WEB ARTICLE
(Posted 4 August 2001)

Contents
Introduction
The Neurogenic Bowel
Bladder Dysfunction
Sexual Dysfunction
Pelvic Pain
Conclusion

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The Unmentionable Symptoms of Arachnoiditis: Bowl, Bladder and Sexual Dysfunction; Pelvic Pain

by Dr. Sarah Smith

SEXUAL DYSFUNCTION

Sexual problems can be divided into:

• Primary: physiological impairment i.e. physical problems directly relating to specific damage.

• Secondary: non-sexual (indirect) physical impairment: e.g. fatigue, pain, spasticity (increased muscle tone and maybe spasms), bladder and bowel dysfunction

• Tertiary: psychological and sociocultural issues: low self-esteem, demoralisation, depression, interpersonal/communication difficulties.

Important issues:

• Medical staff, support groups and individual patients are uncomfortable in discussing issues relating to sexual dysfunction

• Healthcare professional and patients have insufficient knowledge about sexual dysfunction.

• There is a lack of local resources

• Various obstacles prevent effective communication

• The effect of sexual dysfunction on partners is overlooked: this puts further stress on the patient-caregiver relationship.

• There is a need for local cultural factors to be considered

Sexual difficulties include:

• Temporary or long-term reduction in libido (commonest complaint)

•  Inability to achieve orgasm

• Difficulty in engaging in intercourse

• Inability to achieve/maintain an erection

It may be difficult to distinguish between the direct effects of arachnoiditis and the extent to which other factors such as medication or depression may be relevant.

Primary sexual dysfunction which arises due to pain/decreased sensation/loss of function may be difficult to treat if there is loss of sexual desire as a direct result of these problems. However, if loss of libido is due to fatigue or depression, which may respond to good management, then the outcome is generally more favourable.

The important point is to remember that spinal cord injury patients, even those with complete injuries and severe limitation in functional terms, may still be able to engage in fulfilling sexual activity.

It is also vital to keep in mind that a healthy relationship rather than a healthy body is the most important factor in a satisfying sex life.

TYPES OF SEXUAL DYSFUNCTION

In men:

• Loss of libido

• Difficulty in initiating/maintaining erection

• Abnormalities in ejaculation

In women:

• Loss of libido

• Pain on intercourse (pelvic/vaginal)

• Loss of vaginal lubrication

• Loss of sensation, physical arousal

• Difficulty in reaching orgasm

Any or all of these problems may occur in arachnoiditis. Some will be directly related to arachnoiditis and/or to underlying spinal problems ( such as degenerative disc disease, stenosis etc.). Others will be due to medication.

Problems such as incontinence may lead to reluctance to engage in sexual activity.

Pain may be a strong deterrent, both to the sufferer, and to their partner, who may worry about hurting their loved one.

This sort of problem is dealt with in considerable detail in an article available from the Arachnoiditis Trust. 

MEDICATION-INDUCED SEXUAL DYSFUNCTION

Medications from almost every class can affect aspects of sexual function.

In arachnoiditis, the common culprits are:

Narcotics: (morphine and related drugs): aka ‘opiates’; decreased libido is a fairly common side effect and reduced potency may also occur. This is usually related to suppressed testosterone production, and may be remedied using supplemental testosterone orally or injected.

SSRIs: e.g. Prozac (note: if there is depression, it may be hard to tell which is the cause for the problems: depression or the treatment for it)Sexual dysfunction occurs in approximately 20-40% of patients on SSRIs (reports as high as 75% have resulted from direct interviews). The symptoms include anorgasmia, decreased libido and male erectile problems. These problems may persist despite lowering the dose and changing to a different drug such as bupropion, nefazodone or mirtazepine may be necessary. Alternatively, a measure such as a weekend “holiday” (SSRI taken on Thursday and not again until Sunday) may help.(this is only possible with drugs with a short half-life). Adding a second SSRI may counteract the sexual side-effects of the original SSRI. Usually bupropion or buspirone are used given daily with the SSRI. Other agents such as cyproheptadine, sildenafil(Viagra) and dopamine agonists such as methylphenidate(Ritalin), amantadine(Symmetrel) and bromocriptine(Parlodel) may be given 1-2 hours before sexual intercourse.

Viagra has been tested in studies and may have a use in combating SSRI-related sexual dysfunction (see below for more details on Viagra). Reversal may take place from the first dose. Benefits may be found in both men and women.

In summary, treatment option for SSRI-induced sexual dysfunction include: reassurance; decreasing the dose; changing to a different agent; altering the time of administration; drug holiday or augmentation therapy.

Antidepressants/anticholinergic: the ‘older’ type antidepressants such as the tricyclics (amitriptyline, nortriptyline) or imipramine/desipramine may be used for pain relief and tricyclics are often used to reduce incontinence due to an overactive bladder. These cause dryness of the vagina and reduction in orgasm or may affect the ability to achieve/maintain an erection. There may also be less specific effects such as loss of libido.

Gabapentin: the anticonvulsant (Neurontin) is often used to combat neurogenic pain. Cases of gabapentin-induced failure of orgasm have been reported. Anticonvulsants can cause sexual dysfunction. Carbamazepine (Tegretol) may cause impotence and impaired fertility.

Other relevant medication:

Antihypertensives:

Almost any antihypertensive agent may be associated with erectile dysfunction or failure of ejaculation. This may in part be vascular damage in hypertension which can contribute to ED, the medication is undoubtedly implicated. Thiazide diuretics (e.g. bendrofluazide, cyclopenthiazide: Navidrex, indapamide: Natrilix, xipamide: Diurexan and metazolone: metenix-5) and beta-adrenergic antagonists (Propanolol: Inderal; Atenolol: Tenormin; Labetolol: Trandate) are 2 commonly used drug types. They may also be used together in some preparations e.g.: Inderetic= propanolol + bendroflumethazide. The impotence induced by thiazide diuretics is generally reversible on discontinuing the drug. The reported incidence of ED due to thiazides is low: between 3 and 9%.In recent years the recommended dose of thiazides has been reduced from 50-200mg to 6.25-25mg, which may help to reduce the incidence of ED. Propanolol is the beta-blocker drug causing most reported cases of ED. Others such as atenolol appear to have a much lower incidence of ED as a side effect.

Diuretics (water tablets)

Clonidine: may be used as an adjuvant painkiller.

H2 antagonists: e.g cimetidine or ranitidine (Zantac) used to treat indigestion

Illicit drugs:  including cannabis

NB: alcohol: as Shakespeare famously wrote: it heightens desire whilst diminishing performance! Smoking may also contribute to difficulties with erection.

MANAGEMENT:

The first vital step is effective communication between partners. (the second being effective communication with your doctor).

There are a variety of useful medications/techniques which can be used to combat specific dysfunction. There are details of these in a further article available from the Arachnoiditis Trust.

In terms of  tackling the secondary factors, such as fatigue, a lot of the approach comes down to common sense actions: timing (late at night is usually a time when pain is bad in arachnoiditis), appropriate use of medication etc. (e.g. baclofen an hour prior to intercourse to counteract muscle spasm), sensible precautions (emptying the bladder) and setting the scene (e.g.ensuring a warm, draught free environment).