Sexuality and Intimacy in Parkinson’s

Disease
dr Banon Sukoandari, SpS
 Why should talk about sex?
• Natural aspect of life
• Always in human history
 Benefits of Intimate and Sexual Relationship

• Emotional relaxation
• Physical relaxation
• Increased self esteem
• Increased Confidence
• Increased Vitality
• Pain relief
• Expression of gratitude toward your partner
• Better quality of life
• Increased life satisfaction
The right for good quality of sexual life
• The right to love and be-love
• The right to touch and be touched
• The right to share intimacy
• And a remain a sexual human being
WHO Declaration on Sexual Health
• People should have the capacity to enjoy and to
control their sexual and reproductive behavior in
accordance with their social and personal ethic
• Freedom of fear, shame, guilt, false belief and
other factors inhibiting sexual response and
impairing sexual relations
• freedom in organic disorders, disease and
efficiencies that interfere with sexual and
reproductive function
 4 Domain in Intimate and Sexual
Relationship
• Couple time
• Intimate time (emotional and physical)
• Sexual Time (relax / touch and nonsexual
touch)
• Personal Time
Couple time
Intimate Time
• Relax / touch
• Non Sexual touch
EMOTIONAL :
• talk - share – support – listen –
love - care
SEXUAL TIME
• Erotic thoughts
• Erotic touch
• Sexual excitement
• Sexual satisfaction
• Sexual activity
(Are Elderly sexually active?
‘Tua-tua Keladi’
• Goethe completed his Faust at age 82
• Tiziano (Titian) was still drawing at 98
• Toscanini still conducted on orchestra at 93
• Edison continued working in his lab until 89
• Benjamin Franklin wrote the US constitution
at 81
• dr Andradi still active give lecture at 81
 Are Elderly sexually active?:
“Beautiful melodies can be played with old
banjos”

• ‘SEX IS IMPORTANT” = 83% of 319 Swedish

men 50-80 years old
• BUT US National Social Life , Health and Aging
Project conform that elders rarely talk about
sexuality to their doctors
• 57-85 years old (58% of men and 22% of
woman) report having discussed sexual issue
 Are Elderly sexually active?:
“Beautiful melodies can be played with old banjos”

• Sexual Active
– 73% = age 57-64 years old
– 53% = age 65 to 74 years old
– 26% of the age 75-85 years old
• Among married woman, age 60 years old and
older = 59% were sexually active

• Reason of why people engage in sexual

intercourse :
– Physical pleasure, spiritual motivations, love,
commitment, mate gratitude, boosting self esteem
 There are 2 main trend of sexual change in PD

• Decreased
• Increased Sexuality
• The Disease, Treatment, Medications, Comorbid Illness = are
involved in the change sexual life

• PSYCHOSOCIAL FACTORS = family, religion, culture background, role

change and relationship difficulties

• INDIVIDUAL FACTORS = depression, anxiety, self esteem, ageing,

fatigue, concentration problems
– change in desire, arousal, orgasm (erection, lubrication) and sexual
satisfaction
• Sexual functioning and well-being of PD
Patients and Partners are affected by:
– motor disabilities
– non motor symptoms (autonomic, sleep
disturbances, mood disorders, cognitive
abnormalities, pain and sensory disorders)
– Medication
– Relationship issues
 Sexual challenges for people with
Parkinson’s?
• Slowness of movement, tremor and rigidity
interferes with love making
• Reduced desire due to fatigue or medications
• Men struggle with getting or keeping
erections or reaching orgasm
• women may experience dryness, pain, or
difficulty finding their orgasm
 Sexual challenges for partners of PwP
• Changing role from partner to care partner
• Tiredness from taking on more responsibility
 Sexual Problems in Men vs Women
(Prevalence in PD)
Type of Sexual problems
Erectile Dysfunction 68,4
(42,6-
79)
Type of Sexual problems %
Dissatisfaction of Sexual Life 65,1
Difficulties getting aroused 87,5
Premature Ejaculation 40,6
Difficulties reaching Orgasm 75,0
Difficulties reaching Orgasm 39,5
(87) Sexual desire (seldom/never) 46,9-
84
Difficulties Ejaculation 27,3
Premature Ejaculation 40.6 Dissatisfaction of Sexual Life 37,5
Anejaculation 79 Stopped Having Sex 21,9
Sexual desire (seldom/never) 23,2 Dyspareunia (painful sex) 12,5
83
Hipersexuality 0,5
Stopped Having Sex 23,2
Hipersexuality 5.2
COMMON SEXUAL PROBLEMS ASSOCIATED WITH NONMOTOR
SYMPTOMS
NON MOTOR SYMPTOMS SEXUAL PROBLEMS OF PATIENTS AND PARTNERS
Depression, Anxiety and medications Decreased / loss desire, difficulties in arousal, erectile
Fatigue, concentration difficulties, apathy dysfunction, reduced vaginal lubrication and painful sex,
Pain and sensory changes decreased frequency and intensity of orgasm
Decrease/ cessation of sexual activity
Sleep Disturbance Bed separation, decreased opportunities for intimate
activity.
Increased relationship tension
Speech problems decreased couple communication and intimacy
Dribbling, dysphagia, excessive sweating, daytime Patients less attractive, decrease intimacy
somnolence
Bladder dysfunction avoidance from intimate activity
Change in family roles, dependency, low self Patients less attractive
esteem, reduced body image. decreased intimacy
confusion, hallucination, paranoia, delusion increased relationship tension
reduced desire and arousal
Erectile dysfunction Reduced desire, difficulties to reach orgasm
reduced partner’s sexual function : desire, arousal,
orgasm, and satisfaction
Impulse control disorders compulsive or un-controlled sexual behavior
sexual abuse of partner or other person
 COMMON SEXUAL PROBLEMS ASSOCIATED WITH
MOTOR SYMPTOMS

MOTOR SYMPTOMS SEXUAL PROBLEMS OF PATIENTS AND

PARTNERS
Rigidity, tremor, difficulty in fine fingers Impair intimate touch, arousal difficulties,
movement reduced ability to orgasm during
partnered and self sexual activity
Immobility in bed Loss of erection in middle of sexual
activity.
Need for changes in sexual habits and
positions.
Reduced desire an arousal
Rigidity, bradykinesia Patients sexually passive, imposing an
active role on partner.
Decreased desire and arousal
Gait disturbances patients less attractive
General physical limitations Decreased frequency of sex and intensity
of orgasm
• 112 PD patients vs 79
healthy controls
• Hemiparkinsonism
• disease duration less than 2
year
• 1746 patients – 1132 men Three most frequent
(65,2%) autonomic symptoms:
• Mean age 67,6 years old • Nocturia 37,5%
(SD 9,3)
• Impotence 37,9%
• Mean disease duration 1,3
years (SD 0,9) • Constipation 28,46
• UPDRS motor score 22,5
(SD 12,1)
Autonomic dysfunction in Early
Parkinson’s Disease
• Female anorgasmia 57,4%
• Male erection dysfunction 56,1%
• Sialorrhea 51,4%
• Constipation 43,6
• Orthostatic symptoms 39,6%
• Dysphagia 20,1%
 Drugs and Sexual dysfunction
• Dopaminergic Agent (bromocriptine and
pergolide) can decrease latency of ejaculation
and induced spontaneous ejaculation
• Apomorphine lead to penile erection in Rat
model
• Antidepresant
– (SSRIs) can lead sexual disfunction; -
– Tricyclic antidepresant (amytriptilin or nortriptiline)
delay ejaculations with high dossages
• Anti-neuroleptic (risperidon and clozapine) cause
delayed ejaculation
 Hyper sexuality
• Since Mid -1990
• Complication of dopaminergic agent = Impulse control disorders
(ICD)
– Hyper sexuality, gambling, compulsive shopping, compulsive eating,
compulsive hobbyism , punding and repetitive goal-less task
• Incidence = 3-5%
• Risk Factors
– male sex, younger age at onset, personal and family history of drug
abuse, bipolar disorders, traits of gambling, impulsive personality
• Feature
– increased frequency of erection, higher libido, compulsive
masturbation and sexual demanding behavior
• Most the component ICD disappear with discontinuation of
dopaminergic therapy, but Hyper-sexuality to persist for longer time
• Sexually active
• But sexual function is still not routine component in
the neurological examination
• Physical appearance of a person with PD can have an
impact on :
– self esteem
– their ability to feel sexually attractive
– Partners
 YOPD and sexual issue
• Contributors to sexual failure : fatigue, inadequate
symptoms control, autonomic involvement,
depression, tremors during intercourse

YOPD MALE YOPD FEMALE

- autonomic involvement - poor self-image
- depression - anxiety
- unemployment - depression
- inhibition
- vaginal tightness
- fear of losing urine
 THE SEX TALK
• Sexual communication with PD patients
• Physicians are empowered to address sexual
health during the routine office visit
• People that experienced major sexual problems :
only few seek medication help
• About 50% of patients preferred that their
physician initiated the sex talk
• Longitudinal and personal relationship with the
PD patients are asset to dealing with intimate
problems
 Barriers toward discussing sexuality
• High age of patients = 42%
• Insufficient time =37.5%
• Patients do not express sexual problems spontaneously =
36.4%
• Barriers based on language/cultural/religions = 24.1%
• Insufficient training/ knowledge = 18.4%
• Patients is too ill to discussed sexuality = 18.2%
• I feel uncomfortable to talk about sexuality = 14.8%
• Patient is not ready to discuss sexuality = 10,2%
• Age difference between yourself and the patient = 6.8%
• Someone else is accountable for discussing sexuality = 5.7%
• Patients is of the opposite sex = 5.7%
 Assessment and Investigation of Sexual
Dysfunction in Parkinson Disease
• No validated instrument exists which can
incontrovertibly diagnose SD or ICD in Parkinson’s
Disease
• Involvement of the partners and expectations of
the couple toward their sexual life investigated
• Once sexual dysfunction is diagnosed
– recognized whether they belongs to category of lack
of aorusal, diminished libido, erectile dysfunction,
vaginismus, or the socially unacceptable (hyper
sexuality or ICD)
Once Sexual dysfunction is diagnosed :
• Recognized whether they belongs to category of lack of arousal,
diminished libido, erectile dysfunction, vaginismus, or the socially
unacceptable (hyper sexuality or ICD)
• Identify the onset and progression
• The nature of the illness in term of type and time of sexual activity
should be assessed
• sexual history before the onset of Parkinson Disease
• Premorbid illness = cardiovascular disease, diabetes mellitus,
hyperlipidemia, hypertension, genitourinary disorders, depression,
anxiety; and personal habits such as smoking, intake of tea or
coffee, alcohol or any substance abuse
• Diagnostic test = routine blood test, glucose and lipid profile, or
hormone profile

• =MULTIDICIPLE APPROACH, but it not means that neurologist

should not be actively involve in identifying risk factors and
discussing therapeutic plans
 WHAT GUIDELINES SAID
CANADIAN GUIDELINES ON PARKINSONS DISEASE

• C79 – People with PD should be treated

appropriately for the following autonomic
disturbance : NICE Level D (GPP)
– urinary dysfunction, weight loss, dysphagia,
constipation, erectile dysfunction, orthostatic
hypotension, excessive sweating, sialorrhoea
• C84 – For the statement of erectile dysfunction in
PD add sildenafil. EFNS Level A
In assessing a person with YOPD, we
may consider :
• Question about sexual health as part of the total health
history
• Being careful not to make assumptions about sexual
orientation, preference or behavior
• aware of any change in the person medications
regiment that could affect that persons sexual or
psychological status
• prepared to make referrals to appropriate sexual
medicine counselors or therapist
• Counseling patient and their partners to consider
alternatives to traditional pattern of sexual activities
 MANAGEMENT
• Treatment should be individualized
• Erectile dysfunction response well to PDE5 inhibitors
(sildenafil), or to related drug tadalafil or verdenafil. –
these agent do not increased the arousal, they only
help to maintain the erection
• When drug oral fail = sublingual apomorphine, intra-
cavernosal injection of papaverine or prostaglandin E1,
vacuum constrictor pump, penile prosthesis
• Antidepressant like SSRIs delay ejaculation
• Psychotherapy and counseling = increasing open sexual
communication, practicing comfortable position,
training in intimacy, emphasis on foreplay
 MANAGEMENT
• The management of hypersexual in PD is rather
complicated
• Reduce the dose of dopamine agonist or
levodopa or substituting the dopamine agonist
with another agent may be helpful in some cases
• ICD and BDS = ICD wanes in intensity in some
patients after sub-thalamic nucleus stimulation
• The usefulness of newer atypical antipsychotic
and antidepressants (quetiapine, olanzapine or
risperidone) is not completely stabilized in this
context – depend on previous clinical experience
TIPS from Patients and spouse:
HOW TO INCREASED INTIMATE RELATIONSHIP AND
OVERCOME SEXUAL DISFUNCTION
• We prefer tips and sexual advice over prescription of more
medication
• keep expectations real and do not blame your self so much
• Don’t worry about erection, - enjoy the physical intimacy
you have with or without full penetration
• Plan sexual activity when motor dysfunction ia at minimum
• Don’t wait until bedtime. Fatigue makes it stressful
• lots of intimacy and touching can be out of bed as well as in
• Find alternative ways of expressing caring
• find what work for you intimate problems
• Plan appropriate position for intercourse.
• Apply oily lubricants to lessen the effects of tremor or
harsh touch during foreplay
TIPS from Patients and spouse:
HOW TO INCREASED INTIMATE RELATIONSHIP AND
OVERCOME SEXUAL DISFUNCTION

• Use sexual aids to increased pleasure

• use lubricant to enable smooth penetration
• reduced partner stress and burden
• Try to learn about the medication’s effect on your sexual
function
• a good body massage first may allow a good orgasm later
• you need patience in reaching orgasm. Sometimes you feel
like you there, and then you lose it
• Use humor: ‘I say that I shake with excitement. It always
make us smile”
• Use communications : “ talk as much as you can, discuss
problem honestly, it keep you close”
 What can You do?
• Plan your sexual activity
• Plan your sexual activity
• Learn about how to touch your partner : in
erotic and non erotic ways
• Communicate with your partner
TERIMAKASIH