Communicating with Healthcare Providers
Some healthcare providers rarely bring up the subject of sexuality, perhaps because they feel uncomfortable with it, lack professional training in the area, or fear being overly intrusive. Most providers are willing to discuss sexuality, however, if you bring up the subject.
You need to discuss changes in your sexual feelings and ask what treatments are available to enhance your sexuality. Communicate your concerns to your healthcare provider, including your current medications.
Coping with Altered Genital Sensations To enhance sexual response, increase stimulation to other responsive areas such as breasts, buttocks, ears, and lips. Conduct a sensory body map exercise by yourself or with your partner to explore the exact locations of pleasant, decreased, or altered sensations. This exercise can enhance intimacy, as well as teach you about changes in your sensual and sexual pleasure zones. As with the treatment of all sexual symptoms in MS, experimentation and communication are the keys to maximizing sexuality.
Increase genital stimulation through oral stimulation or through mechanical vibrators. This can help stimulate erections in men and provide direct clitoral stimulation for women.
Painful or irritating genital or body sensations can sometimes be treated with medications such as amitriptyline, carba-mazepine, and phenytoin.
Coping with Lowered Libido If you are in an intimate relationship, focus on the sensual aspects. Sensual contact is nongenital; it includes back rubs, gentle stroking of nongenital body zones, and other touching that you find physically and emotionally pleasing. During periods of diminished sex drive, partners often neglect the sensual, nonsexual aspects of their physical relationship.
Make a date for a sensual evening. Partners can enjoy each other physically and engage in sensual exploration of each other's bodies, without the pressure of having to have sexual intercourse.
Restore the special nature of your relationship by showing your partner how important he or she is to you. Loving gestures are often forgotten under the pressure of coping with MS and other stresses. when you treat your partner as a special person, you set the stage for increased intimacy, which can sometimes stimulate libido.
Coping with Erectile Problems A number of oral medications are available to treat erectile dysfunction. The FDA has approved several medicines called phos-phodiesterase-type-5 (PDE-5) inhibitors. PDE-5 inhibitors work by blocking a chemical in the erectile tissues that causes erections to become flaccid. These medicines include sildenafil (Viagra®), vardenafil (Levitra®), and tadalafil (Cialis®). To date, only sildenafil has been completed in clinical trials with men who have MS, although the other medicines are highly similar and can be prescribed for persons with MS. These medicines do not improve libido, but are helpful in maintaining erections when they occur. They are typically taken an hour before anticipated sexual activity. The effects of vardenafil and tadalafil are reported to last somewhat longer than sildenafil, although they have not been directly compared in persons with MS. These medicines cannot be used with some nitrate-based cardiac medicines, since they interact with each other and can lower blood pressure excessively.
In addition to the PDE-5 inhibitors, other oral medicines are in development for erectile dysfunction that work by enhancing or blocking chemical pathways in the brain and spinal cord that are related to sexual function. To date, none of these have been tried in MS.
One noninvasive way to achieve an erection is to use a vacuum assistive device. With this method, a plastic tube is fitted over the flaccid penis, and a pump creates a vacuum that subsequently produces an erection. Then, a latex constriction band is slipped from the base of the tube onto the base of the penis. The band maintains engorgement of the penis for sexual activities, although it cannot be used for more than 30 minutes. If you achieve erections readily, but have trouble maintaining them, you may be able to use the constriction band alone.
Alprostadil is a medicine that can be can injected into the penis, or it can also be used in an urethral suppository. The injections can be easily done with an auto-injector, although it is important to be properly trained in this technique by a urologist or advanced practice nurse. To use the suppository, a small plastic applicator is inserted into the urethra. Through either method, the drug is absorbed into the penile tissues, stimulating a satisfactory erection in most men with erectile dysfunction. However, there is typically some penile discomfort, although the overall satisfaction ratings by men who use these methods are quite high. In rare instances, priapism can occur (prolonged erection).
A more invasive form of treatment for erectile problems is the penile prosthesis. The two types of penile prostheses are: semirigid and inflatable. With the semi-rigid type, a flexible rod is surgically implanted in each of the erection chambers (corpus cavernosa) of the penis. These rods can be bent upward when an erection is desired, and bent downward at other times. Following insertion of the rods, the penis remains somewhat enlarged, with a permanent semi-erection.
With the inflatable type, a fluid reservoir and pump are surgically implanted in the abdomen and scrotum, with inflatable reservoirs inserted into the penis that inflate when an erection is desired. This type of prosthesis is barely noticeable, but the potential risks are significant. Surgical complications, infection, scarring, and difficulty operating the pump can create long-term problems.
Approximately 80 percent of the men who use these types of prostheses find them satisfactory. In general, a penile prosthesis is only recommended when other efforts to manage erectile dysfunction have not been successful.
In coping with erectile dysfunction, it is important to discuss the situation with your partner, particularly if you are in a long-term relationship. Such discussions can enhance feelings of intimacy by allowing partners to learn and explore together. If you are afraid or inhibited about talking openly about these issues, counseling with a mental health professional who is knowledgeable about MS may help.
Similar to the erectile response in men, vaginal lubrication is controlled by multiple pathways in the brain and spinal cord. Psychogenic lubrication originates in the brain and can be enhanced by creating a relaxing, romantic, or stimulating setting for sexual activity; by incorporating relaxing massage into foreplay activities; and by prolonging foreplay. Lubrication can sometimes be increased by manually or orally stimulating the genitals. The simplest way to compensate for vaginal dryness is to apply generous amounts of a water-soluble lubricant. Healthcare professionals advise against using petroleum-based jellies for vaginal lubrication because they can promote bacterial infections and may erode condoms, making them ineffective for birth control or disease prevention.
Although a small trial of sildenafil has been tried in women with Ms to enhance sexual response, the results were disappointing. Women with Ms seem to have a more complex view of their sexuality than men with Ms. it is possible that medicines for Ms women with sexual dysfunction may be more effective if they are delivered with counseling that enhances the overall relationship.
Coping with Spasticity spasticity in the legs can make finding a comfortable position for intercourse difficult. stretching prior to intercourse can help. Medications such as baclofen or tizani-dine, especially when taken about 1 hour before sexual activity, may reduce this prob lem. Be sure to discuss any medication changes with your physician.
Another approach for coping with spastic-ity is to explore alternative positions for intercourse. Women with spasticity of the adductor muscles, which draws the thighs together, may be more comfortable lying on their sides, with the partner approaching from behind. Men who have difficulty straightening their legs may be more comfortable sitting upright in an armless chair while the partner mounts the erect penis. However, everyone's body is different, and the key to finding alternative sexual positions is open exploration and communication between partners.
You may find it helpful to take fatigue medication about 1 hour before sexual activity. You may also compensate for fatigue by having sex in the morning, when energy levels are higher, and by exploring sexual positions that minimize weight-bearing or tiring movements.
Coping with Weakness You can compensate for weakness by finding new positions. Reclining may be less tiring, and pillows can improve positioning and reduce muscle strain. Try the new positions before sex to help you determine whether they are comfortable without the anxiety of introducing them during sexual activity. Finally, oral sex requires less movement than intercourse, and hand-held or strap-on vibrators can provide sexual satisfaction without producing fatigue.
Coping with Bladder Dysfunction The basic approach to coping with bladder dysfunction is to treat the symptoms when you anticipate sexual activity.
strategies include the following:
• If you are taking an anticholinergic medication, which is frequently prescribed for bladder storage dysfunction, take it 30 minutes before sexual activity to minimize bladder contractions during sex. Because vaginal dryness is a side effect of these medicines, use a water-soluble lubricant to compensate for this.
• Restrict fluid intake for several hours before sex.
• Empty your bladder or catheterize just before sexual activity.
Men who have small amounts of urine leakage can wear a condom during sex. Women who have indwelling catheters can tape the catheter securely to the abdomen, empty the collecting bag before sexual activity, and put additional tape around the top ring to minimize the chance of leakage. Lying in a spoon position, with the woman in front, will avoid putting pressure on the catheter or the collection bag.
Changes in attention and concentration may derail your ability to sustain interest in sex. Feelings of confusion, guilt, and rejection may result. Negative feelings can, in turn, increase distractibility or cause you to avoid sex altogether.
Problems with attention and concentration tend to be worse when you are tired, so fatigue must be dealt with. Use a variety of stimulating techniques, such as talking in sexy ways, touching both the sensual and erotic parts of your body, and playing romantic music, to help maintain your focus.
Briefly switching from erotic to nonerot-ic touching when you lose focus can create an atmosphere of acceptance, and ease both you and your partner back into the right mood.
MS is frequently associated with grief, demoralization, changes in self-esteem and body image, and clinical depression. These emotions can temporarily dampen sexual interest and pleasure. To cope with these changes, obtain a professional assessment of your situation, educate yourself about the disease and possible treatments, and learn strategies for coping.
Temporary changes in self-esteem are often part of the grief process that occurs in response to chronic illness. Normal grieving tends to ebb and flow, as you work to redefine yourself in terms of the MS. You can work through the grieving process by learning about the disease, comparing your experiences with others, discussing disappointments, and exploring new options. Support groups can be particularly helpful and private counseling may also speed the adaptation process.
if you are clinically depressed, that is, if you suffer from long-term depression, medications and psychotherapy can usually offer relief and restore sexual interest. Some antidepressants can cause loss of libido or interfere with orgasm. Talk with your physician or healthcare provider about all potential side effects before you begin antidepres-sant medication.
Coping with Role Changes and Loss of Intimacy in our society, people believe that sex should be spontaneous and passionate. when these expectations are not met, lovers can be so disappointed that they withdraw from the sexual relationship. They fail to explore other possibilities.
women, in particular, are susceptible to the effects of negative body image, which Ms may worsen. Men with Ms may view themselves as failures because they do not live up to their ideal role as breadwinners or as sexual initiators. Sometimes the struggle with role expectations, for both yourself and your partner, results in a gradual loss of sexual feeling. This process may be accelerated if the able-bodied partner provides extensive caregiving to the partner with the disability. If caregiving becomes a large part of a relationship, it is difficult for the caregiver to relax and have fun.
Accompanying these role changes, partners may feel a sense of isolation in the relationship and less compassion for each other's concerns. The diminishing capacity to understand and work through such issues creates greater isolation and misunderstanding. In this atmosphere, resentments may grow.
Solutions to the loss of intimacy that stems are not simple. You may need first to develop a language so you can talk comfortably with your partner about issues concerning sexuality and intimacy. Educational materials can facilitate such discussions. Check what is available through the National Multiple Sclerosis Society (NMSS), Paralyzed Veterans of America (PVA), and United Spinal Association. Many self-help books available from local bookstores and libraries are designed to enhance communication.
The following tips may help you and your partner begin to reestablish a dialogue:
• Read books and watch educational videos with your partner. Set aside time to talk about what you are learning, whether or not it applies to your relationship.
• Talk about sexuality and intimacy.
• Make regular dates, free from the responsibilities of work, caregiving, and childrearing, to rediscover your partner. Try to recreate the feeling of romance that characterized your relationship before it was swept away by the burdens of career, parenthood, and MS.
Because MS brings about so many changes, couples living with the disease need to compare their expectations to reality and to share their feelings about the ways in which their lives have changed. In an atmosphere of caring and support, those shared feelings can rekindle the flame of intimacy.
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Are You Depressed? Heard the horror stories about anti-depressants and how they can just make things worse? Are you sick of being over medicated, glazed over and too fat from taking too many happy pills? Do you hate the dry mouth, the mania and mood swings and sleep disturbances that can come with taking a prescribed mood elevator?