Discussions about sexual health can be awkward, but for Daniela Wittmann, Ph.D., MSW, they go with the territory. As a social certified sex therapist, she sees patients with sexual health issues at the Michigan Medicine Center for Sexual Health and in the Department of Urology. She also discusses these types of issues with Parkinson's disease patients during support groups geared toward patients and their partners.

"Men with Parkinson's disease may experience issues such as lack of sexual desire, low libido, erectile dysfunction and difficulties with orgasm at a greater rate than the general population," Wittmann says. "Women with Parkinson's may also have low libido and orgasm difficulties in addition to vaginal dryness."

Parkinson's disease affects the neurons in the brain and causes dopamine-producing nerve cells to die. Dopamine is a chemical that transmits signals in the brain to coordinate smooth muscle movement, which is critical to sexual function.

A decrease in dopamine can impact the nerves that control sexual organs. For men, this can impact their ability to get or maintain an erection. Women may experience loss of vaginal lubrication and issues with orgasm.

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For both sexes, a reduced level of dopamine can result in a decrease in sex drive. Lower levels of dopamine can also result in balance issues, muscle stiffness and tremors — all issues that can impact a sexual relationship.

Associated illnesses, medications and advanced stages of Parkinson's disease can also contribute to sexual dysfunction.

First steps

"The first step is recognizing and addressing common sexual problems in patients with Parkinson's disease," says Wittmann. Her focus is on assessing a patient's sexual dysfunction and determining the most effective method of treating it.

"It's important to find out if the sexual issues have been lifelong or whether they started with PD," Wittmann says. "Usually we find out that the issues are directly related to the condition — both the physical nature of PD and the amount of distress the diagnosis and sexual changes are causing the individual and his/her partner.

WATCH: Daniela Wittmann's talk on sexuality and parkinson's disease

"We also want to find out how important sex is to them as an individual and as a couple. We find that not everyone needs to work on maintaining sexual intimacy. It depends on how important it is to the relationship."

Patient assessment

Wittmann's patient assessment is based on several objectives:

• Opening up the conversation about sexual concerns.
• Assessing physical symptoms that may interfere (urinary, bowel or movement issues).
• Discussing how the individual responds to his/her sexual issues (including loss, depression or anxiety).
• Evaluating the partner's attitude regarding the situation and his/her sexual concerns.
• Discussing any factors that impact the ability of PD patient to have pleasure.

She says it's also important to find out if a patient's sexual dysfunction occurs in all situations or only in certain types of situations, or with certain partners. And how much distress the individual is experiencing.

Sex therapy

The goal of sex therapy, Wittmann says, is to:

• Improve the patient's sexual function.
• Enhance communication between partners.
• Improve sexual interactions, including expansion of an individual's sexual repertoire.
• Boost self-esteem.
• Alleviate symptoms of depression or anxiety.

Wittmann points out the need for other disciplines when treating PD patients.

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"A multidisciplinary approach is important and may include behavioral therapists, urologists, pelvic floor rehab physical therapist, sex therapists, gynecologists for women, mental health providers and physicians who manage chronic conditions."

She says there is often a feeling of loss and uncertainty as well as a grieving period, which adds to the stress of a Parkinson's diagnosis. But, Wittmann stresses, "Many patients find that exploring and redefining their sexual identity helps strengthen their relationship as they move forward with a new normal."