Skip to main content
PMC home page
Therapeutic Advances in Neurological Disorders logoLink to Therapeutic Advances in Neurological Disorders
. 2011 Nov;4(6):375–383. doi: 10.1177/1756285611411504

Management of sexual dysfunction in Parkinson’s disease

Gila Bronner ✉, David B Vodušek
PMCID: PMC3229252  PMID: 22164191

Abstract

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.

Keywords: Parkinson’s disease, sexual dysfunction, erectile dysfunction, desire, orgasm, hypersexuality, management, sexual counseling

Introduction

Parkinson’s disease (PD) is a chronic multisystem neurodegenerative disorder, characterized by typical motor manifestations, which progress over time and cause growing physical disability. In the advanced stage of the disease, deterioration of mobility and communication result with limitations in basic daily activities.

Nonmotor symptoms may precede typical motor features of PD by several years and play a major role in the deterioration of quality of life of patients [Truong et al. 2008; Chaudhuri et al. 2006]. There is convincing evidence that the PD neurodegenerative process begins many years before the onset of motor manifestations by an estimated 3–6 years [Savica et al. 2010]. The spectrum of nonmotor symptoms encompasses constipation, bladder dysfunction, daytime somnolence, delusions/hallucinations, difficulty in concentration, dribbling, dysphagia, episodes of confusion, fatigue, impulse control disorders (ICDs), memory problems, mood disorders (depression, anxiety), orthostatic hypotension, pain, paranoia, sensation of breathlessness, sleep disturbances, sweating, and also sexual dysfunction (SD) [Truong et al. 2008; Chaudhuri et al. 2006].

Sexuality is a basic human right and essential part of healthy life [World Association for Sexual Health, 2008]. For patients with chronic disease, sexuality is also a significant determinant of their quality of life [Clayton and Ramamurthy, 2008] and in PD a healthy sex life is associated with general satisfaction from life [Moore et al. 2002]. Most men with PD consider erectile dysfunction (ED) to be the most distressing of their various disabilities imposed by the disease [Basson, 1996].

In this review we describe the effects of PD on the sexuality of patients and their sexual partners, and recommend treatment options. Healthcare professionals who work with PD patients will be able to implement some of the recommendations within the framework of their clinical work.

The effect of Parkinson’s disease on sexuality

Sexual functioning is a complex process that requires functioning of the body’s autonomic, sensory and motor systems, and depends on the neurological, vascular and endocrine systems, allowing sufficient blood supply to and from genital organs, a balanced hormonal system and a healthy emotional state. Sexual functioning is influenced by numerous psychosocial factors, including family and religious background, the sexual partner and individual factors such as self-concept and self-esteem. Sexuality can be altered by aging, life experiences (e.g. abuse), and various illnesses and their treatments [Verschuren et al. 2010].

It has to be said that SD, such as lack of desire (in both sexes), ED and disturbances of ejaculation (in men), and deficient lubrication, dyspareunia and problems with orgasm (in women), is not uncommon in the general population [Addis et al. 2006; Laumann et al. 2009]. SD in the general population is expected to be a consequence of many different causes, only a few of them being well defined. Usually, SD is linked to ‘risk factors’, known to increase the risk of SD, such as age, smoking and chronic disease. Neurological disease as such is often counted among the ‘general’ risk factors, although neural control is a prerequisite for sexual function [Rees et al. 2007] and particular nervous system lesions are known to cause particular forms of SD. Nevertheless, SD in a patient with a chronic neurological disease is bound to be multifactorial [Bronner et al. 2010].

SD is common in patients with PD [Hand et al. 2010; Celikel et al. 2008; Bronner et al. 2004; Jacobs et al. 2000; Zesiewicz et al. 2000; Welch et al. 1997; Wermuth and Stenager, 1995; Brown et al. 1990; Koller et al. 1990], associated with depression and relationship dissatisfaction [Wielinski et al. 2010]. SD has been reported as common even in young patients with PD (mean age 49.6 years). Couples with the man as the patient have been more dysfunctional. Erectile failure and premature ejaculation were most frequently found. Patients also usually displayed decreased sexual desire. Symptoms of SD were also frequent in their partners [Brown et al. 1990]. Inability to maintain an erection has been found in half of the males [Wermuth and Stenager, 1995; Koller et al. 1990]. ED was reported by 54–79% of men with PD [Bronner et al. 2004; Sakakabira et al. 2001; Koller et al. 1990]. A total of 60% of men with PD reported ED, as compared with 37.5% in age-matched controls [Singer et al. 1991]. Many males were also unable to ejaculate and to achieve an orgasm.

In women with PD, vaginal tightness, loss of lubrication, involuntary urination, anxiety and inhibition were more prevalent than in matched controls. Also women with PD were more likely to be dissatisfied with the quality of their sexual experiences [Welch et al. 1997].

While the greater prevalence of SD in PD patients, when compared with age-matched healthy controls, is not controversial, it is not clear whether the known brain ‘lesions’ related to PD (supposedly relevant for maintaining normal sexual function) have a decisive impact on the prevalence of SD in PD [Celikel et al. 2008; Sakakibara et al. 2001; Jacobs et al. 2000; Welch et al. 1997]. An often-cited study found no greater prevalence of SD in married male PD patients, when compared with matched patients with another chronic, but nonneurologic, disease (arthritis) [Lipe et al. 1990]. However, further studies are needed. Neurological features, autonomic dysfunction and motor symptoms on the left side of body did correlate with loss of desire in PD patients of both genders [Kummer et al. 2009].

In clinical practice one finds that sexual function is reported to be interfered with typical PD symptoms. Muscle rigidity, bradykinesia and ‘clumsiness’ in fine motor control make sexual activities difficult and may be worse in the late evenings if dose scheduling is aimed at favouring daytime activities. Tremor and dyskinesias may be enhanced during sexual arousal. Hypersalivation and sweating are deconcentrating, and in addition to hypomimia may objectively reduce the appeal for the partner, and subjectively negatively influence the self-image of the patient. Urinary urgency and incontinence (or fear of incontinence) during sexual activity seem to be a particular concern of the female PD patient. By sleeping apart because of sleep dysfunction, the partners may lose bed intimacy. A particular problem is a loss of the ability to focus on a particular activity as part of the cognitive involvement in PD.

One study linked ED and low desire in PD patients of both genders to dopaminergic treatment [Bronner et al. 2004], but on the other hand such therapy may in clinical experience result in an apparent increase or normalization of desire. Deep brain stimulation of the subthalamic nucleus (STN) has been found to have a positive influence on sexual well-being. Male (but not female) PD patients under the age of 60 were reportedly more satisfied with their sexual life [Castelli et al. 2004].

A true increase in libido may occur as an adverse reaction to treatment with levodopa [Uitii et al. 1989]. Compulsive sexual behaviour was noted in 3.5% of PD patients using a dopamine agonist [Weintraub et al. 2006].

In addition to the disease process and the influence of dopaminergic drugs, sexual function in PD patients may be influenced by comorbidity, particularly depression [Shulman et al. 2002] and testosterone deficiency [Okun et al. 2002a].

Many medications, such as antihypertensive and antidepressant agents, have adverse effects on sexuality. On the other hand, spontaneous erections have been reported in patients receiving levodopa. Apomorphine treatment may result in erections and benefits sexual function [O’Sullivan and Hughes, 1998].

Treatment modalities for sexual dysfunction in Parkinson’s disease

Given the high prevalence of SD in patients with PD, physicians and other healthcare providers should discuss and treat sexual health issues as an integral part of treating the disease. In all instances, drug regimens should be reviewed for possible effects on sexual function. Sexual education, counselling and specific suggestions about therapeutic methods are important, and should be provided by the treating physician.

In a newly diagnosed patient with PD the possible enhancing influence of dopaminergic treatment on sexuality should be discussed with both partners. The improved (normalized) libido in the male PD patient may be unwelcome, as the elderly spouse has already settled in a situation of not being ‘bothered’. The emergence of hypersexuality in the treated PD patient is, as a rule, drug induced, and modification of treatment is helpful. Profound loss of libido in the well-treated PD patient may call for an endocrinological consultation if it causes distress.

In a newly diagnosed PD patient who present with SD, the dopaminergic drugs should be introduced first, and their effect followed up. Occasionally, the SD will also improve. Difficulties with the motor aspects of the sexual activity may be overcome by counselling and appropriate timing of dopaminergic treatment. Poor lubrication in the female patient with PD may be helped by lubricants; urge incontinence during coitus by previously emptying the bladder and treating the overactive bladder.

In male patients with rapid ejaculation, counselling on the use of particular techniques may lead to improvement. Use of antidepressants (serotoninergic agents such as clomipramine, or selective serotonin reuptake inhibitors such as sertraline or paroxetine) may be successful, but such use of these drugs is off label. If rapid ejaculation is linked to ED, sildenafil may improve both difficulties.

A rather typical problem in some male patients is difficulty in reaching orgasm (delayed ejaculation). An explanation that ejaculation is a reflex often helps. Increased stimulation (apart from vaginal intercourse) is often successful (including the use of a vibrator). Sharing this information with the partner can decrease marital tension, and eliminate the embarrassment involved in coping with these problems.

ED is the only SD with evidence-based drug treatment available [Zesiewicz et al. 2010]. Sildenafil is an effective treatment for ED in men with several neurological disorders, also PD [Raffaele et al. 2002; Hussain et al. 2001]. Its efficacy in PD patients with ED and depression was reported to be 85% [Raffaele et al. 2002]. The other selective inhibitors of type 5 cyclic guanosine monophosphate phosphodiesterase (PDE5-inhibitors), tadalafil and vardenafil also seem to be effective. These drugs augment the nitric-oxide-mediated relaxation pathway in penile tissues by increasing available cyclic guanosine monophosphate in the corpus cavernosum. These medications therefore do not cause erection, but enhance the response to sexual arousal. Thus, sildenafil keeps the response ‘natural’ and may thus advance partner intimacy and bonding. On the other hand, the man has to stay concentrated on sexual activity, or the erection will fade away.

Sildenafil (25, 50 or 100 mg) is taken orally 1 hour before intended sexual activity. Significant effects have been reported between 30 minutes and 4–6 hours after taking the medication. Dose-finding studies have demonstrated a dose–response curve. In the PD patient, treatment may start with 50 mg, but often the larger dose (100 mg) needs to be used.

In our clinic, PD patients with ED reported that they needed a longer time to onset of PDE5 inhibitors for successful intercourse, longer than the recommended time by the physician. Slowed gastrointestinal motility may explain the diminished absorption of drugs [Korczyn, 1990]. During follow-up visits, physicians can inform their patients about the use of PDE5 inhibitors and advise, in the case of failure, to extend the drug time of onset.

Sildenafil can be used repeatedly, and if used once or twice per week there should be no fear of tachyphylaxis [Salonia et al. 2003].

PDE5 inhibitors are contraindicated in combination with vasodilator drugs of the nitro type and nitric oxide donors, but a cardiologist can change such drug regimens in suitable patients with ED requiring treatment. PDE5 inhibitors should not be used in patients with retinitis pigmentosa, and in men with a history of priapism. They are contraindicated in men with hypotension (blood pressure below 90/50 mmHg). Care should be taken to identify men with multiple system atrophy who may present with ED, atypical Parkinsonism and asymptomatic postural hypotension. The most common adverse events of sildenafil are headache, flushing and dyspepsia. Temporary visual symptoms (mainly colour-vision disturbances) may occur with higher doses (100 mg). Adverse effects are mostly transitory and of minor intensity. No evidence was found of effects on the myocardium or the conduction system. Evaluation of functional capacity is necessary in patients with coronary artery disease, who need to know the risks of physical as well as sexual activity. Recommendations for the use of sildenafil in patients with cardiovascular disease have been published [Zusman et al. 1999].

Treatment with apomorphine sublingually is another therapeutic option for PD patients with ED. The action is through a dopaminergic effect in the hypothalamus. Doses of 2–4 mg have been recommended, with the erection occurring within 10–25 minutes. Nausea is the most common adverse reaction [Heaton, 2000]. PD patients may get an erection only with higher doses than originally recommended.

A recent review of oral therapy of ED in neurological patients has proposed sildenafil (grade A), and apomorphine (grade B) for treatment of PD patients [Basson et al. 2010]. In patients who do not respond to oral treatment intrapenile injections of vasoactive drugs can be used. These have been used extensively in men with neurogenic conditions, but not specifically PD; indeed, this therapy seems to be rarely used in PD patients. Prostaglandin E1 (PgE1), papaverine, and a papaverine–phentolamine mixture have all showed an efficacy rate of more than 70%. Acute complications, such as priapism and local long-term complications, are lowest with PgE1 (25% and 8%, respectively) [Porst, 1996]. This treatment is contraindicated in patients taking anticoagulants. PgE1 (alprostadil) is the preferred drug for self-injection therapy in ED, and is very efficacious in neurogenic ED. Therefore, very small doses (2–4 µg) have to be tried first to evade the risk of priapism. Intracavernous injection requires dexterity from the patient or his partner, and should be taught under medical supervision before self-administration is attempted. The effect is very rapid and may last for 2–4 hours. Longer-lasting erection should be treated as priapism, and first treated with cold compresses. Priapism is a urological emergency, but usually has a good prognosis with conservative treatment.

Some PD patients find the ‘guaranteed’ erection induced by the intrapenile injection appealing, as it is not dependent on arousal, and thereby not distractible. It is a therapeutic solution which is rarely tried, as couples can accommodate the medicalization of the intercourse, and spouses become efficient in giving the injection.

In patients unwilling to try ‘chemistry’, a vacuum device may help, but requires dexterity from the patient or his partner. It is rarely adopted by elderly couples. In patients with neurogenic ED, rigidity adequate for penetration has been reported by 90% of respondents. Satisfaction of partners was initially reported as high (70%), but after months of treatment, and despite an increase in sexual activity, only 41% of patients were satisfied [Denil et al. 1996]. Premature loss of rigidity and difficulty in placing and removing the constriction bands are common complaints. The most common complications are bruises, petechiae and skin oedema. The constriction band should not stay in place for longer than 30 minutes. The use of a constriction band alone may help patients who can obtain an erection, albeit not a durable one. The same restrictions concerning the duration of application should be observed.

Depression and the use of antidepressants in PD are common [Chung et al. 2003]. Both are associated with higher frequency of SD. There are some reports on the use of PDE5-inhibitors for the treatment of depression associated sexual dysfunction. Nurnberg and colleagues found that a reduction in sexual difficulties (specifically delayed orgasm responses and inadequate lubrication) in 98 previously sexually functioning women taking serotonin reuptake inhibitors, was associated with sildenafil treatment, while the women were continuing antidepressant treatment [Nurnberg et al. 2008]. Increased sildenafil dose for the treatment of depression associated SD in men is recommended [Nurnberg and Siegel, 2006; Seidman et al. 2003].

Some studies have focused on the effect of testosterone on SD in PD [Ready et al. 2004; Okun et al. 2002a]. There is an unrecognized high prevalence of testosterone deficiency in elderly male patients with PD, similar to that found in the general population (20–25% of males over 60 years old). Testosterone deficiency is a well-documented cause of depression, fatigue, decreased libido, erectile dysfunction and decreased work performance. These symptoms, which may be refractory to antidepressants, anti-anxiety and antiparkinsonian medications, may respond to treatment with testosterone. A daily dose of transdermal testosterone gel improved testosterone deficiency symptoms in men with PD and showed trends in improvement in nonmotor and motor symptoms [Okun et al. 2002b].

Hypersexuality

Pathologic hypersexuality has occasionally been reported in patients with PD, linked to medications [Merims and Giladi, 2008; Klos et al. 2005; Korpelainen et al. 1998; Jiménez-Jiménez et al. 2002; Giovannoni et al. 2000; Fernandez and Durso, 1998; Uitti et al. 1989] and often occur in patients without a prior psychiatric history or obvious cognitive deficits [Klos et al. 2005].

Only few studies propose clear criteria for HS in PD [Voon et al. 2006] and therefore it is not easy to establish the extent of the problem among PD patients.

HS current prevalence was found among six (2.0%) of 297 PD patients [Voon et al. 2006]. Prevalence of increased sexual interest in restless legs syndrome patients treated with dopaminergic medications was reported by 6% [Driver-Dunckley, 2007]. A study of ICDs in 3090 patients with PD identified compulsive sexual behaviours in 3.5% [Weintraub et al. 2010]. The authors used the Minnesota Impulse Disorders Interview, asking patients about preoccupation with sex, repetitive behaviour, fantasies and urges [Christenson et al. 1994]. Increased sexual drive was reported by 8.8% of PD patients and/or the caregiver/spouse [Giladi et al. 2007]. The authors believe that their current percentage of patients with heightened libido is an underestimation of the actual problem. A search of patients’ medical files yielded a small amount of recorded HS [Bostwick et al., 2009; Cannas et al. 2007; Klos et al. 2005]. Cannas and colleagues found nine cases of recorded aberrant sexual behaviours observed during an 11-year period [Cannas et al. 2007], Klos and colleagues reported on 15 cases during an 8-year period [Klos et al. 2005], and of 267 patients with PD new-onset gambling or HS was documented in 7 (2.6%) [Bostwick et al. 2009].

HS in PD is associated with male sex, earlier disease onset, dopamine agonist therapy and depression [Voon et al. 2011, 2006; Bostwick et al. 2009; Weintraub et al. 2006; Klos et al. 2005]. Hypersexual patients showed greater general cognitive impairment, including lower performances on learning tests and poorer inhibitory control in comparison with PD patients with pathological gambling and compulsive eating [Vitale et al. 2011].

The cause of this compulsive behaviour is poorly understood. It may be related to increased sexual drive or lack of sexual impulse control, both dependent on dopaminergic regulation or to neurodegenerative process [Ferreri et al. 2006]. Stimulation of the STN is associated with both favourable and negative outcome in terms of ICDs and related disorders [Broen et al. 2011].

When HS occurs it contributes a considerable tension within the family that is already dealing with the difficult consequences of PD. Therefore, it is imperative to detect and treat as early as possible. Discontinuation of the use of the dopamine agonist was consistently effective in treating HS [Cannas et al. 2007; Weintraub et al. 2006; Voon et al. 2006; Dodd et al. 2005; Klos et al. 2005]. In addition, HS must be addressed in the staff education and counselling, since hypersexual patient can cause a lot of disturbances to the routine nursing work.

Management of sexual problems by the physician

Management of sexual problems can be applied in steps. The ‘Open Sexual Communication’ module is a four-step tool designed to assist physicians in discussing sexual issues with patients and offer them adequate advice or treatment [Bronner, 2009]. Sexual advice can go along with medical interventions for the SD, but also can be applied independently. For example, in couples for whom intercourse is not a realistic possibility either because of physical limitations or because of impairments of genital functioning, suggestions about outercourse (experiencing erotic pleasure without concern for erection, erection without orgasm or extravaginal orgasm) can be offered. The key to a physician’s success in assessing and treating sexual problems is comfort in asking relevant questions and the belief that PD patients are sexual human beings with the ability to share love, intimacy and sexual excitement.

It is important to note that the intricacy, urgency and diversity of needs and experiences in the sexual area are highly personal. PD patients may seem similar with regards to their disabilities, medical treatments, relationship and family support. However, our experience suggests that they might have different problems and different needs. The ‘Open Sexual Communication’ module recommends that the physician inquires PD patients and their partners about their own expectations and past treatment trials in order to offer an appropriate treatment to each individual or couple. The complexity of SD in PD can be better managed in a multidisciplinary team. Neurologists, who are not comfortable to cope with this complicated and sensitive area by themselves, or are too busy, should refer patients to another professional for evaluation and treatment. According to our experience, sometimes it is a good idea to define one member in each multiprofessional team who will competently cope with sexual health of PD patients.

Conclusion

Data on sexual function in PD is incomplete and contradictory, however it is well established that SD is highly frequent among patients. The developments in the area of sexual medicine result in more information and experience regarding assessment and treatment of SD. In this review, we have described the complexity of the sexual problems and the process by which PD related factors (physical, psychological and relational) have an impact on the sexual functioning and well being of patients, their partners and their relationships. Management of sexual problems in PD is a challenging issue for physicians and healthcare professionals who work with PD patients and their partners. We encourage physicians to discuss frankly sexual health issues with their patients, and offer them treatment based on the accumulating knowledge on SD and treatment options.

Footnotes

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

The authors declare no conflicts of interest in preparing this article.

References

  1. Addis I.B., Van Den Eeden S.K., Wassel-Fyr C.L., Vittinghoff E., Brown J.S., Thom D.H., et al. (2006) Sexual activity and function in middle-aged and older women. Obstet Gynecol 107: 755–764 [DOI] [PMC free article] [PubMed] [Google Scholar]
  2. Basson R. (1996) Sexuality and Parkinson’s disease. Parkinsonism Relat Disord 2: 177–185 [DOI] [PubMed] [Google Scholar]
  3. Basson R., Rees P., Wang R., Montejo A.L., Incrocci L. (2010) Sexual function in chronic illness. J Sex Med 7: 374–388 [DOI] [PubMed] [Google Scholar]
  4. Bostwick J.M., Hecksel K.A., Stevens S.R., Bower J.H., Ahlskog J.E. (2009) Frequency of new-onset pathologic compulsive gambling or hypersexuality after drug treatment of idiopathic Parkinson disease. Mayo Clin Proc 84(4): 310–316 [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Broen M., Duits A., Visser-Vandewall V., Temel Y., Winogrodzka A. (2011) Impulse control and related disorders in Parkinson’s disease patients treated with bilateral subthalamic nucleus stimulation: a review. Parkinsonism Relat Disord, in press [DOI] [PubMed] [Google Scholar]
  6. Bronner G. (2009) Practical strategies for the management of sexual problems in Parkinson’s disease. Parkinsonism Relat Dis 15(Suppl. 3): s96–s100 [DOI] [PubMed] [Google Scholar]
  7. Bronner G., Elran E., Golomb J., Korczyn A.D. (2010) Female sexuality in multiple sclerosis—the multidimensional nature of the problem and the intervention. Acta Neurol Scand 21: 289–301 [DOI] [PubMed] [Google Scholar]
  8. Bronner G., Royter V., Korczyn A.D., Giladi N. (2004) Sexual dysfunction in Parkinson’s disease. J Sex Marital Ther 30: 95–105 [DOI] [PubMed] [Google Scholar]
  9. Brown R.G., Jahanshahi N., Quinn N., Marsden C.D. (1990) Sexual function in patients with Parkinson’s disease and their partners. J Neurol Neurosurg Psychiatry 53: 480–486 [DOI] [PMC free article] [PubMed] [Google Scholar]
  10. Cannas A., Solla P., Floris G.L., Serra G., Tacconi P., Marrosu M.G. (2007) Aberrant sexual behaviours in Parkinson’s disease during dopaminergic treatment. J Neurol 254: 110–112 [DOI] [PubMed] [Google Scholar]
  11. Castelli L., Perozzo P., Genesia M.L., Torre E., Pesare M., Cinquepalmi A., et al. (2004) Sexual well being in parkinsonian patients after deep brain stimulation of the subthalamic nucleus. J Neurol Neurosurg Psychiatry 75: 1260–1264 [DOI] [PMC free article] [PubMed] [Google Scholar]
  12. Celikel E., Ozel-Kizil E.T., Akbostanci M.C., Cevik A. (2008) Assessment of sexual dysfunction in patients with Parkinson’s disease: a case–control study. Eur J Neurol 15: 1168–1172 [DOI] [PubMed] [Google Scholar]
  13. Chaudhuri K.R., Healy D.G., Schapira A.H. (2006) Non-motor symptoms of Parkinson’s disease: diagnosis and management. Lancet Neurol 5: 235–245 [DOI] [PubMed] [Google Scholar]
  14. Christenson G.A., Faber R.J., de Zwaan M., Raymond N.C., Specker S.M., Ekern M.D., et al. (1994) Compulsive buying: descriptive characteristics and psychiatric comorbidity. J Clin Psychiatry 55: 5–11 [PubMed] [Google Scholar]
  15. Chung T.H., Deane K.H.O., Ghazi-Noori S., Rickards H., Clarke C.E. (2003) Systematic review of antidepressant therapies in Parkinson’s disease. Parkinsonism Relat Disord 10: 59–65 [DOI] [PubMed] [Google Scholar]
  16. Clayton A., Ramamurthy S. (2008) The impact of physical disease on sexual dysfunction. Adv Psychosom Med 29: 70–88 [DOI] [PubMed] [Google Scholar]
  17. Denil J., Ohl D., Smythe C. (1996) Vacuum erection device in spinal cord injured men: patient and partner satisfaction. Arch Phys Med Rehabil 77: 750–753 [DOI] [PubMed] [Google Scholar]
  18. Dodd M.L., Klos K.J., Bower J.H., Geda Y.E., Josephs K.A., Ahlskog J.E. (2005) Pathological gambling caused by drugs used to treat Parkinson disease. Arch Neurol 62: 1377–1381 [DOI] [PubMed] [Google Scholar]
  19. Driver-Dunckley E.D., Noble B.N., Hentz J.G., Evidente V.G., Caviness J.N., Parish J., et al. (2007) Gambling and increased sexual desire with dopaminergic medications in restless legs syndrome. Clin Neuropharmacol 30: 249–255 [DOI] [PubMed] [Google Scholar]
  20. Ferreri F., Agbokou C., Gauthier S. (2006) Recognition and management of neuropsychiatric complications in Parkinson’s disease. CMAJ 175: 1545–1552 [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Fernandez H.H., Durso R. (1998) Clozapine for dopaminergic-induced paraphilias in Parkinson’s disease. Mov Disord 13: 597–598 [DOI] [PubMed] [Google Scholar]
  22. Giladi N., Weitzman N., Schreiber S., Shabtai H., Peretz C. (2007) New-onset heightened interest or drive for gambling, eating, shopping or sexual activity in patients with Parkinson’s disease: the role of dopamine agonist treatment and age at motor symptoms onset. J Psychopharmacol 21: 501–506 [DOI] [PubMed] [Google Scholar]
  23. Giovannoni G., O’Sullivan J.D., Turner K., Manson A.J., Lees A.J. (2000) Hedonistic homeostatic dysregulation in patients with Parkinson’s disease on dopamine replacement therapies. J Neurol Neurosurg Psychiatry 68: 423–428 [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Hand A., Gray W.K., Chandler B.J., Walker R.W. (2010) Sexual and relationship dysfunction in people with Parkinson’s disease. Parkinsonism Relat Disord 16: 172–176 [DOI] [PubMed] [Google Scholar]
  25. Heaton J.P.W. (2000) Apomorphine: an update of clinical trial results. Int J Impot Res 12(Suppl. 4): S67–S73 [DOI] [PubMed] [Google Scholar]
  26. Hussain I.F., Brady C.M., Swinn M.J., Mathias C.J., Fowler C.J. (2001) Treatment of erectile dysfunction with sildenafil citrate (Viagra) in Parkinsonism due to Parkinson’s disease or multiple system atrophy with observation on orthostatic hypotension. J Neurol Neurosurg Psychiatry 71: 371–374 [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Jacobs H., Vieregge A., Vieregge P. (2000) Sexuality in young patients with Parkinson’s disease: a population based comparison with healthy controls. J Neurol Neurosurg Psychiatry 69: 550–552 [DOI] [PMC free article] [PubMed] [Google Scholar]
  28. Jiménez-Jiménez F.J., Sayed Y., García-Soldevilla M.A., Barcenilla B. (2002) Possible zoophilia associated with dopaminergic therapy in Parkinson disease. Ann Pharmacother 36: 1178–1179 [DOI] [PubMed] [Google Scholar]
  29. Klos K.J., Bower J.H., Josephs K.A., Matsumoto J.Y., Ahlskog J.E. (2005) Pathological hypersexuality predominantly linked to adjuvant dopamine agonist therapy in Parkinson’s disease and multiple system atrophy. Parkinsonism Relat Disord 11: 381–386 [DOI] [PubMed] [Google Scholar]
  30. Koller W.C., Vetere-Overfield B., Williamson A., Busenbark K., Nash J., Parrish D. (1990) Sexual dysfunction in Parkinson’s disease. Clin Neuropharmacol 13: 461–463 [DOI] [PubMed] [Google Scholar]
  31. Korczyn A. D. (1990) Autonomic nervous system disturbances in Parkinson’s disease. Adv Neurol 53: 463–468 [PubMed] [Google Scholar]
  32. Korpelainen J.T., Hiltunen P., Myllylä V.V. (1998) Moclobemide-induced hypersexuality in patients with stroke and Parkinson’s disease. Clin Neuropharmacol 21: 251–254 [PubMed] [Google Scholar]
  33. Kummer A., Cardoso F., Teixeira A.L. (2009) Loss of libido in Parkinson’s disease. J Sex Med 6: 1024–1031 [DOI] [PubMed] [Google Scholar]
  34. Laumann E.O., Glasser D.B., Neves R.C.S., Moreira E.D. (2009) A Population-based survey of sexual activity, sexual problems and associated help-seeking behavior patterns in mature adults in the United States of America. Int J Impot Res 21(3): 171–8 [DOI] [PubMed] [Google Scholar]
  35. Lipe H., Longstreth W.T., Jr, Bird T.D., Linde M. (1990) Sexual function in married men with Parkinson’s disease compared to married men with arthritis. Neurology 40: 1347–1349 [DOI] [PubMed] [Google Scholar]
  36. Merims D., Giladi N. (2008) Dopamine dysregulation syndrome, addiction and behavioral changes in Parkinson’s disease. Parkinsonism Relat Disord 14: 273–280 [DOI] [PubMed] [Google Scholar]
  37. Moore O., Gurevich T., Korczyn A.D., Anca M., Shabtai H., Giladi N. (2002) Quality of sexual life in Parkinson’s disease. Parkinsonism Relat Disord 8: 243–246 [DOI] [PubMed] [Google Scholar]
  38. Nurnberg H.G., Hensley P.L., Heiman J.R., Croft H.A., Debattista C., Paine S. (2008) Sildenafil treatment of women with antidepressant-associated sexual dysfunction: a randomized controlled trial. JAMA 300: 395–404 [DOI] [PubMed] [Google Scholar]
  39. Nurnberg H.G., Siegel R. (2006) Effects of sildenafil citrate treatment on ejaculatory/orgasm delay and erectile dysfunction in serotonergic antidepressant-associated sexual dysfunction. J Urol 175: 300 [Google Scholar]
  40. Okun M.S., McDonald W.M., DeLong M.R. (2002a) Refractory nonmotor symptoms in male patients with Parkinson disease due to testosterone deficiency. Arch Neurol 59: 807–811 [DOI] [PubMed] [Google Scholar]
  41. Okun M.S., Walter B.L., McDonald W.M., Tenover J.L., Green J., Juncos J.L., et al. (2002b) Beneficial effects of testosterone replacement for the nonmotor symptoms of Parkinson disease. Arch Neurol 59: 1750–1753 [DOI] [PubMed] [Google Scholar]
  42. O’Sullivan J., Hughes A. (1998) Apomorphine-induced penile erections in Parkinson’s disease. Mov Disord 13: 536–539 [DOI] [PubMed] [Google Scholar]
  43. Porst H. (1996) The rationale for prostaglandin E1 in erectile failure: a survey of worldwide experience. J Urol 155: 802–815 [PubMed] [Google Scholar]
  44. Raffaele R., Vecchio I., Giammusso B., Morgia G., Brunetto M.B., Rampello L. (2002) Efficacy and safety of fixed-dose oral sildenafil in the treatment of sexual dysfunction in depressed patients with idiopathic Parkinson’s disease. Eur Urol 41: 382–386 [DOI] [PubMed] [Google Scholar]
  45. Ready R.E., Friedman J., Grace J., Fernandez H. (2004) Testosterone deficiency and apathy in Parkinson’s disease: a pilot study. J Neurol Neurosurg Psychiatry 75: 1323–1326 [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Rees P.M., Fowler C.J., Maas C.P. (2007) Sexual function in men and women with neurological disorders. Lancet 369: 512–525 [DOI] [PubMed] [Google Scholar]
  47. Salonia A., Rigatti P., Montorsi F. (2003) Sildenafil in erectile dysfunction: a critical review. Curr Med Res Opin 19: 241–262 [DOI] [PubMed] [Google Scholar]
  48. Sakakibara R., Shinotoh H., Uchiyama T., Sakuma M., Kashiwado M., Yoshiyama M., et al. (2001) Questionnaire-based assessment of pelvic organ dysfunction in Parkinson’s disease. Auton Neurosci 92: 76–85 [DOI] [PubMed] [Google Scholar]
  49. Savica R., Rocca W.A., Ahlskog J.E. (2010) When does Parkinson disease start?. Arch Neurol 67: 798–801 [DOI] [PubMed] [Google Scholar]
  50. Seidman S.N., Pesce V., Roose S.P. (2003) High dose sildenafil citrate for selective serotonin reuptake inhibitor-associated ejaculatory delay: open clinical trial. J Clin Psychiatry 64: 721–725 [DOI] [PubMed] [Google Scholar]
  51. Shulman L.M., Taback R.L., Rabenstein A.A., Weiner W.J. (2002) Non-recognition of depression and other non-motor symptoms in Parkinson’s disease. Parkinsonism Relat Disord 8: 193–197 [DOI] [PubMed] [Google Scholar]
  52. Singer C., Weiner W.J., Sanchez-Ramos I.R., Ackerman M. (1991) Sexual function in patients with Parkinson’s disease. J Neurol Neurosurg Psychiatry 54: 942. [DOI] [PMC free article] [PubMed] [Google Scholar]
  53. Truong D.D., Bhidayasiri R., Wolters E. (2008) Management of non-motor symptoms in advanced Parkinson disease. J Neurol Sci 266: 216–228 [DOI] [PubMed] [Google Scholar]
  54. Uitti R.J., Tanner C.M., Rajut A.H., Goetz C.G., Klawan H.L., Thiessen B. (1989) Hypersexuality in antiparkinsonian therapy. Clin Neuropharmacol 12: 375–383 [DOI] [PubMed] [Google Scholar]
  55. Verschuren J.E., Enzlin P., Dijkstra P.U., Geertzen J.H., Dekker R. (2010) Chronic disease and sexuality: a generic conceptual framework. J Sex Res 47: 153–170 [DOI] [PubMed] [Google Scholar]
  56. Vitale C., Santangelo G., Trojano L., Verde F., Rocco M., Grossi D., et al. (2011) Comparative neuropsychological profile of pathological gambling, hypersexuality, and compulsive eating in Parkinson’s disease. Mov Dis, in press [DOI] [PubMed] [Google Scholar]
  57. Voon V., Hassan K., Zurowski M., de Souza M., Thomsen T., Fox S., et al. (2006) Prevalence of repetitive and reward-seeking behaviors in Parkinson disease. Neurology 67: 1254–1257 [DOI] [PubMed] [Google Scholar]
  58. Voon V., Sohr M., Lang A.E., Potenza M.N., Siderowf A.D., Whetteckey J., et al. (2011) Impulse control disorders in Parkinson disease: A multicenter case-control study. Ann Neurol. [DOI] [PubMed] [Google Scholar]
  59. Weintraub D., Koester J., Potenza M.N., Siderowf A.D., Stacy M., Voon V., et al. (2010) Impulse control disorders in Parkinson disease: a cross-sectional study of 3090 patients. Arch Neurol 67: 589–595 [DOI] [PubMed] [Google Scholar]
  60. Weintraub D., Siderowf A.D., Potenza M.N., Goveas J., Morales K.H., Duda J.E., et al. (2006) Association of dopamine agonist use with impulse control disorders in Parkinson disease. Arch Neurol 63: 969–973 [DOI] [PMC free article] [PubMed] [Google Scholar]
  61. Welch M., Hung L., Waters C.H. (1997) Sexuality in women with Parkinson’s disease. Mov Disord 12: 923–927 [DOI] [PubMed] [Google Scholar]
  62. Wermuth L., Stenager E. (1995) Sexual problems in young patients with Parkinson’s disease. Acta Neurol Scand 91: 453–455 [DOI] [PubMed] [Google Scholar]
  63. Wielinski C.L., Varpness S.C., Erickson-Davis C., Paraschos A.J., Parashos S.A. (2010) Sexual and relationship satisfaction among persons with young- Parkinson’s disease. J Sex Med 7: 1438–1444 [DOI] [PubMed] [Google Scholar]
  64. World Association for Sexual Health (2008) Sexual health for the millennium. World Association for Sexual Health: Minneapolis MN [Google Scholar]
  65. Zesiewicz T.A., Helal M., Hauser M.D. (2000) Sildenafil citrate (Viagra) for the treatment of erectile dysfunction in men with Parkinson’s disease. Mov Disord 15: 305–308 [DOI] [PubMed] [Google Scholar]
  66. Zesiewicz T.A., Sullivan K.L., Arnulf I., Chaudhuri K.R., Morgan J.C., Gronseth G.S., et al. (2010) Practice Parameter: treatment of nonmotor symptoms of Parkinson disease: report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 74(11): 924–931 [DOI] [PubMed] [Google Scholar]
  67. Zusman R.M., Morales A., Glasser D.B., Osterloh I.H. (1999) Overall cardiovascular profile of sildenafil citrate. Am J Cardiol 83(5A): 35C–44C [DOI] [PubMed] [Google Scholar]

Articles from Therapeutic Advances in Neurological Disorders are provided here courtesy of SAGE Publications

RESOURCES