Catastrophizing mediates the relationship between non-motor symptoms and quality of life in Parkinson's disease.

BACKGROUND: The non-motor symptoms of Parkinson's disease (PD), pain, depression, anxiety and sleep disturbances are highly prevalent in persons with PD and have a profound impact on their quality of life (QOL). Catastrophizing is a negative coping style known to influence individuals' ability to cope with their medical symptoms and contributes to negative health-related outcomes, yet, it has not been studied in persons with PD. OBJECTIVE: The objectives of this study were to measure catastrophizing in PD and explore its role as a mediator of the relationship between non-motor symptoms and QOL. METHODS: One-hundred and three individuals diagnosed with PD completed questionnaires regarding pain catastrophizing, QOL and non-motor symptoms: pain, depression, anxiety and sleep disturbances. RESULTS: More than half of the sample exhibited high levels of pain, anxiety and sleep disturbances. Catastrophizing was significantly correlated with QOL and with all of the non-motor symptoms. Catastrophizing mediated the relationship between all of non-motor symptoms and QOL as well as the relationship between age and QOL. CONCLUSIONS: Negative psychologic coping, specifically catastrophizing, has an important role in determining how destructive non-motor symptoms can be on the QOL of persons with PD. This is the first study to measure catastrophizing in this population and demonstrate its negative impact on QOL. Our findings emphasize the need to identify persons at risk for poor QOL and referrer them to appropriate psychological care. Evidence based interventions that target catastrophizing should be tested for their efficacy in persons with PD.

The Role of Sex Therapy in the Management of Patients with Parkinson's Disease.

BACKGROUND: Patients with Parkinson disease (PD) and their partners report deterioration in their sexual life. Sexual dysfunction (SD), an important and often ignored aspect, is common in PD. Motor and nonmotor symptoms are involved in limiting pleasure and disturbing function. Sexual dissatisfaction is more common in men that in women. Frequently, both patients and partners have SD associated with PD, and both need suitable treatment. These issues need to be evaluated by neurologists or PD nurses and by specialized sex therapists. The objectives of this study were to describe the complexity and multidimensional nature of sexual problems in PD, enable practitioners to assess and treat sexual difficulties of their patients, and increase awareness of the role of sex therapy in the therapeutic process of PD. METHODS: Based on clinical experience of over 30 years in movement disorder clinics and a review of the literature, the authors suggest practical approaches, including an "Open Sexual Communication" module, prescribing medications, and/or referring to specialists. RESULTS AND DISCUSSION: The longitudinal nature of treating neurologic patients puts physicians in an important position to introduce sexual issues and to assess and plan the interventions and follow-up needed to ensure that sexual difficulties are resolved. The management of hypersexuality requires a thoughtful distinction between lack of opportunities for sexual expression, limited ability to perform, and true hypersexuality. Sex therapists have a major role in the assessment and treatment of the multiple factors that may underlie sexual dissatisfaction in PD, differentiating between hypersexual behaviors and other sexual preoccupation behaviors, and training the professional team.

Acquired premature ejaculation in Parkinson's disease and possible mechanisms.

Premature ejaculation (PE) has been reported in 40.6-51.5% of men affected by Parkinson's disease (PD), however, this non-motor sexual complaint has not been studied in detail. We describe eight PD patients who asked for a sexological consultation between 2008 and 2014 because of a new-onset of PE. They were diagnosed with acquired PE (APE) according to the DSM-V criteria and the International Society for Sexual Medicine (ISSM) committee. Patients' demographic, medical and sexual related data were retrieved and studied. The average age of onset of PD was 53.3 ± 12.7 years (range 38-77 years) and the sexual problem appeared 4.0 ± 3.1 years later. The mean intravaginal ejaculation latency (IELT) before APE onset was 7.3 (range 2-20) min. Interestingly, the ejaculatory disorder appeared abruptly, characterized by a dramatically shortened IELT in all patients, while in three of the cases ejaculation occurred before vaginal penetration, hampering sexual intercourse. Some patients had 2 additional sexual problems, (four with erectile dysfunctions, five with libido changes: increased desire in four and reduced in one). In this case series of PD patients with APE, the ejaculatory dysfunction developed when patients were on antiparkinsonian medications, suggesting a possible medication effect.

Sexual Preoccupation Behavior in Parkinson's Disease.

People with Parkinson's disease (PD) present with problematic sexual behaviors that are often misunderstood or ignored. Sexual problems in PD are part of a non-motor syndrome, and they play a  prominent role in the life of affected individuals and their partners. Based on our considerable clinical experience, we describe four common types of sexual preoccupation behaviors in people with PD: (1) sexual behavior with underlying sexual dysfunction, (2) sexual desire discrepancy with partner after restored desire, (3) hypersexuality and compulsive sexual behavior, and (4) sexual behavior with underlying restless genital syndrome. We also suggest methods of assessing and diagnosing these sexual behaviors, and propose alternative possible treatments for people with PD and their partners/caregivers. Understanding these four behavioral types will assist healthcare professionals in explaining and educating people with PD and their partners, contribute to decreased stress and tension between them, and help them manage these sexual issues.

Sexuality in patients with Parkinson's disease, Alzheimer's disease, and other dementias.

Sexual dysfunction (SD) is common among patients with Parkinson's disease (PD), Alzheimer's disease (AD), and other dementias. Sexual functioning and well-being of patients with PD and their partners are affected by many factors, including motor disabilities, non-motor symptoms (e.g., autonomic dysfunction, sleep disturbances, mood disorders, cognitive abnormalities, pain, and sensory disorders), medication effects, and relationship issues. The common sexual problems are decreased desire, erectile dysfunction, difficulties in reaching orgasm, and sexual dissatisfaction. Hypersexuality is one of a broad range of impulse control disorders reported in PD, attributed to antiparkinsonian therapy, mainly dopamine agonists. Involvement of a multidisciplinary team may enable a significant management of hypersexuality. Data on SD in demented patients are scarce, mainly reporting reduced frequency of sex and erectile dysfunction. Treatment of SD is advised at an early stage. Behavioral problems, including inappropriate sexual behavior (ISB), are distressing for patients and their caregivers and may reflect the prevailing behavior accompanying dementia (disinhibition or apathy associated with hyposexuality). The neurobiologic basis of ISB is still only vaguely understood but assessment and intervention are recommended as soon as ISB is suspected. Management of ISB in dementia demands a thorough evaluation and understanding of the behavior, and can be treated by non-pharmacologic and pharmacologic interventions.

Management and rehabilitation of neurologic patients with sexual dysfunction.

Neurologic disease frequently negatively affects sexual experience in multiple ways. The patient's sexual self-image, sexual function, propensity to sexual pain, and motivation to be sexually active may be impacted, as may the sexual experiences of the partner. Difficulties with mobility can limit both partners' sexual arousal and pleasure. Conditions associated with chronic pain or continence concerns add further distress. Thus sexual rehabilitation needs to address many areas. Comorbid depression is common and needs to be stabilized before definitive treatment of sexual dysfunction. Management strategies include cognitive behavioral therapy, mindfulness-based cognitive therapy, and sex therapy and, for erectile dysfunction and premature ejaculation, pharmacotherapy can be added. Benefit from all these modalities is confirmed in the general population but only pharmacologic treatment of erectile dysfunction has been studied in neurologic patients, where benefit is also seen. Testosterone is indicated only for comorbid testosterone deficit: very occasionally the neurologic condition causes secondary male hypogonadism. No androgen deficiency state has been identified in women. Results of testosterone treatment in women are conflicting: recruited women were not clearly dysfunctional and women with neurologic conditions have not been studied. Future research involving both partners using combined medical and psychologic therapy as followed in clinical practice is advocated.

Correlates of quality of sexual life in male and female patients with Parkinson disease and their partners.

INTRODUCTION: Patients with Parkinson disease (PD) and their partners may experience a worsening of their sexual life. AIM: To assess quality of sexual life (QoSL) in male and female PD patients and their partners. MATERIALS AND METHODS: Medical, demographic and clinical data was collected regarding consecutive PD patients, including depression, and motor symptom rating. Partners' data included the short form-12 health questionnaire (SF-12). All patients and partners filled the 5-item QoSL questionnaire. RESULTS: Data from 89 PD patients (66 men) and 69 spouses (52 women) was analyzed. Male patients rejected sex significantly less than female patients and their sexual desire was higher, but female patients reported higher sexual satisfaction. Patients and partners similarly perceived their relationship which was averagely good. Analysis within couples demonstrated that better QoSL of patients could be predicted by gender (male), better QoSL of their partners and, motor severity, but not the patient's depression, age or use of l-dopa. The partner's QoSL was explained by younger age, and better motor scores of their parkinsonian partner. Treatment of the PD patient with l-dopa or dopamine agonist was associated with worse partner's QoSL. CONCLUSION: Differences in QoSL of male and female PD patients and within couples were found. These findings suggest that focusing on partner's needs may improve QoSL of patients and partners troubled by PD.

The impact of vaginal penetration difficulties on the sexual functioning of women and their male partners.

OBJECTIVES: To compare the sexual function of women with and without vaginal penetration difficulties (VPDs) and relate it to the sexual function of their male partners. METHODS: All consenting women attending a sexual medicine centre during 2005-2007 completed the Female Sexual Function Index (FSFI) and answered questions about five VPDs (placement of a tampon, gynaecological examination, insertion of her or her partner's finger, and penile-vaginal intercourse). Male partners filled the International Index of Erectile Function (IIEF). RESULTS: Full data were available for 223 women, and 118 male partners. Male partners of women with VPDs (n = 53) had lower sexual desire (p = 0.0225). The number of VPDs in the women concerned negatively correlated with their partners' desire (r = - 0.18339, p = 0.0468) and erectile function (r = - 0.19848, p = 0.0312). All women with at least one VPD (n = 109) reported significantly more sexual pain (p < 0.0001) and had worse sexual function scores (p = 0.014) than women with no VPDs (n = 114). Women with VPDs other than penile-vaginal penetration had worse orgasmic functioning (p = 0.0119). CONCLUSIONS: The women's VPDs are correlated with worse sexual functioning for them and for their male partners. The five VPDs are a practical and useful tool for identifying impaired sexual functioning.

Unusual masturbatory practice as an etiological factor in the diagnosis and treatment of sexual dysfunction in young men.

INTRODUCTION: Masturbation is a common sexual activity among people of all ages throughout life. It has been traditionally prohibited and judged as immoral and sinful by several religions. Although it is no longer perceived as a negative behavior, masturbation is often omitted in the diagnostic inquiry of patients with sexual problems. AIMS: The aims of this study are to increase the awareness of clinicians to the importance of including questions regarding masturbatory habits in the process of sexual history taking, to analyze cases of male sexual dysfunction (SD) associated with unusual masturbatory practices, and to propose a practical tool for clinicians to diagnose and manage such problems. METHODS: A clinical study of four cases that include a range of unusual masturbatory practices by young males who applied for sex therapy is described. An intervention plan involving specific questions in case history taking was devised. It was based on detailed understanding of each patient's masturbatory practice and its manifestation in his SD. MAIN OUTCOME MEASURES: Effects of identifying and altering masturbatory practices on sexual function. RESULTS: The four men described unusual and awkward masturbatory practices, each of which was associated with different kinds of SD. The unlearning of the masturbatory practices contributed notably to improvement of their sexual function. CONCLUSIONS: The four cases in this study indicate that the detailed questioning of masturbatory habits is crucial for a thorough assessment and adequate treatment of sexual problems in men. We propose specific questions on masturbatory behavior as well as a diagnostic and therapeutic flowchart for physicians and sex therapists to address those problems.

Exploring hypersexual behavior in men with Parkinson's disease: is it compulsive sexual behavior?

BACKGROUND: A range of impulse control disorders has been described in Parkinson's disease, including compulsive sexual behavior. Excessive sexual demands of parkinsonian men can lead to considerable tension within the couple. Thorough sexual interviews reveal that these cases may reflect various types of sexual dysfunctions that present as hypersexuality. OBJECTIVE: This study aims to analyze cases of presumed and true compulsive male sexual behavior, and to propose a practical tool for clinicians, assisting them with the diagnosis and management of compulsive sexual behavior and other sexual dysfunctions in parkinsonian patients. METHODS: We describe four male patients with Parkinson's disease from the movement disorders clinic, which were referred to the sex therapist as suspected hypersexuality. RESULTS: The sexual assessment revealed that only one of the cases involved true hypersexuality due to compulsive sexual behavior. The other three presented with erectile dysfunction, difficulties reaching orgasm (delayed ejaculation), and a gap in desire within the couple. CONCLUSIONS: Complaints about hypersexual behavior in patients with Parkinson's disease must be carefully evaluated, involving a multidisciplinary team. A comprehensive diagnostic and therapeutic algorithm is suggested.

Management of sexual dysfunction in Parkinson's disease.

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.

Sexual problems in Parkinson's disease: the multidimensional nature of the problem and of the intervention.

Sexual problems are common in Parkinson's disease and contribute to poor quality of life of patients and partners. Nonmotor and motor disease manifestations can affect sexual function. This article reviews the progressive and multidimensional sexual manifestations and provides practical suggestions for taking sexual history and treating sexual problems, which may enable clinicians to contribute to the sexual wellbeing of patients.

Sexual dysfunction after radical prostatectomy: treatment failure or treatment delay?

This study defines characteristics of delayed help-seeking in men who fail phosphodiesterase-5 inhibitors (PDE5I) treatment for their post radical retropubic prostatectomy (RRP) erectile dysfunction (ED). Medical charts were reviewed retrospectively. All men were offered second line treatment with vacuum devices or intracavernous injection (ICI) and sex therapy. This study included thirty one patients. Average age at surgery was 60 years (SD = 5.3, range 46-70). Average period for second line help-seeking was 25.9 months (SD = 12.9, range 3-111). All subjects believed that surgery would not affect their sexual function. Twenty men (65%) used ICI as a second line treatment. Eleven men (35%) declined treatment, waiting for spontaneous recovery. In ICI sub-group, 5 men (25%) regained spontaneous erection within 7-10 months after initial treatment (16-19 months post-surgery). Seven men (35%) responded positively to PDE5I 3-5 months after starting ICI. Three men (15%) used vacuum device. None regained spontaneous erection. All 7 men (23%) who met sex therapist with their partner reported improved sexual life, even if ED wasn't resolved. Patients should receive comprehensive information about sexual recovery, to encourage early ED treatment after RRP and to overcome unwanted misconceptions regarding spontaneous recovery.

Female sexuality in multiple sclerosis: the multidimensional nature of the problem and the intervention.

Female sexual functioning is a complex process involving physiological, psychosocial and interpersonal factors. Sexual dysfunction (SD) is frequent (40-74%) among women with multiple sclerosis (MS), reflecting neurological dysfunction, psychological factors, depression, side effects of medications and physical manifestations of the disease, such as fatigue and muscle weakness. A conceptual model for sexual problems in MS characterizes three levels. Primary SD includes impaired libido, lubrication, and orgasm. Secondary SD is composed of limiting sexual expressions due to physical manifestations. Tertiary SD results from psychological, emotional, social, and cultural aspects. Sexual problems cause distress and may affect the family bond. Practical suggestions on initiation of discussion of sexual issues for MS patients are included in this review. Assessment and treatment of sexual problems should combine medical and psychosexual approaches and begin early after MS diagnosis. Intervention can be done by recognizing sexual needs, educating and providing information, by letting patients express their difficulties and referring them to specialists and other information resources.

Practical strategies for the management of sexual problems in Parkinson's disease.

INTRODUCTION: Patients with Parkinson's disease (PD) report frequent sexual dissatisfaction, desire, arousal and orgasmic problems. Motor and non-motor symptoms contribute to further manifestations of sexual dysfunction (SD). Studies have indicated that the need for intimacy and sexual expression are important dimensions of quality of life for PD patients. Inquiry about sexual functioning may be overlooked by neurologists due to time constraints, confusion about sexual conversation, and lack of proper training. METHODS: Practical strategies will be presented. "Open Sexual Communication" (OSEC) module will be used to overcome barriers for sexual discussion. Suggestion for further assessment and analysis of cases will enable understanding of specific sexual interventions adapted for PD patients. RESULTS: Physicians will be empowered to address sexual problems of PD patients and encounter a range of practical interventions. CONCLUSIONS: The physical and emotional changes in PD and treatment of the disease have a major effect on SD of patients and their partners. All patients may experience impairment of sexual function and quality of life. Health care providers can proactively address sexual health issues by providing information, by recognizing and treating the sexual needs of PD patients and by referring them to specialists.

[Sexual function and dysfunction: from theory to practice].

Sexual dysfunctions are common phenomena in healthy as well as in ill populations. The introduction of PDE5-inhibitors gave primary health-care physicians and specialists a tool to treat erectile dysfunction. This focused the attention on the need of physicians to be trained to discuss helpfully sexual issues. Sexual dysfunctions are biopsychosocial phenomena with many causes, including specific diseases and some treatments. These dysfunctions can be a cause for much distress. It seems that nowadays people are more prepared to ask sexual questions than physicians are ready to discuss and answer them. In this issue of Harefuah, we present many aspects of a combined, multi-professional, biopsychosocial model, for identifying and treating sexual dysfunctions. We also propose some ideas that could serve medical professionals in their efforts to better deal with sexual matters.

[Contribution of psychosexual approach to assessment and treatment of sexual dysfunction: a working model].

INTRODUCTION: Increasing awareness and medical studies of sexual dysfunction (SD) unveil the multi-dimensional nature of SD and the need for a multidisciplinary treatment approach. PURPOSE: To describe the psychosexual contribution to the multidisciplinary model for the assessment and treatment of SD. METHODS: The psychosexual contribution will be demonstrated by 4 case reports and data of subjects applying for sex therapy during 2004-8. OUTCOMES: A total of 822 women (age 35 +/- 12.0 years) and 813 men (age 38 +/- 13.2 years) applied for sex therapy; 44% were referred by a physician, 37% found information on the internet or in other media resources. The most frequent SDs in women were: hypoactive sexual desire disorder (HSDD] (29.7%), sexual pain (28.5%) and anorgasmia (20.9%); and in men: erectile dysfunction (44.2%), premature ejaculation (24.5%) and HSDD (17.5%). Co-morbid relationship distress was found in 217 of the cases (26.5%). CONCLUSIONS: Subjects, referred by a physician or on their own initiation, present a variety of SDs, stemming from a combination of physical, psychological and interpersonal contributing factors. The presenting sexual problem is frequently the tip of the iceberg of hidden psychological problems, relationship distress or partner's SD. The overall goal of treatment is increased pleasure and satisfaction, rather than achieving a perfect genital response. Therefore, successful treatment outcome depends on multi-professional assessment and successful resolution of the issues that accompany the sexual complaint, sharing the process with patients and their partners.

[Model approach for evaluation and treatment of men with premature ejaculation].

INTRODUCTION: Premature ejaculation (PE) is one of the most common sexual dysfunctions among men. PE is poorly defined and inadequately characterized, therefore, professionals find it difficult to cope with the diagnosis, treatment and research. Men who complain about their PE also describe their problem in different ways. PURPOSE: This article describes the prevalence of PE, presents the different definitions of the problem and provides a model for evaluation and treatment combining medical and psychosexual techniques. METHODS: The proposed model for the diagnosis and treatment of PE was composed by combining information from relevant literature with the multi-professional staff experience in our Sexual Medicine Center. OUTCOMES: Selective serotonin release inhibitors (SSRIs) have been the most promising medication for treatment of PE. Psychosexual therapy, offering cognitive-behavioral techniques contribute to the man's ability to improve his sexual and couple relationships. CONCLUSIONS: Diagnosis of PE is mainly based on sexual history as described by the male patient. Therefore, it is essential to have a comprehensive medical and sexual history, description of the effect of PE on sexual activity, and the degree of personal and couple distress. It is important to clarify the onset of the problem, as PE may be the result of another sexual dysfunction of the man or his sexual partner.

[Female sexual function and chronic disease].

Female sexual dysfunction (FSD) is a multifactorial set of conditions associated with multiple anatomical, physiological, biological, medical and psychological factors that can have major impact on self-esteem, quality of life, mood and relationships. Studies indicate that FSD is commonly seen in women who report a low level of satisfaction with partner relationship and in women with male partners who have erectile dysfunction. This complexity of FSD is augmented by the presence of chronic disease. Negative sexual effects are widely reported in studies of women with chronic diseases (such as metabolic syndrome, diabetes mellitus, chronic kidney disease, cancer, spinal cord injury, lupus, rheumatic diseases, Parkinson's disease, fibromyalgia and chronic pain) as compared to a general healthy female population. Physical problems, emotional problems and partnership difficulties arising from disease-related stress contribute to less active and less enjoyable sex life. Chronic pain, fatigue, low self-esteem as well as use of medications might reduce sexual function. These effects of chronic diseases on female sexual function still remain largely unstudied. The study by Manor and Zohar published in this issue of Harefuah draws our attention to the sexual dysfunction of women with breast cancer and examines their needs for information regarding their sexual function. In the absence of definite treatment evidence, psychological counseling, improved vaginal lubrication, low dose of hormonal therapy can be used to relieve FSD. Physicians must consider integrating diagnosis of their female patients' sexual needs and dysfunction, especially women with chronic diseases. Patients' education and counseling may contribute to a better quality of life in spite of their chronic disease.