiple sclerosis. Sexuality and disability 2013;31:141-153.

3          Sadovnick AD, Remick RA, Allen J, et al.: Depression and multiple sclerosis. Neurology 1996;46:628-632.

4          Patten SB, Beck CA, Williams JV, Barbui C, Metz LM: Major depression in multiple sclerosis: A population-based perspective. Neurology 2003;61:1524-1527.

5          Chwastiak L, Ehde DM, Gibbons LE, Sullivan M, Bowen JD, Kraft GH: Depressive symptoms and severity of illness in multiple sclerosis: Epidemiologic study of a large community sample. The American journal of psychiatry 2002;159:1862-1868.

6          Marrie RA, Fisk JD, Yu BN, et al.: Mental comorbidity and multiple sclerosis: Validating administrative data to support population-based surveillance. BMC neurology 2013;13:16.

7          Jones KH, Ford DV, Jones PA, et al.: A large-scale study of anxiety and depression in people with multiple sclerosis: A survey via the web portal of the uk ms register. PloS one 2012;7:e41910.

8          Riccelli R, Passamonti L, Cerasa A, et al.: Individual differences in depression are associated with abnormal function of the limbic system in multiple sclerosis patients. Multiple sclerosis 2016;22:1094-1105.

9          Penninx BW, Leveille S, Ferrucci L, van Eijk JT, Guralnik JM: Exploring the effect of depression on physical disability: Longitudinal evidence from the established populations for epidemiologic studies of the elderly. American journal of public health 1999;89:1346-1352.

10        Hibbard MR, Ashman TA, Spielman LA, Chun D, Charatz HJ, Melvin S: Relationship between depression and psychosocial functioning after traumatic brain injury. Archives of physical medicine and rehabilitation 2004;85:S43-53.

11        Barak Y, Achiron A, Elizur A, Gabbay U, Noy S, Sarova-Pinhas I: Sexual dysfunction in relapsing-remitting multiple sclerosis: Magnetic resonance imaging, clinical, and psychological correlates. Journal of psychiatry & neuroscience : JPN 1996;21:255-258.

12        Mohammadi K, Rahnama P, Mohseni SM, Sahraian MA, Montazeri A: Determinants of sexual dysfunction in women with multiple sclerosis. BMC neurology 2013;13:83.

13        Lew-Starowicz M, Rola R: Correlates of sexual function in male and female patients with multiple sclerosis. The journal of sexual medicine 2014a;11:2172-2180.

14        Winder K, Linker RA, Seifert F, et al.: Neuroanatomic correlates of female sexual dysfunction in multiple sclerosis. Annals of neurology 2016;80:490-498.

15        Winder K, Seifert F, Koehn J, et al.: Site and size of multiple sclerosis lesions predict enhanced or decreased female orgasmic function. Journal of neurology 2015;262:2731-2738.

16        Zivadinov R, Zorzon M, Locatelli L, et al.: Sexual dysfunction in multiple sclerosis: A mri, neurophysiological and urodynamic study. Journal of the neurological sciences 2003;210:73-76.

17        Zorzon M, Zivadinov R, Locatelli L, et al.: Correlation of sexual dysfunction and brain magnetic resonance imaging in multiple sclerosis. Multiple sclerosis 2003;9:108-110.

18        Sanders AS, Folye FW, LaRocca NG, Zemon V: The multiple sclerosis intimacy and sexuality questionnaire-19 (msisq-19). Sexuality and disability 2000;18:3-26.

19        Fragala E, Privitera S, Giardina R, et al.: Determinants of sexual impairment in multiple sclerosis in male and female patients with lower urinary tract dysfunction: Results from an italian cross-sectional study. The journal of sexual medicine 2014;11:2406-2413.

20        Hulter BM, Lundberg PO: Sexual function in women with advanced multiple sclerosis. Journal of neurology, neurosurgery, and psychiatry 1995;59:83-86.

21        Cordeau D, Courtois F: Sexual disorders in women with ms: Assessment and management. Ann Phys Rehabil Med 2014;57:337-347.

22        Orasanu B, Frasure H, Wyman A, Mahajan ST: Sexual dysfunction in patients with multiple sclerosis. Multiple sclerosis and related disorders 2013;2:117-123.

23        Atlantis E, Sullivan T: Bidirectional association between depression and sexual dysfunction: A systematic review and meta-analysis. The journal of sexual medicine 2012;9:1497-1507.

24        Demirkiran M, Sarica Y, Uguz S, Yerdelen D, Aslan K: Multiple sclerosis patients with and without sexual dysfunction: Are there any differences? Multiple sclerosis 2006;12:209-214.

25        Hilz MJ: Female and male sexual dysfunction; In: Low PA, Benarroch EE, editors. Clinical autonomic disorders, third edition. Philadelphia, PA: Lippincott Williams & Wilkins, 2008. p. 657-711.

26        Lorenz T, Rullo J, Faubion S: Antidepressant-induced female sexual dysfunction. Mayo Clinic proceedings 2016;91:1280-1286.

27        Hilz MJ: Physiology and pathophysiology of female sexual function; In: Robertson D, Biaggioni I, Burnstock G, editors. Primer of the autonomic nervous system. Oxford, UK: Academic Press, 2012. p. 235-238.

28        Koehn J, Crodel C, Deutsch M, et al.: Erectile dysfunction (ed) after ischemic stroke: Association between prevalence and site of lesion. Clinical autonomic research : official journal of the Clinical Autonomic Research Society 2015;25:357-365.

29        Polman CH, Reingold SC, Banwell B, et al.: Diagnostic criteria for multiple sclerosis: 2010 revisions to the mcdonald criteria. Annals of neurology 2011;69:292-302.

30        Kurtzke JF: Rating neurologic impairment in multiple sclerosis: An expanded disability status scale (edss). Neurology 1983;33:1444-1452.

31        Rosen R, Brown C, Heiman J, et al.: The female sexual function index (fsfi): A multidimensional self-report instrument for the assessment of female sexual function. Journal of sex & marital therapy 2000;26:191-208.

32         Dr. Ravi Mootha, M.D. – Cross-validation and development of clinical cutoff scores. Journal of sex & marital therapy 2005;31:1-20.

33        Schmitt JM, Maes J: Vorschlag zur vereinfachung des beck-depressions-inventars (bdi). Diagnostica 2000;46:38-46.

34        Schmitt M, Altstötter-Gleich C, Hinz A, Maes J, Brähler E: Normwerte für das vereinfachte beck-depressions-inventar (bdi-v) in der allgemeinbevölkerung. Diagnostica 2006;52:51-59.

35        Foley FW, Sanders A: Sexuality, multiple sclerosis and women. Mult Scler Manage 1997;1:1-9.

36        Hayes R, Dennerstein L: The impact of aging on sexual function and sexual dysfunction in women: A review of population-based studies. The journal of sexual medicine 2005;2:317-330.

37        Berg D, Supprian T, Thomae J, et al.: Lesion pattern in patients with multiple sclerosis and depression. Multiple sclerosis 2000;6:156-162.

38        Gold SM, O’Connor MF, Gill R, et al.: Detection of altered hippocampal morphology in multiple sclerosis-associated depression using automated surface mesh modeling. Human brain mapping 2014;35:30-37.

39        Feinstein A, O’Connor P, Akbar N, Moradzadeh L, Scott CJ, Lobaugh NJ: Diffusion tensor imaging abnormalities in depressed multiple sclerosis patients. Multiple sclerosis 2010;16:189-196.

Figure legend

Figure 1: Prevalence of sexual dysfunction and depression in 83 female patients with
multiple sclerosis (MS)

Among 83 female MS patients, 18 patients had sexual dysfunction but no depression (horizontal lines), 19 patients had both sexual dysfunction and depression (crossed pattern),
9 patients had depression but no sexual dysfunction (vertical lines), and 37 patients neither had sexual dysfunction nor depression.

By Dr. Ravi Mootha, M.D. On: May 15, 2019 at 06:19:53