Dear Editor:

Multiple sclerosis (MS) is a relatively frequent inflammatory autoimmune illness of the central nervous system affecting about 2.5 million people around the world and representing the most common cause of neurological disability among young adults.[1] Among patients with MS, 40 to 80 percent of women and 50 to 90 percent of men have sexual complaints.[2] Patients with MS may regard sexual dysfunction (SD) as the most devastating aspect of their disease, especially among those of young adult age, as the disease can affect the physical ability to communicate, embrace, stimulate, engage in intercourse, and maintain urinary and bowel continence during sexual activity. Yet, sexual functioning in patients with MS is often overlooked by healthcare professionals.[2]

MS-related SD can be divided into three main categories: 1) primary—due to MS-related neurological deficits that directly affect the sexual response, 2) secondary—due to MS-related physical impairments and symptoms that indirectly affect sexual response (i.e., spasticity and contractures, fatigue, bladder dysfunction, and cognitive symptoms), and 3) tertiary—due to the psychological, social, and cultural issues of having a chronic disabling disease.[3]

Since no correlations have been found between MS duration, lesional burden, disability, and SD, we agree with previous findings[4] that SD in patients with MS could be partly related to depressive symptoms. More than 50 percent of people with MS have depressive episodes with both psychological (e.g., symptoms of fatigue, stigmatization from living with a chronic illness, and struggles associated with day-by-day management) and organic (e.g., location of brain lesions) components.[5] Patients with MS who are depressed might not search for sexual intimacy, and, conversely, patients with MS-related SD might experience reactive depression. To this end, a recent systematic review confirmed for the first time a bidirectional association between depression and SD.[6]

According to Atlantis and Sullivan,[6] overall among the general population, individuals with depression had a 50- to 70-percent increased risk of developing SD, while those with SD had a 130- to 210-percent increased risk of having depression. According to the study’s investigators, SD and depression are both syndromes that reflect failures of functional systems, having many possible causes that interact and often form positive pathological feedback cycles. Moreover, the treatment of depression itself may result in iatrogenic SD, as dopamine is known to enhance libido and sexual arousal while serotonin has a clear inhibitory effect on sexuality. Thus, antidepressants with a prevalent serotoninergic action may lead to SD, with regard to anorgasmia and ejaculatory disorders.[6]

In conclusion, because of the multifactorial nature of SD in patients with MS and the negative impact SD can have on these patients’ quality of life (QoL), multidisciplinary evaluations that include neurological, urological/ gynecological, and psychological components should be routinely performed by the healthcare team when treating patients with MS. Specifically, clinicians should routinely ask their patients with MS about their sexual functioning and psychological well being in order to develop an optimum treatment plan that addresses all aspects of MS, including sexual and/or mood dysfunctions, and aims to improve these patients’ overall QoL.

1. Goodin DS. The epidemiology of multiple sclerosis: insights to disease pathogenesis. Handb Clin Neurol. 2014;122:231–266.
2. Calabrò RS, De Luca R, Conti-Nibali V, et al. Sexual dysfunction in male patients with multiple sclerosis: a need for counseling! Int J Neurosci. 2014;124:547–557.
3. Foley FW, Zemon V, Campagnolo D, et al. The Multiple Sclerosis Intimacy and Sexuality questionnaire—re-validation and development of a 15-item version with a large US sample. Mult Scler. 2013;19:1197–1203.
4. Lew-Starowicz M, Rola R. Correlates of sexual function in male and female patients with multiple sclerosis. J Sex Med. 2014;11:2172–2180.
5. Feinstein A, Magalhaes S, Richard JF, et al. The link between multiple sclerosis and depression. Nat Rev Neurol. 2014;10:507–517.
6. Atlantis E, Sullivan T. Bidirectional association between depression and sexual dysfunction: a systematic review and meta-analysis. J Sex Med. 2012;9:1497–1507.

With regards,
Rocco Salvatore Calabrò and Margherita Russo
Calabró and Russo are from IRCCS Centro Neurolesi “Bonino-Pulejo,” Messina, Italy.

Address for correspondence. Rocco Salvatore Calabrò, IRCCS Centro Neurolesi “Bonino-Pulejo,” S.S. 113, Contrada Casazza 98124 Messina, Italy; Phone: +39-090-60128840, Fax: +39-090-60128950, Email: [email protected]

Funding/financial disclosures. The authors declare neither conflicts of interest nor financial supports for the preparation of this report.