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Insular multiple sclerosis lesions are associated with erectile dysfunction


Erectile function (EF) is frequently compromised in men with multiple sclerosis (MS). Functional neuroimaging in healthy men identified a network of brain areas, such as the insula, visual and somatosensory association areas, cingulate gyrus, prefrontal cortex, as well as subcortical regions, contributing to EF. This study intended to determine associations between EF deterioration during MS and cerebral MS-associated lesion sites. In 31 men with MS (mean age 38.2 ± 11.2 years), we evaluated MS-related EF deterioration by comparing scores of the 5-item International Index of Erectile Function-5 questionnaire (IIEF5) at the time of study and retrospectively, 3 months prior to MS diagnosis, by calculating score differences as DeltaIIEF5 (DeltaIIEF5 score < 0 indicated EF deterioration). To assess the impact of confounding factors of EF, patient age, disease duration, disease severity, depressiveness, bladder and bowel symptoms, and total cerebral MS lesion volume were correlated with DeltaIIEF5 scores (Spearman rank correlation) and compared between patients with and without EF deterioration (t tests or Mann–Whitney U test). MS lesions were assessed on T2-weighted magnetic resonance imaging (MRI; 1.5 or 3 T). We determined the lesion overlap (prevalence of identical lesion sites among patients), subtracted lesion overlaps in patients without EF deterioration from overlaps in patients with EF deterioration, and compared DeltaIIEF5 scores voxel-wise between patients with and without lesions in a given voxel (t test; significance: p < 0.05). In 14 patients (45.2%), DeltaIIEF5 scores indicated EF deterioration. DeltaIIEF5 scores were not associated with age (ρ = 0.06; p = 0.74), disease duration (ρ = 0.26; p = 0.15), disease severity (ρ = − 0.19; p = 0.31), depressiveness (ρ = 0.07; p = 0.72), bladder symptoms (ρ = − 0.11; p = 0.57), bowel symptoms (ρ = 0.17; p = 0.37), and total lesion volume (ρ = − 0.13; p = 0.47). The voxel-wise analysis showed associations between EF deterioration and MS lesions primarily in the bilateral, and predominantly left juxtacortical insular region. In conclusion, MS lesions particularly in the left insular region, which is activated with sexual arousal, contribute to erectile dysfunction.

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Corresponding author

Correspondence to Max J. Hilz.

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Conflicts of interest

MJH reports grants and personal fees from Bayer HealthCare pharmaceuticals, during the conduct of the study; grants and personal fees from Genzyme, a Sanofi company, grants and personal fees from Novartis Pharma GmbH, outside the submitted work. DHL reports grants and personal fees from Bayer HealthCare Pharmaceuticals, grants and personal fees from Biogen Idec, grants and personal fees from Merck Serono, grants and personal fees from Novartis Pharma GmbH, grants and personal fees from TEVA Pharmaceutical Industries LTD, outside the submitted work. RAL reports grants and personal fees from Bayer HealthCare Pharmaceuticals, grants and personal fees from Biogen Idec, grants and personal fees from Merck Serono, grants and personal fees from Novartis Pharma GmbH, grants and personal fees from Roche, grants and personal fees from TEVA Pharmaceutical Industries LTD, and from Novartis foundation, outside the submitted work. RAL holds an endowed professorship supported by the Novartis Foundation.

Ethical approval

The study has been approved by the local ethics committee and has been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki and its later amendments. Written informed consent has been obtained for all study participants.

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Winder, K., Linker, R.A., Seifert, F. et al. Insular multiple sclerosis lesions are associated with erectile dysfunction. J Neurol 265, 783–792 (2018).

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  • Multiple sclerosis
  • Sexual dysfunction
  • Erectile dysfunction
  • Autonomic dysfunction
  • Voxel-based lesion symptom mapping