Parkinson's Toolkit

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.