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Abstract

Nonmotor symptoms, among them sexual dysfunction, are common and underrecognized in patients with Parkinson disease; they play a major role in the deterioration of quality of life of patients and their partners. Loss of desire and dissatisfaction with their sexual life is encountered in both genders. Hypersexuality (HS), erectile dysfunction and problems with ejaculation are found in male patients, and loss of lubrication and involuntary urination during sex are found in female patients. Tremor, hypomimia, muscle rigidity, bradykinesia, 'clumsiness' in fine motor control, dyskinesias, hypersalivation and sweating may interfere with sexual function. Optimal dopaminergic treatment should facilitate sexual encounters of the couple. Appropriate counselling diminishes some of the problems (reluctance to engage in sex, problems with ejaculation, lubrication and urinary incontinence). Treatment of erectile dysfunction with sildenafil and apomorphine is evidence based. HS or compulsive sexual behaviour are side effects of dopaminergic therapy, particularly by dopaminergic agonists, and should be treated primarily by diminishing their dose. Neurologists should actively investigate sexual dysfunction in their Parkinsonian patients and offer treatment, optimally within a multidisciplinary team, where a dedicated professional would deal with sexual counselling.
Management of sexual dysfunction
in Parkinson’s disease
Gila Bronner and David B. Vodus
ˇek
Abstract:Nonmotor symptoms, among them sexual dysfunction, are common and underre-
cognized in patients with Parkinson disease; they play a major role in the deterioration of
quality of life of patients and their partners. Loss of desire and dissatisfaction with their sexual
life is encountered in both genders. Hypersexuality (HS), erectile dysfunction and problems
with ejaculation are found in male patients, and loss of lubrication and involuntary urination
during sex are found in female patients. Tremor, hypomimia, muscle rigidity, bradykinesia,
‘clumsiness’ in fine motor control, dyskinesias, hypersalivation and sweating may interfere
with sexual function. Optimal dopaminergic treatment should facilitate sexual encounters of
the couple. Appropriate counselling diminishes some of the problems (reluctance to engage in
sex, problems with ejaculation, lubrication and urinary incontinence). Treatment of erectile
dysfunction with sildenafil and apomorphine is evidence based. HS or compulsive sexual
behaviour are side effects of dopaminergic therapy, particularly by dopaminergic agonists, and
should be treated primarily by diminishing their dose. Neurologists should actively investigate
sexual dysfunction in their Parkinsonian patients and offer treatment, optimally within a
multidisciplinary team, where a dedicated professional would deal with sexual counselling.
Keywords:Parkinson’s disease, sexual dysfunction, erectile dysfunction, desire, orgasm,
hypersexuality, management, sexual counseling
Introduction
Parkinson’s disease (PD) is a chronic multisystem
neurodegenerative disorder, characterized by typ-
ical motor manifestations, which progress over
time and cause growing physical disability. In
the advanced stage of the disease, deterioration
of mobility and communication result with limi-
tations in basic daily activities.
Nonmotor symptoms may precede typical motor
features of PD by several years and play a major
role in the deterioration of quality of life of patients
[Truong et al. 2008; Chaudhuri et al. 2006]. There
is convincing evidence that the PD neurodegener-
ative process begins many years before the onset of
motor manifestations by an estimated 3–6 years
[Savica et al. 2010]. The spectrum of nonmotor
symptoms encompasses constipation, bladder
dysfunction, daytime somnolence, delusions/hal-
lucinations, difficulty in concentration, dribbling,
dysphagia, episodes of confusion, fatigue, impulse
control disorders (ICDs), memory problems,
mood disorders (depression, anxiety), orthostatic
hypotension, pain, paranoia, sensation of breath-
lessness, sleep disturbances, sweating, and also
sexual dysfunction (SD) [Truong et al. 2008;
Chaudhuri et al. 2006].
Sexuality is a basic human right and essential part
of healthy life [World Association for Sexual
Health, 2008]. For patients with chronic disease,
sexuality is also a significant determinant of their
quality of life [Clayton and Ramamurthy, 2008]
and in PD a healthy sex life is associated with gen-
eral satisfaction from life [Moore et al. 2002].
Most men with PD consider erectile dysfunction
(ED) to be the most distressing of their various
disabilities imposed by the disease [Basson,
1996].
In this review we describe the effects of PD on
the sexuality of patients and their sexual partners,
and recommend treatment options. Healthcare
professionals who work with PD patients will be
able to implement some of the recommendations
within the framework of their clinical work.
http://tan.sagepub.com 375
Therapeutic Advances in Neurological Disorders Review
Ther Adv Neurol Disord
(2011) 4(6) 375–383
DOI: 10.1177/
1756285611411504
ÓThe Author(s), 2011.
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Correspondence to:
Gila Bronner, MPH, MSW
Sexual Medicine Center,
Department of Urology,
Sheba Medical Center,
Tel-Hashomer, Israel,
gilab@netvision.net.il
David B. Vodus
ˇek, MD,
PhD
Division of Neurology,
University Medical Center
and Medical Faculty,
University of Ljubljana,
Slovenia
The effect of Parkinson’s disease on sexuality
Sexual functioning is a complex process that
requires functioning of the body’s autonomic,
sensory and motor systems, and depends on the
neurological, vascular and endocrine systems,
allowing sufficient blood supply to and from gen-
ital organs, a balanced hormonal system and a
healthy emotional state. Sexual functioning is
influenced by numerous psychosocial factors,
including family and religious background, the
sexual partner and individual factors such as
self-concept and self-esteem. Sexuality can be
altered by aging, life experiences (e.g. abuse),
and various illnesses and their treatments
[Verschuren et al. 2010].
It has to be said that SD, such as lack of desire (in
both sexes), ED and disturbances of ejaculation
(in men), and deficient lubrication, dyspareunia
and problems with orgasm (in women), is not
uncommon in the general population [Addis
et al. 2006; Laumann et al. 2009]. SD in the gen-
eral population is expected to be a consequence
of many different causes, only a few of them
being well defined. Usually, SD is linked to
‘risk factors’, known to increase the risk of SD,
such as age, smoking and chronic disease.
Neurological disease as such is often counted
among the ‘general’ risk factors, although
neural control is a prerequisite for sexual function
[Rees et al. 2007] and particular nervous system
lesions are known to cause particular forms of
SD. Nevertheless, SD in a patient with a chronic
neurological disease is bound to be multifactorial
[Bronner et al. 2010].
SD is common in patients with PD [Hand et al.
2010; Celikel et al. 2008; Bronner et al. 2004;
Jacobs et al. 2000; Zesiewicz et al. 2000; Welch
et al. 1997; Wermuth and Stenager, 1995;
Brown et al. 1990; Koller et al. 1990], associated
with depression and relationship dissatisfaction
[Wielinski et al. 2010]. SD has been reported as
common even in young patients with PD (mean
age 49.6 years). Couples with the man as the
patient have been more dysfunctional. Erectile
failure and premature ejaculation were most fre-
quently found. Patients also usually displayed
decreased sexual desire. Symptoms of SD were
also frequent in their partners [Brown et al.
1990]. Inability to maintain an erection has been
found in half of the males [Wermuth and
Stenager, 1995; Koller et al. 1990]. ED was
reported by 54–79% of men with PD [Bronner
et al. 2004; Sakakabira et al. 2001; Koller et al.
1990]. A total of 60% of men with PD reported
ED, as compared with 37.5% in age-matched
controls [Singer et al. 1991]. Many males were
also unable to ejaculate and to achieve an orgasm.
In women with PD, vaginal tightness, loss of
lubrication, involuntary urination, anxiety and
inhibition were more prevalent than in matched
controls. Also women with PD were more likely
to be dissatisfied with the quality of their sexual
experiences [Welch et al. 1997].
While the greater prevalence of SD in PD
patients, when compared with age-matched
healthy controls, is not controversial, it is not
clear whether the known brain ‘lesions’ related
to PD (supposedly relevant for maintaining
normal sexual function) have a decisive impact
on the prevalence of SD in PD [Celikel et al.
2008; Sakakibara et al. 2001; Jacobs et al. 2000;
Welch et al. 1997]. An often-cited study found no
greater prevalence of SD in married male PD
patients, when compared with matched patients
with another chronic, but nonneurologic, disease
(arthritis) [Lipe et al. 1990]. However, further
studies are needed. Neurological features, auto-
nomic dysfunction and motor symptoms on the
left side of body did correlate with loss of desire
in PD patients of both genders [Kummer et al.
2009].
In clinical practice one finds that sexual function
is reported to be interfered with typical PD symp-
toms. Muscle rigidity, bradykinesia and ‘clumsi-
ness’ in fine motor control make sexual activities
difficult and may be worse in the late evenings if
dose scheduling is aimed at favouring daytime
activities. Tremor and dyskinesias may be
enhanced during sexual arousal. Hypersalivation
and sweating are deconcentrating, and in addi-
tion to hypomimia may objectively reduce the
appeal for the partner, and subjectively negatively
influence the self-image of the patient. Urinary
urgency and incontinence (or fear of inconti-
nence) during sexual activity seem to be a partic-
ular concern of the female PD patient. By
sleeping apart because of sleep dysfunction, the
partners may lose bed intimacy. A particular
problem is a loss of the ability to focus on a par-
ticular activity as part of the cognitive involve-
ment in PD.
One study linked ED and low desire in PD
patients of both genders to dopaminergic treat-
ment [Bronner et al. 2004], but on the other
Therapeutic Advances in Neurological Disorders 4 (6)
376 http://tan.sagepub.com
hand such therapy may in clinical experience
result in an apparent increase or normalization
of desire. Deep brain stimulation of the subtha-
lamic nucleus (STN) has been found to have a
positive influence on sexual well-being. Male (but
not female) PD patients under the age of 60 were
reportedly more satisfied with their sexual life
[Castelli et al. 2004].
A true increase in libido may occur as an adverse
reaction to treatment with levodopa [Uitii et al.
1989]. Compulsive sexual behaviour was noted
in 3.5% of PD patients using a dopamine agonist
[Weintraub et al. 2006].
In addition to the disease process and the influ-
ence of dopaminergic drugs, sexual function in
PD patients may be influenced by comorbidity,
particularly depression [Shulman et al. 2002] and
testosterone deficiency [Okun et al. 2002a].
Many medications, such as antihypertensive and
antidepressant agents, have adverse effects on
sexuality. On the other hand, spontaneous erec-
tions have been reported in patients receiving
levodopa. Apomorphine treatment may result in
erections and benefits sexual function
[O’Sullivan and Hughes, 1998].
Treatment modalities for sexual dysfunction
in Parkinson’s disease
Given the high prevalence of SD in patients with
PD, physicians and other healthcare providers
should discuss and treat sexual health issues as
an integral part of treating the disease. In all
instances, drug regimens should be reviewed for
possible effects on sexual function. Sexual educa-
tion, counselling and specific suggestions about
therapeutic methods are important, and should
be provided by the treating physician.
In a newly diagnosed patient with PD the possi-
ble enhancing influence of dopaminergic treat-
ment on sexuality should be discussed with
both partners. The improved (normalized)
libido in the male PD patient may be unwelcome,
as the elderly spouse has already settled in a sit-
uation of not being ‘bothered’. The emergence of
hypersexuality in the treated PD patient is, as a
rule, drug induced, and modification of treat-
ment is helpful. Profound loss of libido in the
well-treated PD patient may call for an endocri-
nological consultation if it causes distress.
In a newly diagnosed PD patient who present
with SD, the dopaminergic drugs should be
introduced first, and their effect followed up.
Occasionally, the SD will also improve.
Difficulties with the motor aspects of the sexual
activity may be overcome by counselling and
appropriate timing of dopaminergic treatment.
Poor lubrication in the female patient with PD
may be helped by lubricants; urge incontinence
during coitus by previously emptying the bladder
and treating the overactive bladder.
In male patients with rapid ejaculation, counsel-
ling on the use of particular techniques may lead
to improvement. Use of antidepressants (seroto-
ninergic agents such as clomipramine, or selec-
tive serotonin reuptake inhibitors such as
sertraline or paroxetine) may be successful, but
such use of these drugs is off label. If rapid ejac-
ulation is linked to ED, sildenafil may improve
both difficulties.
A rather typical problem in some male patients is
difficulty in reaching orgasm (delayed ejacula-
tion). An explanation that ejaculation is a reflex
often helps. Increased stimulation (apart from
vaginal intercourse) is often successful (including
the use of a vibrator). Sharing this information
with the partner can decrease marital tension,
and eliminate the embarrassment involved in
coping with these problems.
ED is the only SD with evidence-based drug treat-
ment available [Zesiewicz et al. 2010]. Sildenafil is
an effective treatment for ED in men with several
neurological disorders, also PD [Raffaele et al.
2002; Hussain et al. 2001]. Its efficacy in PD
patients with ED and depression was reported to
be 85% [Raffaele et al. 2002]. The other selective
inhibitors of type 5 cyclic guanosine monophos-
phate phosphodiesterase (PDE5-inhibitors),
tadalafil and vardenafil also seem to be effective.
These drugs augment the nitric-oxide-mediated
relaxation pathway in penile tissues by increasing
available cyclic guanosine monophosphate in the
corpus cavernosum. These medications therefore
do not cause erection, but enhance the response
to sexual arousal. Thus, sildenafil keeps the
response ‘natural’ and may thus advance partner
intimacy and bonding. On the other hand, the
man has to stay concentrated on sexual activity,
or the erection will fade away.
Sildenafil (25, 50 or 100 mg) is taken orally 1
hour before intended sexual activity. Significant
G Bronner and DB Vodus
ˇek
http://tan.sagepub.com 377
effects have been reported between 30 minutes
and 4–6 hours after taking the medication.
Dose-finding studies have demonstrated a dose–
response curve. In the PD patient, treatment may
start with 50 mg, but often the larger dose
(100 mg) needs to be used.
In our clinic, PD patients with ED reported that
they needed a longer time to onset of PDE5
inhibitors for successful intercourse, longer than
the recommended time by the physician. Slowed
gastrointestinal motility may explain the dimin-
ished absorption of drugs [Korczyn, 1990].
During follow-up visits, physicians can inform
their patients about the use of PDE5 inhibitors
and advise, in the case of failure, to extend the
drug time of onset.
Sildenafil can be used repeatedly, and if used
once or twice per week there should be no fear
of tachyphylaxis [Salonia et al. 2003].
PDE5 inhibitors are contraindicated in combina-
tion with vasodilator drugs of the nitro type and
nitric oxide donors, but a cardiologist can change
such drug regimens in suitable patients with ED
requiring treatment. PDE5 inhibitors should not
be used in patients with retinitis pigmentosa, and
in men with a history of priapism. They are con-
traindicated in men with hypotension (blood
pressure below 90/50 mmHg). Care should be
taken to identify men with multiple system atro-
phy who may present with ED, atypical
Parkinsonism and asymptomatic postural hypo-
tension. The most common adverse events of sil-
denafil are headache, flushing and dyspepsia.
Temporary visual symptoms (mainly colour-
vision disturbances) may occur with higher
doses (100 mg). Adverse effects are mostly tran-
sitory and of minor intensity. No evidence was
found of effects on the myocardium or the con-
duction system. Evaluation of functional capacity
is necessary in patients with coronary artery dis-
ease, who need to know the risks of physical as
well as sexual activity. Recommendations for the
use of sildenafil in patients with cardiovascular
disease have been published [Zusman et al.
1999].
Treatment with apomorphine sublingually is
another therapeutic option for PD patients with
ED. The action is through a dopaminergic effect
in the hypothalamus. Doses of 2–4 mg have been
recommended, with the erection occurring
within 10–25 minutes. Nausea is the most
common adverse reaction [Heaton, 2000].
PD patients may get an erection only with
higher doses than originally recommended.
A recent review of oral therapy of ED in neuro-
logical patients has proposed sildenafil (grade A),
and apomorphine (grade B) for treatment of PD
patients [Basson et al. 2010]. In patients who do
not respond to oral treatment intrapenile injec-
tions of vasoactive drugs can be used. These have
been used extensively in men with neurogenic
conditions, but not specifically PD; indeed, this
therapy seems to be rarely used in PD patients.
Prostaglandin E
1
(PgE
1
), papaverine, and a
papaverine–phentolamine mixture have all
showed an efficacy rate of more than 70%.
Acute complications, such as priapism and local
long-term complications, are lowest with PgE
1
(25% and 8%, respectively) [Porst, 1996]. This
treatment is contraindicated in patients taking
anticoagulants. PgE
1
(alprostadil) is the preferred
drug for self-injection therapy in ED, and is very
efficacious in neurogenic ED. Therefore, very
small doses (2–4 mg) have to be tried first to
evade the risk of priapism. Intracavernous injec-
tion requires dexterity from the patient or his
partner, and should be taught under medical
supervision before self-administration is
attempted. The effect is very rapid and may last
for 2–4 hours. Longer-lasting erection should be
treated as priapism, and first treated with cold
compresses. Priapism is a urological emergency,
but usually has a good prognosis with conserva-
tive treatment.
Some PD patients find the ‘guaranteed’ erection
induced by the intrapenile injection appealing, as
it is not dependent on arousal, and thereby not
distractible. It is a therapeutic solution which is
rarely tried, as couples can accommodate the
medicalization of the intercourse, and spouses
become efficient in giving the injection.
In patients unwilling to try ‘chemistry’, a vacuum
device may help, but requires dexterity from the
patient or his partner. It is rarely adopted by
elderly couples. In patients with neurogenic ED,
rigidity adequate for penetration has been
reported by 90% of respondents. Satisfaction of
partners was initially reported as high (70%), but
after months of treatment, and despite an
increase in sexual activity, only 41% of patients
were satisfied [Denil et al. 1996]. Premature loss
of rigidity and difficulty in placing and removing
the constriction bands are common complaints.
Therapeutic Advances in Neurological Disorders 4 (6)
378 http://tan.sagepub.com
The most common complications are bruises,
petechiae and skin oedema. The constriction
band should not stay in place for longer than
30 minutes. The use of a constriction band
alone may help patients who can obtain an erec-
tion, albeit not a durable one. The same restric-
tions concerning the duration of application
should be observed.
Depression and the use of antidepressants in PD
are common [Chung et al. 2003]. Both are asso-
ciated with higher frequency of SD. There are
some reports on the use of PDE5-inhibitors for
the treatment of depression associated sexual
dysfunction. Nurnberg and colleagues found
that a reduction in sexual difficulties (specifically
delayed orgasm responses and inadequate lubri-
cation) in 98 previously sexually functioning
women taking serotonin reuptake inhibitors,
was associated with sildenafil treatment, while
the women were continuing antidepressant treat-
ment [Nurnberg et al. 2008]. Increased sildenafil
dose for the treatment of depression associated
SD in men is recommended [Nurnberg and
Siegel, 2006; Seidman et al. 2003].
Some studies have focused on the effect of tes-
tosterone on SD in PD [Ready et al. 2004; Okun
et al. 2002a]. There is an unrecognized high prev-
alence of testosterone deficiency in elderly male
patients with PD, similar to that found in the
general population (20–25% of males over 60
years old). Testosterone deficiency is a well-docu-
mented cause of depression, fatigue, decreased
libido, erectile dysfunction and decreased work
performance. These symptoms, which may be
refractory to antidepressants, anti-anxiety and
antiparkinsonian medications, may respond to
treatment with testosterone. A daily dose of
transdermal testosterone gel improved testoster-
one deficiency symptoms in men with PD and
showed trends in improvement in nonmotor
and motor symptoms [Okun et al. 2002b].
Hypersexuality
Pathologic hypersexuality has occasionally been
reported in patients with PD, linked to medica-
tions [Merims and Giladi, 2008; Klos et al. 2005;
Korpelainen et al. 1998; Jime
´nez-Jime
´nez et al.
2002; Giovannoni et al. 2000; Fernandez and
Durso, 1998; Uitti et al. 1989] and often occur
in patients without a prior psychiatric history or
obvious cognitive deficits [Klos et al. 2005].
Only few studies propose clear criteria for HS in
PD [Voon et al. 2006] and therefore it is not easy
to establish the extent of the problem among
PD patients.
HS current prevalence was found among six
(2.0%) of 297 PD patients [Voon et al. 2006].
Prevalence of increased sexual interest in restless
legs syndrome patients treated with dopaminer-
gic medications was reported by 6% [Driver-
Dunckley, 2007]. A study of ICDs in 3090
patients with PD identified compulsive sexual
behaviours in 3.5% [Weintraub et al. 2010].
The authors used the Minnesota Impulse
Disorders Interview, asking patients about preoc-
cupation with sex, repetitive behaviour, fantasies
and urges [Christenson et al. 1994]. Increased
sexual drive was reported by 8.8% of PD patients
and/or the caregiver/spouse [Giladi et al. 2007].
The authors believe that their current percentage
of patients with heightened libido is an underes-
timation of the actual problem. A search of
patients’ medical files yielded a small amount of
recorded HS [Bostwick et al., 2009; Cannas et al.
2007; Klos et al. 2005]. Cannas and colleagues
found nine cases of recorded aberrant sexual
behaviours observed during an 11-year period
[Cannas et al. 2007], Klos and colleagues
reported on 15 cases during an 8-year period
[Klos et al. 2005], and of 267 patients with PD
new-onset gambling or HS was documented in 7
(2.6%) [Bostwick et al. 2009].
HS in PD is associated with male sex, earlier dis-
ease onset, dopamine agonist therapy and depres-
sion [Voon et al. 2011, 2006; Bostwick et al.
2009; Weintraub et al. 2006; Klos et al. 2005].
Hypersexual patients showed greater general cog-
nitive impairment, including lower performances
on learning tests and poorer inhibitory control in
comparison with PD patients with pathological
gambling and compulsive eating [Vitale et al.
2011].
The cause of this compulsive behaviour is poorly
understood. It may be related to increased sexual
drive or lack of sexual impulse control, both
dependent on dopaminergic regulation or to neu-
rodegenerative process [Ferreri et al. 2006].
Stimulation of the STN is associated with both
favourable and negative outcome in terms of
ICDs and related disorders [Broen et al. 2011].
When HS occurs it contributes a considerable
tension within the family that is already
G Bronner and DB Vodus
ˇek
http://tan.sagepub.com 379
dealing with the difficult consequences of PD.
Therefore, it is imperative to detect and treat as
early as possible. Discontinuation of the use of
the dopamine agonist was consistently effective
in treating HS [Cannas et al. 2007; Weintraub
et al. 2006; Voon et al. 2006; Dodd et al. 2005;
Klos et al. 2005]. In addition, HS must be
addressed in the staff education and counselling,
since hypersexual patient can cause a lot of dis-
turbances to the routine nursing work.
Management of sexual problems
by the physician
Management of sexual problems can be applied
in steps. The ‘Open Sexual Communication’
module is a four-step tool designed to assist phy-
sicians in discussing sexual issues with patients
and offer them adequate advice or treatment
[Bronner, 2009]. Sexual advice can go along
with medical interventions for the SD, but also
can be applied independently. For example, in
couples for whom intercourse is not a realistic
possibility either because of physical limitations
or because of impairments of genital functioning,
suggestions about outercourse (experiencing
erotic pleasure without concern for erection,
erection without orgasm or extravaginal orgasm)
can be offered. The key to a physician’s success in
assessing and treating sexual problems is comfort
in asking relevant questions and the belief that
PD patients are sexual human beings with the
ability to share love, intimacy and sexual
excitement.
It is important to note that the intricacy, urgency
and diversity of needs and experiences in the
sexual area are highly personal. PD patients
may seem similar with regards to their disabil-
ities, medical treatments, relationship and
family support. However, our experience sug-
gests that they might have different problems
and different needs. The ‘Open Sexual
Communication’ module recommends that the
physician inquires PD patients and their partners
about their own expectations and past treatment
trials in order to offer an appropriate treatment to
each individual or couple. The complexity of SD
in PD can be better managed in a multidisciplin-
ary team. Neurologists, who are not comfortable
to cope with this complicated and sensitive area
by themselves, or are too busy, should refer
patients to another professional for evaluation
and treatment. According to our experience,
sometimes it is a good idea to define one
member in each multiprofessional team who
will competently cope with sexual health of PD
patients.
Conclusion
Data on sexual function in PD is incomplete and
contradictory, however it is well established that
SD is highly frequent among patients. The devel-
opments in the area of sexual medicine result in
more information and experience regarding
assessment and treatment of SD. In this review,
we have described the complexity of the sexual
problems and the process by which PD related
factors (physical, psychological and relational)
have an impact on the sexual functioning and
well being of patients, their partners and their
relationships. Management of sexual problems
in PD is a challenging issue for physicians and
healthcare professionals who work with PD
patients and their partners. We encourage physi-
cians to discuss frankly sexual health issues with
their patients, and offer them treatment based on
the accumulating knowledge on SD and treat-
ment options.
Funding
This research received no specific grant from any
funding agency in the public, commercial, or not-
for-profit sectors.
Conflict of interest statement
The authors declare no conflicts of interest in
preparing this article.
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... In Parkinson's disease (PD), quality of sexual life (QoSL) (Bronner et al., 2014;Bronner, Royter, Korczyn, & Giladi, 2004) and sexual selfesteem (Brown, Jahanshahi, Quinn, & Marsden, 1990) are reduced and sexual dysfunction (SD) is more frequent in PD patients than in controls (Bronner & Vodušek, 2011). Possible causes are motor dysfunctions known to interfere with sexual function, such as tremor, hypomimia, muscular rigidity, bradykinesia or dyskinesia (Bronner & Vodušek, 2011). ...
... In Parkinson's disease (PD), quality of sexual life (QoSL) (Bronner et al., 2014;Bronner, Royter, Korczyn, & Giladi, 2004) and sexual selfesteem (Brown, Jahanshahi, Quinn, & Marsden, 1990) are reduced and sexual dysfunction (SD) is more frequent in PD patients than in controls (Bronner & Vodušek, 2011). Possible causes are motor dysfunctions known to interfere with sexual function, such as tremor, hypomimia, muscular rigidity, bradykinesia or dyskinesia (Bronner & Vodušek, 2011). Furthermore, SD seems to be more evident in the postural instability gait difficulty (PIGD) subtype of PD (Deng et al., 2015). ...
... Also PD-related non-motor dysfunction can impair sexuality. This includes autonomic failures such as sweating (Bronner & Vodušek, 2011) or urinary incontinence (Welsh, Hung, & Waters, 1997) and neuropsychiatric impairment, especially depression (Kotkova & Weiss, 2013) and cognitive decline (Kummer, Cardoso, & Teixeira, 2009). Depression and other psychological disease-related effects such as apathy or fatique were suggested to compromise sexual desire in both men and women and, in turn, might increase SD (Moore et al., 2002;Ozcan et al., 2015). ...
Chapter
Sexual dysfunction is one of the commonest non-motor symptoms in Parkinson's disease (PD) and has been found about twice as high in PD patients compared to age-matched controls. The quality of sexual life is reduced in PD patients compared to healthy peers and impairment affects wide aspects of physical sexual function as well as sexual desire, sexual satisfaction and sexual partnership. Overall, male PD patients are more frequently affected by sexual disorders than females and seem to suffer more from sexual impairment. The reported frequencies and presentations of various sexual dysfunctions vary widely in the literature, which is likely related to the patient cohorts examined, in particular with regard to age and gender, duration and severity of disease and applied measurement instruments. This chapter gives an overview of the prevalence, phenotype and clinical presentation of sexual dysfunction in PD and its influence on the partnership.
... The most common SD in men with PD are erectile dysfunction (ED), premature ejaculation (PE), hypersexuality, and difficulty in reaching orgasm. The most common SD in women with PD are low sexual desire, urination during sex, reduced lubrication, and difficulty in arousal and reaching orgasm [26,27]. Both genders have reported a loss of desire and dissatisfaction in their sexual life when suffering from PD [27]. ...
... The most common SD in women with PD are low sexual desire, urination during sex, reduced lubrication, and difficulty in arousal and reaching orgasm [26,27]. Both genders have reported a loss of desire and dissatisfaction in their sexual life when suffering from PD [27]. ...
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... Appropriate counseling diminishes some of the problems (reluctance to engage in sex, problems with ejaculation, lubrication, and urinary incontinence). Treatment of ED with sildenafil and apomorphine is evidence-based (21). We performed a narrative review to briefly discuss the epidemiology, pathogenesis, risk factors, genetic contribution, clinical course, diagnosis, and treatment of PD. ...
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Parkinson's disease (PD) is recognized as the most common neurodegenerative disorder after Alzheimer's disease. Lower urinary tract symptoms are common in patients with PD, either storage symptoms (overactive bladder symptoms or OAB) or voiding symptoms. The most important diagnostic clues for urinary disturbances are provided by the patient's medical history. Urodynamic evaluation allows the determination of the underlying bladder disorder and may help in the treatment selection. Pharmacologic interventions especially anticholinergic medications are the first-line option for treating OAB in patients with PD. However, it is important to balance the therapeutic benefits of these drugs with their potential adverse effects. Intra-detrusor Botulinum toxin injections, electrical stimulation were also used to treat OAB in those patients with variable efficacy. Mirabegron is a β3-agonist that can also be used for OAB with superior tolerability to anticholinergics. Desmopressin is effective for the management of nocturnal polyuria which has been reported to be common in PD. Deep brain stimulation (DBS) surgery is effective in improving urinary functions in PD patients. Sexual dysfunction is also common in PD. Phosphodiesterase type 5 inhibitors are first-line therapies for PD-associated erectile dysfunction (ED). Treatment with apomorphine sublingually is another therapeutic option for PD patients with ED. Pathologic hypersexuality has occasionally been reported in patients with PD, linked to dopaminergic agonists. The first step of the treatment of hypersexuality consists of reducing the dose of dopaminergic medication. This review summarizes the epidemiology, pathogenesis, risk factors, genetics, clinical manifestations, diagnostic test, and management of PD. Lastly, the urologic outcomes and therapies are reviewed.
... In female PD patients SD is present in up to 87% [13]. Loss of libido is reported to be the most common SD and is 83% twice as prevalent than in the healthy population [12,[14][15][16]. SD furthermore can have a negative impact on the partnership [17,18]. ...
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Background: Sexual dysfunctions (SD) are common but underreported in Parkinson's disease (PD) and have negative impacts on the quality of life (QoL) and partnership. Methods: We analyzed the data set from the PRISM study for demographics of SD and their influence on quality of life and partnership. Results: 449/861 (52.1%) PD patients reported SD, with male patients being affected more often and having a longer course of disease. The most common SD in men was erectile dysfunction (ED) (n = 152), while women's most frequent complaints were orgasm dysfunction (n = 84) and reduced libido (n = 81). Hypersexual SDs were reported significantly more often by men. Spousal caregivers of patients reporting inability to relax and enjoy sex and reduced libido indicated a negative influence on the relationship in general. Negative effects on the sexual relationship were reported significantly more often for patients with ED, difficulties with sexual arousal, inability to relax and enjoy sex, and reduced libido. Hypersexual dysfunctions showed no effect on the relationship. Conclusion: SD is a common but underreported problem in the treatment of patients with PD. Due to the negative influence on the relationship and QoL of patients and caregivers, SD should be assessed routinely.
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Sexuality and disability is an important topic in our global society. Dismantling myths about sexuality and disability is considered a final frontier for people with disabilities. Dismantling myths about sexuality and disability is vital to the overall health and well-being of people with disabilities. A major aspect of the dismantling process is to acknowledge that sexuality is a significant quality of life determinant for all human beings. This chapter provides information that will promote a healthier and more accurate view of Sexuality and Disability. Dismantling this last frontier involves providing the readership with relevant historical information; information about psychosocial factors and attitudes that influence sexuality; and information about ethical practice guidelines. Information pertaining to sexuality training, specific provider competencies and how select disabilities and chronic illness impact sexuality is also covered in the chapter.
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Chapter
Sexual dysfunction (SD) is defined as a combination of reduction in libido, and problems with a person's ability to have sex. It is a frequent but neglected and poorly recognized nonmotor symptom (NMS) in Parkinson's disease (PD) which correlates with reduced quality of life (QoL). Hypersexuality forms another spectrum of SD and is an impulse control disorder (ICD) of behavior, which also affects the sexual desires of people with Parkinson's (PwP) and impacts their partner, family, and QoL. NMS occur in various forms and represents a range of symptoms, from cognitive dysfunction to pain and SD, and this chapter explores the relationship of comorbid NMS with SD and also how NMS, motor symptoms, and hypersexuality experienced by patients may impact sexual function in people with Parkinson's (PwP).
Chapter
Nonmotor symptoms of Parkinson's disease (PD) range from neuropsychiatric and cognitive to sleep, sensory, and genito-urinary disorders, and occur as a result of the disease process as well as due to side effects of drug treatment for PD. Sexual dysfunction is an important aspect of the nonmotor profile of Parkinson's but is rarely discussed. Sexual health is considered an integral element of holistic health, thus sexual dysfunction can also significantly impact quality of life in people with Parkinson’s. The effect of sexual dysfunction of PD, both disease related and drug induced, on the concept of “wellness” of patients and their intimate partners is poorly understood, inadequately researched and a key unmet need in care and support. In this chapter we discuss the concept of “wellness” as applied to the treatment of PD, the ways in which nonmotor symptoms and other aspects of living may affect wellness in PD, and strategies for addressing sexual health utilizing a wellness model.
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Sexual dysfunction is a very frequent non-motor symptom in Parkinson's disease (PD). However, patients are often reluctant to declare their sexual problems and many clinicians do not inquire about them during routine visits. The use of validated rating scales and questionnaires allows overcoming these difficulties, characterizing the nature and causes of the patient's sexual dysfunction, and helping to implement and monitor the most adequate interventions. There is a wide range of instruments available for assessing sexual dysfunction in PD, including generic and specific ones. In this chapter, we review the most used rating scales and questionnaires, with a description of its components, characteristics and psychometric attributes.
Chapter
This chapter will focus on the diagnostic work around sexual dysfunction in Parkinson's disease, especially laboratory tests and biomarkers. A number of methods to analyze if sexual dysfunction is caused by neural pathology, vascular dysfunction or other mechanisms are now available. Other methods can be used to differentiate between psychogenic/functional reasons behind sexual dysfunction and organic ones. The role of biomarkers for diagnosis, but also for understanding the reason behind and for counteracting sexual dysfunction is becoming more evident. There is also a rich and increasing number of scales and other instruments available for detecting and quantifying sexual hypo- and hyperactivity. When investigating the reason behind sexual dysfunction in patients with Parkinson's disease comorbidities should also be considered. Finally, early and pronounced sexual dysfunction might in some cases be an indication that differential diagnosis, like Multisystem Atrophy, should be thought about. All these aspects of the diagnostic procedures around sexual dysfunction in Parkinson's disease will be covered in this chapter.
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Results In an intention-to-treat analysis, women treated with sildenafil had a mean Clinical Global Impression-sexual function score of 1.9 (95% confidence interval (CI), 1.6-2.3) compared with those taking placebo (1.1; 95% CI, 0.8-1.5), with a mean end point difference of 0.8 (95% CI, 0.6-1.0; P=.001). Assigning baseline values car- ried forward to the 22% of patients who prematurely discontinued resulted in a mean end point in the sexual function score of 1.5 (95% CI, 1.1-1.9) among women taking sildenafil compared with 0.9 (95% CI, 0.6-1.3) among women taking placebo with a mean end point difference of 0.6 (95% CI, 0.3-0.8; P=.03). Baseline endocrine levels were within normal limits and did not differ between groups. The mean (SD) Hamil- ton scores for depression remained consistent with remission in both groups (4.0 (3.6); P=.90). Headache, flushing, and dyspepsia were reported frequently during treat- ment, but no patients withdrew because of serious adverse effects. Conclusion In this study population, sildenafil treatment of sexual dysfunction in women taking SRIs was associated with a reduction in adverse sexual effects.
Article
Background: Selective serotonin reuptake inhibitor (SSRI)-induced ejaculatory delay is a common problem that has no treatment with established efficacy. Sildenafil citrate is effective for erectile dysfunction and appears to be safe at doses up to 200 mg. Method: We enrolled men who were in remission from depression according to DSM-IV criteria and who reported that they had developed new-onset ejaculatory delay in the setting of SSRI treatment. Enrolled patients were instructed to use 25 mg of sildenafil I hour prior to sexual activity on at least 2 occasions. If this was not effective for the ejaculatory delay, they were instructed to increase the dose progressively up to a maximum of 200 mg. We compared baseline sexual functioning to 2 phases of open treatment: low-dose phase (sildenafil 25-100 mg) and high-dose phase (sildenafil 150-200 mg). The primary outcome measure was a modified, self-report Clinical Global Impressions (CGI) scale that was specific for erectile (CGI-EF) and ejaculatory (CGI-EJF) aspects of sexual function. Results: Twenty-one men (mean age = 56 years) with major depressive disorder (MDD) in remission and SSRI-associated ejaculatory delay enrolled in the study and received sildenafil. At baseline, 14 of 21(67%) had comorbid erectile dysfunction. At the low-dose phase follow-up assessment, 12 of 14 achieved full erectile dysfunction remission, and 4 of 21 achieved ejaculatory delay remission. Sixteen patients with persistent ejaculatory delay were eligible for the high-dose phase: 5 withdrew from the study, 4 increased to a maximum dose of 150 mg, and 6 increased to a maximum dose of 200 mg. The 1 patient who had clinically significant erectile dysfunction and ejaculatory delay reported improvement of both conditions after the high-dose phase. Of the 10 patients who had ejaculatory delay without significant erectile dysfunction and who chose to take high-dose sildenafil, 9 reported a significant clinical improvement in ejaculatory delay (CGI-EJF improvement score of 1 or 2) and 7 achieved full remission (CGI-EJF severity score of 1 or 2 and CGI-EJF improvement score of 1 or 2). Conclusion: In this open clinical trial with men who had SSRI-induced ejaculatory delay, high-dose sildenafil appeared to be effective in reducing ejaculatory latency.
Article
Sexual functioning was investigated in 50 parkinsonian male and female patients using a questionnaire. A loss of sexual interest and functioning was reported in a high percentage of patients. Depression was not prevalent but 70% had some evidence of autonomic nervous system dysfunction that may be related to sexual dysfunction. It is concluded that the sexual function is frequently impaired in Parkinson's disease.
Article
Background Many patients with Parkinson disease (PD) suffer from nonmotor symptoms including depression, anxiety, sexual dysfunction, decreased energy level, and an overall decline in quality of life. Comorbid depression, hypothyroidism, and sleep disorders may account for some, but not all, of these problems. Testosterone deficiency affects 20% to 25% of males over the age of 60 years in the general population and may cause signs and symptoms of the nonmotor symptoms seen in PD. We observed numerous patients with PD whose nonmotor symptoms were refractory to treatment. Objective To determine whether treatment of comorbid testosterone deficiency in male patients with PD can lead to improvements in refractory nonmotor symptoms. Methods Case studies were reviewed of the first 5 male patients who had PD with symptoms of testosterone deficiency who were treated in our clinic. All patients had low serum testosterone levels. Screening for testosterone deficiency symptoms using the St Louis Testosterone Deficiency Questionnaire was performed for 4 of the 5 patients. Additionally, to assess the prevalence of PD, total testosterone levels in 68 patients in our PD registry were sent for evaluation. Results Following testosterone replacement therapy, all 5 patients experienced significant improvements in their refractory nonmotor symptoms. Of 68 male patients with PD enrolled in our PD registry, 24 (35%) had plasma evidence of testosterone deficiency. We also noted that the risk of testosterone deficiency per decade was found to increase 2.8-fold per decade (P<.001), paralleling that which is found in the general elderly male population. Conclusions The findings from this study reveal the heretofore unrecognized high prevalence of testosterone deficiency in elderly male patients with PD similar to that found in the general population. These symptoms, which may be refractory to antidepressants, anxiolytics, and antiparkinsonian medications, may respond to treatment with testosterone. More rigorous controlled studies will need to be undertaken to examine the treatment of this common comorbidity in male patients with PD.
Article
In Reply: Dr Harinstein raises concerns that treatment with additional medication such as sildenafil can add to patient adverse effects and cost burdens and suggests further consideration of different management options. Although we agree that no single treatment is definitive, the large number of reports evaluating treatment modalities (including SRI agonists, antagonists, partial agonists, switching, or augmentation, or nonpharmacological approaches such as waiting, drug holiday, or dose reduction) include only a few randomized clinical trials. With the exception of phosphodiesterase type 5 inhibitors,1 no clinically meaningful and significant data support those treatment modalities, leaving patients at risk for excess random pharmacology.2
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Background: Impulse control disorders (ICDs), in particular pathological gambling, hypersexuality, and compulsive eating, are being increasingly identified in Parkinson's disease (PD) patients. Pathological gambling has been associated with frontal/executive dysfunctions, whereas hypersexuality and compulsive eating, and their relation with cognitive dysfunctions, have not been investigated in PD. Methods: We investigated cognitive correlates underpinning pathological gambling, hypersexuality, and compulsive eating in PD. PD outpatients were screened for pathological gambling, hypersexuality, and compulsive eating. Based on clinical criteria, we identified 13 patients with hypersexuality, 12 with compulsive eating, 14 with pathological gambling, and 10 with multiple ICDs. Fourteen PD patients matched for age and education without ICDs served as controls. Clinical features and neuropsychiatric and neuropsychological functioning were assessed in the 5 groups. Results: Demographic, clinical, neuropsychiatric, and neurological aspects did not differ among groups. All 4 groups of ICD patients were impaired on tasks exploring spatial-planning and set-shifting tasks compared with the controls. The main difference among patients with pathological gambling, hypersexuality, and compulsive eating was that patients with hypersexuality were more impaired on the Stroop test than patients with pathological gambling. Individuals with hypersexuality, compulsive eating, and multiple ICDs performed worse on verbal learning and memory tests than did patients with pathological gambling. Discussion: ICDs are associated with impaired cognitive functions; the severity of impairment decreased in the order multiple ICDs and hypersexuality > compulsive eating > pathological gambling. Our findings support the idea that hypersexuality is associated with prefrontal and memory dysfunctions, whereas pathological gambling seems to be related only to frontal dysfunction. NS065070