Sexual Dysfunction

 Key Facts

  • Hypersexuality, decreased desire, and erectile dysfunction are the most common presentations.
  • Antiparkinsonian medications can cause side effects that affect sex drive.
  • You should directly ask your patient regardin his or her sexual activity.
  • Management should include adjustment in medications.

Clinical Best Practices

  • Yearly review of sexual health of PD patients should take place, due to the frequency and the dynamic nature of sexual dysfunction in this population.
  • Patients on dopamine agonists require specific attention and more frequent inquiry regarding all possible types of compulsive behavior, including sexual.
  • Medication prescription and adjustment is essential and should be complemented with couples counseling as appropriate.
  • If possible, partners should always be involved in the evaluation of the sexual problems.

Sexual dysfunction is common among patients with PD and represents one of the disabling features of the disease.

The need for intimacy and sexual expression are important dimensions of quality of life of people with PD. Given the high prevalence of sexual dysfunctions in PD, health care providers should play a major role in advocating sexual health and treat sexual health issues as part of the holistic approach to people with PD.

Presentation

The most common sexual dysfunctions affecting PD individuals are:

  • Decreased desire
  • Hypersexuality
  • Reduced testosterone
  • Erectile dysfunction (ED)

Common Causes

  • Decrease in sexual desire, manifesting also as ED, is frequently associated with depression, fatigue, and apathy in PD patients, who are coping with motor and non-motor symptoms.
  • ED is also affected by the disease itself, by other co-morbid illness (eg, diabetes, hypertension, cardiovascular disease), and by the medical treatments of all these diseases.
  • Hypersexuality is a possible side effect of medications  in some patients.
  • Symptoms of dopamine-activated hypersexuality can manifest themselves in delusions or hallucinations of a sexual nature, decreased control over sexual impulses, and a desire to engage in more frequent sexual activity.

Diagnosis

  • Regular inquiry of each patient about sexual activity, especially those on dopamine agonists, is crucial to tracking sexual problems.
  • Speaking to sexual partners, if available, can inform the clinical diagnosis of either decreased desire, and associated ED problems, or hypersexuality.
  • Framing questions broadly and asking about changes in sexual behavior and function will lead to more specific sharing by the patient.

Barriers to Diagnosis

  • Sexuality is a highly sensitive topic for many people, and many PD patients may not realize that changes in sexual behavior and function are associated with the disease.
  • Older patients may especially regard decrease in desire as normal, and hypersexual behavior may be embarrassing or shameful to some patients and partners, who may view it as a psychological or moral issue and not medication induced.

Treatment Options

  • Concomitant treatment for ED and depression is best, as treatment of ED will likely improve patient’s adherence to anti-depressant medication, and mitigating depression will improve sexual desire.
  • Hypersexuality due to dopamine dysregulation is a complex issue that often requires repeated medication adjustments to achieve an optimal balance between medication efficacy and side effect mitigation. Referral to the treating neurologist, if possible is advised.
  • Associated sexually-based relationship problems caused by either depression or hypersexual tendencies may benefit from counseling with a couples therapist with training in sexual dysfunction issues.
  • Referral to specialists (eg, specialist in sexual medicine, sex therapist, couples therapist) is very important, since sexual dysfunction is a multidimensional problem.
References: 

Bronner G, Royter V, Korczyn AD, Giladi N. Sexual dysfunction in Parkinson's disease. J Sex Marital Ther. 2004;30(2):95-105.

Bronner G. Practical strategies for the management of sexual problems in Parkinson's disease. Parkinsonism Relat Dis. 2009;15(suppl 3):96S-100S.