Sexual Dysfunction in Multiple Sclerosis: Prevalence, Risk Factors, and Impact on Quality of Life in a Large Cohort Study

Sexual Dysfunction in Multiple Sclerosis: Prevalence, Risk Factors, and Impact on Quality of Life in a Large Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Sexual Dysfunction in Multiple Sclerosis: Prevalence, Risk Factors, and Impact on Quality of Life in a Large Cohort Study Ozlem Totuk, Merve Türkkol, Feyzullah Yadi, Hasan Can Güdek, Güldeniz Çetin Erci, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6835200/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Nov, 2025 Read the published version in BMC Neurology → Version 1 posted 12 You are reading this latest preprint version Abstract Background Sexual dysfunction (SD) is a prevalent but underreported symptom in people with multiple sclerosis (pwMS), significantly affecting quality of life (QoL). Despite its clinical relevance, SD is often overlooked during routine care. This study aimed to determine the prevalence of SD, identify associated risk factors, assess its impact on depression and QoL, and explore help-seeking behaviors among pwMS. Methods A cross-sectional study was conducted with 504 pwMS followed at a tertiary MS clinic between November 2023 and May 2024. Data on demographics, disease characteristics, and medications were collected. The Arizona Sexual Experiences Scale (ASEX) was used to assess SD, the Beck Depression Inventory (BDI) for depression, and the Short Form-12 (SF-12) for QoL. EDSS scores were used to evaluate disability. Statistical analyses included t-tests, ANOVA, chi-square, and correlation analyses, with significance set at p < 0.05. Results SD was identified in 69.0% of patients (73.9% of women, 57.6% of men). SD was significantly associated with female gender (p = 0.001), older age (p = 0.006), higher EDSS scores (p = 0.046), and increased depression levels (r = 0.38). SF-12 scores were significantly lower among those with SD (p < 0.001). No significant associations were found between SD and MS type, disease duration, or type of disease-modifying therapy. Only 16.9% of patients with SD reported seeking medical or psychological support. Conclusion SD is highly prevalent among pwMS and is closely linked to age, disability, depression, and reduced QoL. Despite this burden, most patients do not seek help. We recommend routine screening and multidisciplinary management approaches are essential for addressing SD in this population. Multiple sclerosis Sexual dysfunction Quality of life Depression Help-seeking behavior Expanded Disability Status Scale Arizona Sexual Experience Scale Figures Figure 1 Figure 2 Introduction Multiple sclerosis (MS) is an autoimmune neurodegenerative disorder characterized by inflammation, demyelination, gliosis, and axonal loss in the central nervous system [ 1 ]. Typically beginning in young adulthood, MS manifests with a wide range of clinical symptoms, including spasticity, pain, vesicourethral dysfunction, cognitive impairment, chronic fatigue, and sexual dysfunction [ 1 ]. Sexual dysfunction (SD) is frequently encountered but often underrecognized, with studies showing that approximately 50% of patients with MS (pwMS) become sexually inactive over the course of the disease, and an additional 20% report decreased sexual activity [ 2 ]. The prevalence of SD in pwMS is estimated to be nearly five times higher than in the general population [ 3 ]. Sexual complaints in men with MS most commonly include decreased libido, erectile dysfunction, absence of morning erection, premature ejaculation, orgasmic dysfunction, and reduced penile sensation [ 4 ]. In women, the most frequently reported symptoms are decreased libido, difficulty achieving orgasm, reduced vaginal lubrication and sensation, and dyspareunia [ 4 ]. Sexual dysfunction in MS can be classified into three categories: (1) Primary SD , resulting directly from demyelination or disruption of neurological pathways involved in sexual response; (2) Secondary SD , which arises from MS-related physical symptoms such as fatigue or spasticity; and (3) Tertiary SD , associated with psychosocial consequences such as altered self-image, mood disorders, and fear of rejection [ 5 ]. Despite its significant impact on quality of life and emotional well-being, sexual dysfunction is often overlooked during routine clinical evaluations. This may be due to patient reluctance, time constraints, or discomfort among healthcare providers in addressing intimate issues. Proactive screening and open dialogue are therefore essential to support rehabilitation and improve quality of life in this patient population. Recent studies have explored the relationship between sexual dysfunction and quality of life in pwMS. However, most have involved relatively small sample sizes and limited exploration of help-seeking behaviors [ 6 ]. Therefore, further large-scale, multidimensional studies are warranted. The primary aim of the present study was to determine the prevalence of sexual dysfunction and identify associated risk factors in a large cohort of pwMS. Secondary objectives included assessing the impact of SD on depression and quality of life, evaluating associations with disease duration, Expanded Disability Status Scale (EDSS) scores, MS subtypes, and medication use, and investigating whether patients seek help for SD. We hypothesized that the prevalence of sexual dysfunction would be higher among patients with progressive MS types, elevated EDSS scores, longer disease duration, and advanced age, and that SD would significantly impair overall quality of life. Methods Participants This cross-sectional study included patients who were followed at the MS outpatient clinic of Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital between November 2023 and May 2024. All patients were diagnosed with definite multiple sclerosis (MS) according to the McDonald criteria [ 7 ]. The clinical subtypes of MS represented in the sample were Clinically Isolated Syndrome (CIS), Relapsing-Remitting MS (RRMS), Primary Progressive MS (PPMS), and Secondary Progressive MS (SPMS). Diagnosis confirmation, MS subtype classification, and longitudinal outpatient follow-up were all conducted at the same center. Functional status was assessed using the Expanded Disability Status Scale (EDSS) [ 8 ]. In addition to EDSS scores, demographic and clinical data were recorded, including patient age, disease duration, and neurological examination findings. Exclusion criteria were as follows: a known diagnosis of sexual dysfunction prior to MS diagnosis, being menopausal, absence of a regular sexual partner, use of medications known to influence sexual function (e.g., psychotropic agents, antidepressants) within the past two months, and a recent MS relapse or corticosteroid treatment within the past three months. Measures To assess the prevalence of sexual dysfunction among patients with multiple sclerosis (pwMS), the Arizona Sexual Experiences Scale (ASEX) was selected as a brief, validated screening tool with separate versions for male and female patients. Additionally, the Beck Depression Inventory (BDI) and the Short Form-12 (SF-12) Health Survey were used to evaluate depression and quality of life, respectively, as both are widely applied in clinical and research settings. Arizona Sexual Experiences Scale (ASEX) The ASEX was developed by McGahuey et al. [ 9 ] to efficiently assess core dimensions of sexual functioning. It comprises five items evaluating sexual desire, arousal, penile erection or vaginal lubrication, ability to reach orgasm, and satisfaction with orgasm. Each item is scored on a 6-point Likert scale (1–6), resulting in total scores ranging from 5 to 30. A total ASEX score above 19, a score of 5 or more on any single item, or a score of 4 or more on three or more items is indicative of sexual dysfunction. The Turkish adaptation, including validity and reliability analyses, was conducted by Soykan [ 10 ]. Beck Depression Inventory (BDI) The BDI was originally developed by Beck et al. in 1978 [ 11 ] to assess the severity of depressive symptoms, including motivational, cognitive, emotional, and vegetative domains. It consists of 21 self-reported items, each scored from 0 to 3, producing a total score ranging from 0 to 63. Higher scores reflect greater severity of depression. The Turkish version of the BDI was validated by Hisli [ 12 ], with a cutoff score of 17 indicating the need for clinical attention. Short Form-12 (SF-12) Health Survey The SF-36 was designed by Ware et al. [ 13 ] to evaluate health-related quality of life across multiple domains. The SF-12 is a shortened version consisting of 12 items that cover general health perception, physical functioning, mental health, and role limitations, among others. The Turkish reliability and validity of the SF-12 were established by Koçyiğit et al. [ 14 ]. Subscale scores range from 0 to 100, with higher scores reflecting better perceived health status. Statistical Analysis Descriptive statistics for numerical variables included the mean, standard deviation (SD), median, minimum, and maximum values. Data normality was assessed by evaluating skewness and kurtosis values, with thresholds between − 3 and + 3 considered indicative of normal distribution [ 15 ]. For group comparisons, independent samples t-tests were applied to evaluate differences between two groups with normally distributed data, while one-way analysis of variance (ANOVA) was used for comparisons among three or more groups. When ANOVA indicated significant differences and homogeneity of variances was assumed, Tukey's post-hoc test was performed for pairwise comparisons. Categorical variables were analyzed using Pearson’s chi-square test when expected cell counts were greater than 5; otherwise, Fisher’s exact test was employed. Correlations among continuous variables were visualized using the ggcorrplot package in R [ 16 , 17 ]. All statistical analyses were performed using IBM SPSS Statistics for Windows, version 27 [ 18 ]. A two-tailed p-value of < 0.05 was considered statistically significant. Results The study included 504 patients with multiple sclerosis. The mean age of the participants was 38.14 ± 9.90 years, with an average disease duration of 7.70 ± 6.40 years. The mean Expanded Disability Status Scale (EDSS) score was 2.48 ± 1.72. Descriptive Characteristics Among the participants, 151 (30.0%) were male and 353 (70.0%) were female. Regarding disease duration, 4.8% had MS for less than 1 year, 40.1% for 1–4 years, 26.2% for 5–9 years, and 29.0% for 10 years or more. In terms of treatment, 472 patients (93.7%) were receiving disease-modifying therapy, while 32 (6.3%) were not. The distribution of disease-modifying therapies is shown in Table 1 . Table 1 Descriptive Characteristics of the Study Participants. Variable n % Sex Male 151 30.0% Female 353 70.0% Disease Duration < 1 year 24 4.8% 1–4 years 202 40.1% 5–9 years 132 26.2% ≥10 years 146 29.0% MS Medications Dimethyl fumarate (DMF) 110 21.8% Ocrelizumab 98 19.4% Fingolimod 81 16.1% Teriflunomide 61 12.1% Interferon beta 35 6.9% Cladribine 21 4.2% Glatiramer acetate 19 3.8% Natalizumab 12 2.4% Alemtuzumab 10 2.0% Rituximab 9 1.8% Ofatumumab 2 0.4% Regarding educational level, 7.9% had completed primary education or less, 6.2% secondary school, 25.6% high school, 49.2% undergraduate degrees, and 11.1% had graduate-level education. There was no statistically significant association between the type of MS medication used and ASEX scores (p > 0.05). Sexual Dysfunction and Quality of Life Scores The mean Arizona Sexual Experiences Scale (ASEX) score was 15.32 ± 7.41, and the mean SF-12 (quality of life) score was 36.57 ± 9.63. According to ASEX criteria, 69.0% of participants met the threshold for sexual dysfunction, while 31.0% did not ( Table 2 ). Table 2 Descriptive Statistics of Clinical Scales (SD: Standard Deviation). Scale / Measure Mean ± SD -Short Form-12 (Quality of Life) 36.57 ± 9.63 -Arizona Sexual Experiences Scale (ASEX) 15.32 ± 7.41 Sexual Dysfunction Status According to ASEX n (%) -No sexual dysfunction 156 (31.0%) -Sexual dysfunction present 348 (69.0%) Sexual Dysfunction by MS Subtype No statistically significant difference in ASEX scores was found among different MS subtypes (p = 0.094), although SPMS patients had numerically higher scores. However, a significant difference in SF-12 quality of life scores was observed (p < 0.001), with SPMS patients having the lowest scores compared to CIS, PPMS, and RRMS patients ( Table 3 ). Table 3 The Relationship Between MS Types and Scores on the Arizona Sexual Experiences (ASEX) and Quality of Life Scale (Short Form-12) F: One-way ANOVA test. CIS: Clinically Isolated Syndrome, PPMS: Primary Progressive MS, RRMS: Relapsing-Remitting MS, SPMS : Secondary Progressive MS. Scale / Measure CIS (n = 5)a PPMS (n = 22)b RRMS (n = 397)c SPMS (n = 80)d Test Value / p ASEX 10.00 ± 2.00 13.86 ± 6.97 15.18 ± 7.37 16.71 ± 7.75 2.144 / 0.094F SF-12 44.40 ± 4.65 37.18 ± 8.78 37.86 ± 9.25 29.54 ± 8.78 19.700 / <0.001F (d < a,b,c) Factors Associated with Sexual Dysfunction As shown in Table 4 , sexual dysfunction was significantly associated with gender (higher prevalence in females; p = 0.001), older age (p = 0.006), and higher EDSS scores (p = 0.046). There were no significant associations with disease duration, MS subtype, or medication use. Table 4 Relationship Between Sexual Dysfunction and Descriptive Characteristics. χ²: Chi-square test, t: Independent samples t-test Variable No Sexual Dysfunction (n = 156) Sexual Dysfunction Present (n = 348) Test Value p-value Gender (Male %) 64 (42.4%) 87 (57.6%) 13.183 0.001^χ² Age (Mean ± SD, Range) 36.34 ± 9.55 (20–70) 38.94 ± 9.97 (18–66) 2.746 0.006^t EDSS (Mean ± SD, Range) 2.25 ± 1.76 (0–7) 2.58 ± 1.70 (0–8) 2.003 0.046^t SD: Standard Deviation Quality of Life and Sexual Dysfunction Participants with sexual dysfunction had significantly lower SF-12 scores compared to those without (34.71 ± 8.92 vs. 40.72 ± 9.88; p < 0.001), as shown in Table 5 . Table 5 Relationship Between Quality of Life (SF-12) and Sexual Dysfunction Sexual Dysfunction Quality of Life (Mean ± SD) Test Value p-value None 40.72 ± 9.88 -6.766 0.001^t Yes 34.71 ± 8.92 t: Independent samples t-test SD: Standard Deviation Correlation Analysis Figure 1 displays correlation analyses. ASEX scores showed a moderate negative correlation with SF-12 scores (r = − 0.35), a moderate positive correlation with BDI scores (r = 0.38), and a low positive correlation with age (r = 0.19). The correlation between ASEX and EDSS was weak and not statistically significant (r = 0.07). In the subgroup of participants with sexual dysfunction ( Fig. 2 ) , correlations were similar: a negative correlation with SF-12 (r = − 0.31), positive with BDI (r = 0.27), and age (r = 0.20); again, the relationship with EDSS remained weak and nonsignificant (r = 0.12). Help-Seeking Behavior A brief survey was conducted among participants identified as having sexual dysfunction. Of the 71 who responded, only 9.8% reported consulting a physician, and 7.0% sought psychological support. The majority (83.1%) did not seek any assistance. Among those who did not seek help, 33.9% cited embarrassment or fear of discussing the issue, while the rest believed it was a natural symptom of MS that did not require treatment. Discussion Sexual dysfunction (SD) is a significant but often underrecognized burden among people with multiple sclerosis (pwMS). Due to the intimate nature of the topic and social stigma, both patients and clinicians may avoid addressing these symptoms in routine clinical care. Previous studies report a wide range of prevalence, from 50–90% in men and 40–80% in women [ 19 ]. In our study, SD was identified in 57.6% of male participants, 73.9% of females, and 69% of the total cohort, findings that are consistent with existing literature [ 20 ]. Although we did not analyze SD subtypes separately, previous studies indicate that decreased libido is the most commonly reported complaint across both sexes, with a prevalence as high as 80.5% [ 21 ], while erectile dysfunction is the most frequent symptom in men [ 22 ]. SD in MS is typically categorized into three domains: primary (direct neurological involvement), secondary (indirect effects of MS symptoms such as fatigue or spasticity), and tertiary (psychosocial and emotional consequences) [ 5 ]. Due to the screening nature of our study, we did not differentiate between these categories. Our findings support a significant association between age and SD, confirming our first hypothesis. While some previous studies have reported similar age-related increases in SD [ 23 ], others have found no such association [ 24 ]. No statistically significant relationship was found between disease duration and the presence of SD, consistent with earlier studies showing mixed or inconclusive results [ 25 ]. Thus, our second hypothesis was not supported. Despite the commonly held view that SD becomes more prominent in progressive MS types, our data showed no significant difference in SD prevalence across MS subtypes. Therefore, our third hypothesis was also not confirmed. However, patients with SPMS did have significantly lower quality of life scores, which may suggest cumulative burden even in the absence of increased SD frequency. EDSS score, a measure of disability in MS, was significantly associated with the presence of SD, validating our fourth hypothesis. This finding aligns with previous studies highlighting EDSS as a robust predictor of sexual impairment in pwMS [ 25 ]. Although disease-modifying therapies (DMTs) have been proposed to influence sexual functioning, largely due to their role in controlling disease activity and progression [ 26 , 27 ], our study did not find any significant association between DMT type and SD. This may be due to a complex interplay of biological, psychological, and social variables rather than direct drug effects. Depression, a common comorbidity in MS, is well established as a contributor to SD in both clinical and non-clinical populations [ 28 ]. In our sample, higher ASEX scores were positively correlated with BDI scores, reinforcing the close link between emotional health and sexual well-being. Our results further confirm that sexual dysfunction is associated with decreased quality of life in pwMS, supporting our fifth hypothesis. Although SF-12 scores were lower in patients with SPMS, ASEX scores did not differ significantly between MS subtypes. This suggests that sexual health may impact QoL independently of MS disease type [ 25 , 28 , 29 ]. Importantly, we investigated help-seeking behaviors related to SD, a topic rarely addressed in existing literature. Among patients reporting SD, only a minority sought medical or psychological support, while the vast majority did not disclose their symptoms. Reasons included embarrassment, fear of stigmatization, or perceiving SD as a normal part of the disease experience. Our findings are in line with a recent study by Dehghaniathar et al. (2025), which also reported a high prevalence of SD in pwMS and its detrimental impact on QoL. However, that study was limited by a smaller sample size and did not assess help-seeking behaviors or perform multivariate risk analysis. In contrast, our study offers a more comprehensive assessment of associated factors and highlights the need for proactive clinical screening [ 6 ]. Given its high prevalence and significant psychosocial impact, SD should be systematically screened in routine outpatient evaluations of pwMS. Early identification of at-risk individuals may facilitate timely referral for sexual health counseling, psychological support, and multidisciplinary rehabilitation. Even brief conversations about sexual health have been shown to positively impact patient well-being [ 30 ]. Ultimately, management of SD in MS should involve collaborative care between neurology, urology, and mental health professionals [ 31 ]. Conclusion Sexual dysfunction is highly prevalent among people with multiple sclerosis, particularly in individuals of older age, with greater disability (higher EDSS scores), and elevated depressive symptoms. Despite affecting patients during their sexually active years, SD often remains unreported unless specifically queried during clinical visits. These findings underscore the need for increased clinical awareness and systematic screening. Understanding the prevalence and multidimensional nature of SD—including its physical, emotional, and psychosocial components—can facilitate targeted interventions. Comprehensive assessment strategies and larger multicenter studies are warranted to further delineate subtypes and predictors. Ultimately, the management of SD in MS should be approached through a multidisciplinary lens, incorporating neurologists, urologists, psychologists, and rehabilitation professionals to deliver holistic care. Limitations This study has several limitations. First, it lacked a control group from the general population, preventing direct comparison of SD prevalence between MS patients and healthy individuals. Second, fatigue—an MS symptom known to contribute significantly to sexual dysfunction—was not evaluated. Third, the study focused on the presence and frequency of SD but did not distinguish between primary, secondary, and tertiary subtypes. Addressing these limitations in future research will help refine clinical screening tools and intervention strategies. Declarations Ethics Approval and Consent to Participate The study was approved by the Ethics Committee of the University of Health Sciences, Sancaktepe Prof. Dr. İlhan Varank Training and Research Hospital (Approval No: 2023/242, Date: 19.12.2023) and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their inclusion in the study. Authors’ Contributions ÖT conceptualized and supervised the study. ÖT, MT, FY, HCG, İGD and DÇT contributed to data collection. ÖT, GÇE conducted statistical analyses. ÖT contributed to literature review and manuscript drafting. ŞŞ and SD critically revised the manuscript for intellectual content. All authors read and approved the final version of the manuscript. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Competing Interests The authors declare that they have no competing interests. Availability of Data and Materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. References Bar-Or A, Oliveira EM, Anderson DE, Hafler DA. Molecular pathogenesis of multiple sclerosis. J Neuroimmunol . 1999;100(1-2):252–9. doi:10.1016/s0165-5728(99)00193-9. Hennessey A, Robertson NP, Swingler R, Compston DA. Urinary, faecal and sexual dysfunction in patients with multiple sclerosis. J Neurol . 1999;246(11):1027–32. doi:10.1007/s004150050508. Drulovic J, Kisic-Tepavcevic D, Pekmezovic T. Epidemiology, diagnosis, and management of sexual dysfunction in multiple sclerosis. Acta Neurol Belg . 2020;120(4):791–7. doi:10.1007/s13760-020-01323-4. 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Cite Share Download PDF Status: Published Journal Publication published 14 Nov, 2025 Read the published version in BMC Neurology → Version 1 posted Editorial decision: Revision requested 21 Aug, 2025 Reviews received at journal 16 Aug, 2025 Reviewers agreed at journal 29 Jul, 2025 Reviewers agreed at journal 28 Jul, 2025 Reviews received at journal 08 Jul, 2025 Reviewers agreed at journal 21 Jun, 2025 Reviewers agreed at journal 16 Jun, 2025 Reviewers invited by journal 16 Jun, 2025 Editor invited by journal 12 Jun, 2025 Editor assigned by journal 10 Jun, 2025 Submission checks completed at journal 10 Jun, 2025 First submitted to journal 06 Jun, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6835200","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":472076834,"identity":"de63a630-878c-41a0-97d4-bcf3913ad00f","order_by":0,"name":"Ozlem Totuk","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA2klEQVRIiWNgGAWjYJACxgYGBhkGBuYDQLaEDEHlPAzMYC08DAxsCSAtPKRo4TGACBAC9uz9xyRnVNTx8Iud+fzqRo0FDwP74aMb8NrCc5hNcsMZNh7J2bnbrHOOAR3Gk5Z2A68WiWQ2yYdtPDwGt3O3GeewAbVI8JgRo0WCx/52zjPjnH/EatnYZsBjIJ3D/Di3jRgtZw4bW844k8AjcTvNjDm3T4KHjZBf2NsbH97sqaiT45+d/Phzzjcgg/3wMbxakAGbBJgkVjkIMH8gRfUoGAWjYBSMHAAAGZw+Jay6pCsAAAAASUVORK5CYII=","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":true,"prefix":"","firstName":"Ozlem","middleName":"","lastName":"Totuk","suffix":""},{"id":472076835,"identity":"5a8d330b-e8a8-4da4-bcd9-18d714762b2b","order_by":1,"name":"Merve Türkkol","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Merve","middleName":"","lastName":"Türkkol","suffix":""},{"id":472076836,"identity":"b95ff663-7455-48c4-a2d9-225b948f2400","order_by":2,"name":"Feyzullah Yadi","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Feyzullah","middleName":"","lastName":"Yadi","suffix":""},{"id":472076837,"identity":"5ba5353a-ae2f-41af-8a28-53b1afb7b8d6","order_by":3,"name":"Hasan Can Güdek","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Hasan","middleName":"Can","lastName":"Güdek","suffix":""},{"id":472076838,"identity":"8971414b-feba-4d24-9966-7be71f850e44","order_by":4,"name":"Güldeniz Çetin Erci","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Güldeniz","middleName":"Çetin","lastName":"Erci","suffix":""},{"id":472076839,"identity":"d6902f74-d1d0-4e4d-9c75-b978ec2cbb69","order_by":5,"name":"İpek Güngör Doğan","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"İpek","middleName":"Güngör","lastName":"Doğan","suffix":""},{"id":472076840,"identity":"6eb80680-88a6-4619-8b70-67d7159ddcae","order_by":6,"name":"Damla Çetinkaya Tezer","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Damla","middleName":"Çetinkaya","lastName":"Tezer","suffix":""},{"id":472076843,"identity":"e36ab000-e064-4046-b01f-219c9a11ed6a","order_by":7,"name":"Sevki Sahin","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Sevki","middleName":"","lastName":"Sahin","suffix":""},{"id":472076845,"identity":"16acf931-5aac-4aca-8da4-eb83c2e6e85f","order_by":8,"name":"Serkan Demir","email":"","orcid":"","institution":"Sağlık Bilimleri Üniversitesi","correspondingAuthor":false,"prefix":"","firstName":"Serkan","middleName":"","lastName":"Demir","suffix":""}],"badges":[],"createdAt":"2025-06-06 08:38:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6835200/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6835200/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12883-025-04492-y","type":"published","date":"2025-11-14T15:57:59+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":85176058,"identity":"13962881-f82e-4d37-a32e-762bdd53fa7d","added_by":"auto","created_at":"2025-06-23 06:33:54","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":19730,"visible":true,"origin":"","legend":"\u003cp\u003eRelationships between participants' ASEX (Arizona Sexual Experiences Scale), SF-12 (Quality of Life Scale - short form), BDI (Beck Depression Scale), EDSS (Extended Disability Status Scoring) and their ages\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6835200/v1/796343f4ed4adb625d77a482.png"},{"id":85177196,"identity":"d92379cc-a440-4fcb-940f-0bbb6ea90f2b","added_by":"auto","created_at":"2025-06-23 06:41:54","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":18776,"visible":true,"origin":"","legend":"\u003cp\u003eRelationships between ASEX (Arizona Sexual Experiences Scale), SF-12 (Quality of Life Scale - short form), BDI (Beck Depression Scale), EDSS (Expanded Disability Status Score) and ages of participants with sexual dysfunction\u0026nbsp;\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-6835200/v1/0e0414ed2ea25b37c4042c46.png"},{"id":96105180,"identity":"38dda9d5-cd6b-4d76-ba5b-c1ca52b98b3b","added_by":"auto","created_at":"2025-11-17 16:09:41","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":880807,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6835200/v1/da3ba921-fabf-4e9b-92a6-b6d3afc8f7d2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Sexual Dysfunction in Multiple Sclerosis: Prevalence, Risk Factors, and Impact on Quality of Life in a Large Cohort Study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eMultiple sclerosis (MS) is an autoimmune neurodegenerative disorder characterized by inflammation, demyelination, gliosis, and axonal loss in the central nervous system [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Typically beginning in young adulthood, MS manifests with a wide range of clinical symptoms, including spasticity, pain, vesicourethral dysfunction, cognitive impairment, chronic fatigue, and sexual dysfunction [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Sexual dysfunction (SD) is frequently encountered but often underrecognized, with studies showing that approximately 50% of patients with MS (pwMS) become sexually inactive over the course of the disease, and an additional 20% report decreased sexual activity [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. The prevalence of SD in pwMS is estimated to be nearly five times higher than in the general population [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual complaints in men with MS most commonly include decreased libido, erectile dysfunction, absence of morning erection, premature ejaculation, orgasmic dysfunction, and reduced penile sensation [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. In women, the most frequently reported symptoms are decreased libido, difficulty achieving orgasm, reduced vaginal lubrication and sensation, and dyspareunia [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSexual dysfunction in MS can be classified into three categories:\u003c/p\u003e \u003cp\u003e(1) \u003cb\u003ePrimary SD\u003c/b\u003e, resulting directly from demyelination or disruption of neurological pathways involved in sexual response;\u003c/p\u003e \u003cp\u003e(2) \u003cb\u003eSecondary SD\u003c/b\u003e, which arises from MS-related physical symptoms such as fatigue or spasticity; and\u003c/p\u003e \u003cp\u003e(3) \u003cb\u003eTertiary SD\u003c/b\u003e, associated with psychosocial consequences such as altered self-image, mood disorders, and fear of rejection [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eDespite its significant impact on quality of life and emotional well-being, sexual dysfunction is often overlooked during routine clinical evaluations. This may be due to patient reluctance, time constraints, or discomfort among healthcare providers in addressing intimate issues. Proactive screening and open dialogue are therefore essential to support rehabilitation and improve quality of life in this patient population.\u003c/p\u003e \u003cp\u003eRecent studies have explored the relationship between sexual dysfunction and quality of life in pwMS. However, most have involved relatively small sample sizes and limited exploration of help-seeking behaviors [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Therefore, further large-scale, multidimensional studies are warranted.\u003c/p\u003e \u003cp\u003eThe primary aim of the present study was to determine the prevalence of sexual dysfunction and identify associated risk factors in a large cohort of pwMS. Secondary objectives included assessing the impact of SD on depression and quality of life, evaluating associations with disease duration, Expanded Disability Status Scale (EDSS) scores, MS subtypes, and medication use, and investigating whether patients seek help for SD.\u003c/p\u003e \u003cp\u003eWe hypothesized that the prevalence of sexual dysfunction would be higher among patients with progressive MS types, elevated EDSS scores, longer disease duration, and advanced age, and that SD would significantly impair overall quality of life.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eParticipants\u003c/h2\u003e \u003cp\u003e This cross-sectional study included patients who were followed at the MS outpatient clinic of Sancaktepe Şehit Prof. Dr. İlhan Varank Training and Research Hospital between November 2023 and May 2024. All patients were diagnosed with definite multiple sclerosis (MS) according to the McDonald criteria [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The clinical subtypes of MS represented in the sample were Clinically Isolated Syndrome (CIS), Relapsing-Remitting MS (RRMS), Primary Progressive MS (PPMS), and Secondary Progressive MS (SPMS).\u003c/p\u003e \u003cp\u003eDiagnosis confirmation, MS subtype classification, and longitudinal outpatient follow-up were all conducted at the same center. Functional status was assessed using the Expanded Disability Status Scale (EDSS) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In addition to EDSS scores, demographic and clinical data were recorded, including patient age, disease duration, and neurological examination findings.\u003c/p\u003e \u003cp\u003eExclusion criteria were as follows: a known diagnosis of sexual dysfunction prior to MS diagnosis, being menopausal, absence of a regular sexual partner, use of medications known to influence sexual function (e.g., psychotropic agents, antidepressants) within the past two months, and a recent MS relapse or corticosteroid treatment within the past three months.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cp\u003eTo assess the prevalence of sexual dysfunction among patients with multiple sclerosis (pwMS), the Arizona Sexual Experiences Scale (ASEX) was selected as a brief, validated screening tool with separate versions for male and female patients. Additionally, the Beck Depression Inventory (BDI) and the Short Form-12 (SF-12) Health Survey were used to evaluate depression and quality of life, respectively, as both are widely applied in clinical and research settings.\u003c/p\u003e\n\u003ch3\u003eArizona Sexual Experiences Scale (ASEX)\u003c/h3\u003e\n\u003cp\u003eThe ASEX was developed by McGahuey et al. [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e] to efficiently assess core dimensions of sexual functioning. It comprises five items evaluating sexual desire, arousal, penile erection or vaginal lubrication, ability to reach orgasm, and satisfaction with orgasm. Each item is scored on a 6-point Likert scale (1\u0026ndash;6), resulting in total scores ranging from 5 to 30. A total ASEX score above 19, a score of 5 or more on any single item, or a score of 4 or more on three or more items is indicative of sexual dysfunction. The Turkish adaptation, including validity and reliability analyses, was conducted by Soykan [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\n\u003ch3\u003eBeck Depression Inventory (BDI)\u003c/h3\u003e\n\u003cp\u003eThe BDI was originally developed by Beck et al. in 1978 [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] to assess the severity of depressive symptoms, including motivational, cognitive, emotional, and vegetative domains. It consists of 21 self-reported items, each scored from 0 to 3, producing a total score ranging from 0 to 63. Higher scores reflect greater severity of depression. The Turkish version of the BDI was validated by Hisli [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], with a cutoff score of 17 indicating the need for clinical attention.\u003c/p\u003e\n\u003ch3\u003eShort Form-12 (SF-12) Health Survey\u003c/h3\u003e\n\u003cp\u003eThe SF-36 was designed by Ware et al. [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] to evaluate health-related quality of life across multiple domains. The SF-12 is a shortened version consisting of 12 items that cover general health perception, physical functioning, mental health, and role limitations, among others. The Turkish reliability and validity of the SF-12 were established by Ko\u0026ccedil;yiğit et al. [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Subscale scores range from 0 to 100, with higher scores reflecting better perceived health status.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eDescriptive statistics for numerical variables included the mean, standard deviation (SD), median, minimum, and maximum values. Data normality was assessed by evaluating skewness and kurtosis values, with thresholds between \u0026minus;\u0026thinsp;3 and +\u0026thinsp;3 considered indicative of normal distribution [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFor group comparisons, independent samples t-tests were applied to evaluate differences between two groups with normally distributed data, while one-way analysis of variance (ANOVA) was used for comparisons among three or more groups. When ANOVA indicated significant differences and homogeneity of variances was assumed, Tukey's post-hoc test was performed for pairwise comparisons.\u003c/p\u003e \u003cp\u003eCategorical variables were analyzed using Pearson\u0026rsquo;s chi-square test when expected cell counts were greater than 5; otherwise, Fisher\u0026rsquo;s exact test was employed. Correlations among continuous variables were visualized using the \u003cb\u003eggcorrplot\u003c/b\u003e package in R [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAll statistical analyses were performed using IBM SPSS Statistics for Windows, version 27 [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e]. A two-tailed p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 504 patients with multiple sclerosis. The mean age of the participants was 38.14\u0026thinsp;\u0026plusmn;\u0026thinsp;9.90 years, with an average disease duration of 7.70\u0026thinsp;\u0026plusmn;\u0026thinsp;6.40 years. The mean Expanded Disability Status Scale (EDSS) score was 2.48\u0026thinsp;\u0026plusmn;\u0026thinsp;1.72.\u003c/p\u003e\n\u003ch3\u003eDescriptive Characteristics\u003c/h3\u003e\n\u003cp\u003eAmong the participants, 151 (30.0%) were male and 353 (70.0%) were female. Regarding disease duration, 4.8% had MS for less than 1 year, 40.1% for 1\u0026ndash;4 years, 26.2% for 5\u0026ndash;9 years, and 29.0% for 10 years or more. In terms of treatment, 472 patients (93.7%) were receiving disease-modifying therapy, while 32 (6.3%) were not. The distribution of disease-modifying therapies is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Characteristics of the Study Participants.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003en\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e%\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e151\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e353\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e70.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisease Duration\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u0026ndash;4 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e202\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e40.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u0026ndash;9 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e132\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026ge;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e146\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMS Medications\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimethyl fumarate (DMF)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOcrelizumab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e98\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFingolimod\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e16.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTeriflunomide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e61\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInterferon beta\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCladribine\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGlatiramer acetate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNatalizumab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlemtuzumab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRituximab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOfatumumab\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding educational level, 7.9% had completed primary education or less, 6.2% secondary school, 25.6% high school, 49.2% undergraduate degrees, and 11.1% had graduate-level education.\u003c/p\u003e \u003cp\u003eThere was no statistically significant association between the type of MS medication used and ASEX scores (p\u0026thinsp;\u0026gt;\u0026thinsp;0.05).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eSexual Dysfunction and Quality of Life Scores\u003c/h2\u003e \u003cp\u003eThe mean Arizona Sexual Experiences Scale (ASEX) score was 15.32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41, and the mean SF-12 (quality of life) score was 36.57\u0026thinsp;\u0026plusmn;\u0026thinsp;9.63. According to ASEX criteria, 69.0% of participants met the threshold for sexual dysfunction, while 31.0% did not \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive Statistics of Clinical Scales (SD: Standard Deviation).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale / Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-Short Form-12 (Quality of Life)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36.57\u0026thinsp;\u0026plusmn;\u0026thinsp;9.63\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-Arizona Sexual Experiences Scale (ASEX)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.32\u0026thinsp;\u0026plusmn;\u0026thinsp;7.41\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSexual Dysfunction Status According to ASEX\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003en (%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-No sexual dysfunction\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e156 (31.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e-Sexual dysfunction present\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e348 (69.0%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eSexual Dysfunction by MS Subtype\u003c/h2\u003e \u003cp\u003eNo statistically significant difference in ASEX scores was found among different MS subtypes (p\u0026thinsp;=\u0026thinsp;0.094), although SPMS patients had numerically higher scores. However, a significant difference in SF-12 quality of life scores was observed (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with SPMS patients having the lowest scores compared to CIS, PPMS, and RRMS patients \u003cb\u003e(\u003c/b\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e\u003cb\u003e).\u003c/b\u003e\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe Relationship Between MS Types and Scores on the Arizona Sexual Experiences (ASEX) and Quality of Life Scale (Short Form-12) F: One-way ANOVA test. CIS: Clinically Isolated Syndrome, PPMS: Primary Progressive MS, RRMS: Relapsing-Remitting MS, SPMS : Secondary Progressive MS.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eScale / Measure\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCIS (n\u0026thinsp;=\u0026thinsp;5)a\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePPMS (n\u0026thinsp;=\u0026thinsp;22)b\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eRRMS (n\u0026thinsp;=\u0026thinsp;397)c\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSPMS (n\u0026thinsp;=\u0026thinsp;80)d\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eTest Value / p\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eASEX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e10.00\u0026thinsp;\u0026plusmn;\u0026thinsp;2.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e13.86\u0026thinsp;\u0026plusmn;\u0026thinsp;6.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e15.18\u0026thinsp;\u0026plusmn;\u0026thinsp;7.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e16.71\u0026thinsp;\u0026plusmn;\u0026thinsp;7.75\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.144 / 0.094F\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSF-12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e44.40\u0026thinsp;\u0026plusmn;\u0026thinsp;4.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c3\"\u003e \u003cp\u003e37.18\u0026thinsp;\u0026plusmn;\u0026thinsp;8.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c4\"\u003e \u003cp\u003e37.86\u0026thinsp;\u0026plusmn;\u0026thinsp;9.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c5\"\u003e \u003cp\u003e29.54\u0026thinsp;\u0026plusmn;\u0026thinsp;8.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e19.700 / \u0026lt;0.001F (d\u0026thinsp;\u0026lt;\u0026thinsp;a,b,c)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eFactors Associated with Sexual Dysfunction\u003c/h2\u003e \u003cp\u003eAs shown in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e, sexual dysfunction was significantly associated with gender (higher prevalence in females; p\u0026thinsp;=\u0026thinsp;0.001), older age (p\u0026thinsp;=\u0026thinsp;0.006), and higher EDSS scores (p\u0026thinsp;=\u0026thinsp;0.046). There were no significant associations with disease duration, MS subtype, or medication use.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationship Between Sexual Dysfunction and Descriptive Characteristics. χ\u0026sup2;: Chi-square test, t: Independent samples t-test\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo Sexual Dysfunction (n\u0026thinsp;=\u0026thinsp;156)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSexual Dysfunction Present (n\u0026thinsp;=\u0026thinsp;348)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTest Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender (Male %)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e64 (42.4%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e87 (57.6%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e13.183\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.001^χ\u0026sup2;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36.34\u0026thinsp;\u0026plusmn;\u0026thinsp;9.55 (20\u0026ndash;70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.94\u0026thinsp;\u0026plusmn;\u0026thinsp;9.97 (18\u0026ndash;66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.746\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.006^t\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEDSS (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD, Range)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.76 (0\u0026ndash;7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.58\u0026thinsp;\u0026plusmn;\u0026thinsp;1.70 (0\u0026ndash;8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e2.003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.046^t\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eSD: Standard Deviation\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eQuality of Life and Sexual Dysfunction\u003c/h2\u003e \u003cp\u003eParticipants with sexual dysfunction had significantly lower SF-12 scores compared to those without (34.71\u0026thinsp;\u0026plusmn;\u0026thinsp;8.92 vs. 40.72\u0026thinsp;\u0026plusmn;\u0026thinsp;9.88; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as shown in Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRelationship Between Quality of Life (SF-12) and Sexual Dysfunction\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\"\u0026plusmn;\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSexual Dysfunction\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eQuality of Life (Mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTest Value\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e40.72\u0026thinsp;\u0026plusmn;\u0026thinsp;9.88\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e-6.766\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001^t\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\"\u0026plusmn;\" colname=\"c2\"\u003e \u003cp\u003e34.71\u0026thinsp;\u0026plusmn;\u0026thinsp;8.92\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003et: Independent samples t-test\u003c/p\u003e \u003cp\u003eSD: Standard Deviation\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eCorrelation Analysis\u003c/h2\u003e \u003cp\u003eFigure \u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e displays correlation analyses. ASEX scores showed a moderate negative correlation with SF-12 scores (r = \u0026minus;\u0026thinsp;0.35), a moderate positive correlation with BDI scores (r\u0026thinsp;=\u0026thinsp;0.38), and a low positive correlation with age (r\u0026thinsp;=\u0026thinsp;0.19). The correlation between ASEX and EDSS was weak and not statistically significant (r\u0026thinsp;=\u0026thinsp;0.07).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the subgroup of participants with sexual dysfunction \u003cb\u003e(\u003c/b\u003eFig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e\u003cb\u003e)\u003c/b\u003e, correlations were similar: a negative correlation with SF-12 (r = \u0026minus;\u0026thinsp;0.31), positive with BDI (r\u0026thinsp;=\u0026thinsp;0.27), and age (r\u0026thinsp;=\u0026thinsp;0.20); again, the relationship with EDSS remained weak and nonsignificant (r\u0026thinsp;=\u0026thinsp;0.12).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eHelp-Seeking Behavior\u003c/h2\u003e \u003cp\u003e A brief survey was conducted among participants identified as having sexual dysfunction. Of the 71 who responded, only 9.8% reported consulting a physician, and 7.0% sought psychological support. The majority (83.1%) did not seek any assistance. Among those who did not seek help, 33.9% cited embarrassment or fear of discussing the issue, while the rest believed it was a natural symptom of MS that did not require treatment.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eSexual dysfunction (SD) is a significant but often underrecognized burden among people with multiple sclerosis (pwMS). Due to the intimate nature of the topic and social stigma, both patients and clinicians may avoid addressing these symptoms in routine clinical care. Previous studies report a wide range of prevalence, from 50\u0026ndash;90% in men and 40\u0026ndash;80% in women [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. In our study, SD was identified in 57.6% of male participants, 73.9% of females, and 69% of the total cohort, findings that are consistent with existing literature [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough we did not analyze SD subtypes separately, previous studies indicate that decreased libido is the most commonly reported complaint across both sexes, with a prevalence as high as 80.5% [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], while erectile dysfunction is the most frequent symptom in men [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e]. SD in MS is typically categorized into three domains: primary (direct neurological involvement), secondary (indirect effects of MS symptoms such as fatigue or spasticity), and tertiary (psychosocial and emotional consequences) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Due to the screening nature of our study, we did not differentiate between these categories.\u003c/p\u003e \u003cp\u003eOur findings support a significant association between age and SD, confirming our first hypothesis. While some previous studies have reported similar age-related increases in SD [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], others have found no such association [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eNo statistically significant relationship was found between disease duration and the presence of SD, consistent with earlier studies showing mixed or inconclusive results [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Thus, our second hypothesis was not supported.\u003c/p\u003e \u003cp\u003eDespite the commonly held view that SD becomes more prominent in progressive MS types, our data showed no significant difference in SD prevalence across MS subtypes. Therefore, our third hypothesis was also not confirmed. However, patients with SPMS did have significantly lower quality of life scores, which may suggest cumulative burden even in the absence of increased SD frequency.\u003c/p\u003e \u003cp\u003eEDSS score, a measure of disability in MS, was significantly associated with the presence of SD, validating our fourth hypothesis. This finding aligns with previous studies highlighting EDSS as a robust predictor of sexual impairment in pwMS [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAlthough disease-modifying therapies (DMTs) have been proposed to influence sexual functioning, largely due to their role in controlling disease activity and progression [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e], our study did not find any significant association between DMT type and SD. This may be due to a complex interplay of biological, psychological, and social variables rather than direct drug effects.\u003c/p\u003e \u003cp\u003eDepression, a common comorbidity in MS, is well established as a contributor to SD in both clinical and non-clinical populations [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. In our sample, higher ASEX scores were positively correlated with BDI scores, reinforcing the close link between emotional health and sexual well-being.\u003c/p\u003e \u003cp\u003eOur results further confirm that sexual dysfunction is associated with decreased quality of life in pwMS, supporting our fifth hypothesis. Although SF-12 scores were lower in patients with SPMS, ASEX scores did not differ significantly between MS subtypes. This suggests that sexual health may impact QoL independently of MS disease type [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eImportantly, we investigated help-seeking behaviors related to SD, a topic rarely addressed in existing literature. Among patients reporting SD, only a minority sought medical or psychological support, while the vast majority did not disclose their symptoms. Reasons included embarrassment, fear of stigmatization, or perceiving SD as a normal part of the disease experience.\u003c/p\u003e \u003cp\u003eOur findings are in line with a recent study by Dehghaniathar et al. (2025), which also reported a high prevalence of SD in pwMS and its detrimental impact on QoL. However, that study was limited by a smaller sample size and did not assess help-seeking behaviors or perform multivariate risk analysis. In contrast, our study offers a more comprehensive assessment of associated factors and highlights the need for proactive clinical screening [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eGiven its high prevalence and significant psychosocial impact, SD should be systematically screened in routine outpatient evaluations of pwMS. Early identification of at-risk individuals may facilitate timely referral for sexual health counseling, psychological support, and multidisciplinary rehabilitation. Even brief conversations about sexual health have been shown to positively impact patient well-being [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Ultimately, management of SD in MS should involve collaborative care between neurology, urology, and mental health professionals [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e].\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eSexual dysfunction is highly prevalent among people with multiple sclerosis, particularly in individuals of older age, with greater disability (higher EDSS scores), and elevated depressive symptoms. Despite affecting patients during their sexually active years, SD often remains unreported unless specifically queried during clinical visits. These findings underscore the need for increased clinical awareness and systematic screening.\u003c/p\u003e \u003cp\u003eUnderstanding the prevalence and multidimensional nature of SD\u0026mdash;including its physical, emotional, and psychosocial components\u0026mdash;can facilitate targeted interventions. Comprehensive assessment strategies and larger multicenter studies are warranted to further delineate subtypes and predictors. Ultimately, the management of SD in MS should be approached through a multidisciplinary lens, incorporating neurologists, urologists, psychologists, and rehabilitation professionals to deliver holistic care.\u003c/p\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThis study has several limitations. First, it lacked a control group from the general population, preventing direct comparison of SD prevalence between MS patients and healthy individuals. Second, fatigue\u0026mdash;an MS symptom known to contribute significantly to sexual dysfunction\u0026mdash;was not evaluated. Third, the study focused on the presence and frequency of SD but did not distinguish between primary, secondary, and tertiary subtypes. Addressing these limitations in future research will help refine clinical screening tools and intervention strategies.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and Consent to Participate\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The study was approved by the Ethics Committee of the University of Health Sciences, Sancaktepe Prof. Dr. İlhan Varank Training and Research Hospital (Approval No: 2023/242, Date: 19.12.2023)\u0026nbsp;and was conducted in accordance with the Declaration of Helsinki. Written informed consent was obtained from all participants prior to their inclusion in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; Contributions\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;\u0026Ouml;T conceptualized and supervised the study. \u0026Ouml;T, MT, FY, HCG, İGD and D\u0026Ccedil;T contributed to data collection. \u0026Ouml;T, G\u0026Ccedil;E conducted statistical analyses.\u0026nbsp;\u0026Ouml;T contributed to literature review and manuscript drafting. ŞŞ and SD critically revised the manuscript for intellectual content. All authors read and approved the final version of the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting Interests\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of Data and Materials\u003c/strong\u003e\u003cbr\u003e\u0026nbsp;The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBar-Or A, Oliveira EM, Anderson DE, Hafler DA. 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Beck Depresyon Envanteri\u0026apos;nin ge\u0026ccedil;erliği \u0026uuml;zerine bir \u0026ccedil;alışma. \u003cem\u003ePsikoloji Dergisi\u003c/em\u003e. 1988;6(22):118\u0026ndash;22.\u003c/li\u003e\n \u003cli\u003eWare JE Jr, Sherbourne CD. The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection. \u003cem\u003eMed Care\u003c/em\u003e. 1992;30(6):473\u0026ndash;83.\u003c/li\u003e\n \u003cli\u003eKo\u0026ccedil;yiğit H, Aydemir \u0026Ouml;, Fişek G, \u0026Ouml;lmez N, Memiş A. Kısa Form-36 (KF-36)\u0026apos;nın T\u0026uuml;rk\u0026ccedil;e versiyonunun g\u0026uuml;venilirliği ve ge\u0026ccedil;erliliği. \u003cem\u003eİla\u0026ccedil; ve Tedavi Dergisi\u003c/em\u003e. 1999;12:102\u0026ndash;6.\u003c/li\u003e\n \u003cli\u003eGroeneveld RA, Meeden G. Measuring skewness and kurtosis. \u003cem\u003eStatistician\u003c/em\u003e. 1984;33(4):391\u0026ndash;9. doi:10.2307/2987742.\u003c/li\u003e\n \u003cli\u003eKassambara A. \u003cem\u003eggcorrplot: Visualization of a Correlation Matrix using ggplot2\u003c/em\u003e. R package version 0.1.0. https://CRAN.R-project.org/package=ggcorrplot. Accessed 5 June 2025.\u003c/li\u003e\n \u003cli\u003eR Core Team. \u003cem\u003eR: A language and environment for statistical computing\u003c/em\u003e. Vienna: R Foundation for Statistical Computing; 2024. https://www.R-project.org/. Accessed 5 June 2025.\u003c/li\u003e\n \u003cli\u003eIBM Corp. \u003cem\u003eIBM SPSS Statistics for Windows, Version 27.0\u003c/em\u003e. Armonk, NY: IBM Corp; 2020.\u003c/li\u003e\n \u003cli\u003eKessler TM, Fowler CJ, Panicker JN. 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Sexual disorders in women with MS: assessment and management. \u003cem\u003eAnn Phys Rehabil Med\u003c/em\u003e. 2014;57(5):337\u0026ndash;47. doi:10.1016/j.rehab.2014.05.008.\u003c/li\u003e\n \u003cli\u003eCelik DB, Poyraz E\u0026Ccedil;, Bing\u0026ouml;l A, Idiman E, Ozakbaş S, Kaya D. Sexual dysfunction in multiple sclerosis: gender differences. \u003cem\u003eJ Neurol Sci\u003c/em\u003e. 2013;324(1-2):17\u0026ndash;20. doi:10.1016/j.jns.2012.08.019.\u003c/li\u003e\n \u003cli\u003eWinder K, Linker RA, Seifert F, et al. Insular multiple sclerosis lesions are associated with erectile dysfunction. \u003cem\u003eJ Neurol\u003c/em\u003e. 2018;265(4):783\u0026ndash;92. doi:10.1007/s00415-018-8763-5.\u003c/li\u003e\n \u003cli\u003eAltmann P, Leutmezer F, Leithner K, et al. Predisposing factors for sexual dysfunction in multiple sclerosis. \u003cem\u003eFront Neurol\u003c/em\u003e. 2021;12:618370. doi:10.3389/fneur.2021.618370.\u003c/li\u003e\n \u003cli\u003eBalsamo R, Arcaniolo D, Stizzo M, et al. Increased risk of erectile dysfunction in men with multiple sclerosis: an Italian cross-sectional study. \u003cem\u003eCent European J Urol\u003c/em\u003e. 2017;70(3):289\u0026ndash;95. doi:10.5173/ceju.2017.1380.\u003c/li\u003e\n \u003cli\u003ePauli F, Zinganell A, B\u0026ouml;ttcher B, et al. Sexual dysfunction in female and male people with multiple sclerosis: disability, depression and hormonal status matter. \u003cem\u003eEur J Neurol\u003c/em\u003e. 2023;30(4):991\u0026ndash;1000. doi:10.1111/ene.15696.\u003c/li\u003e\n \u003cli\u003eKim D, Leurer C, So B, et al. Sexual dysfunction in multiple sclerosis: a systematic review and meta-analysis of prevalence. \u003cem\u003eNeurology\u003c/em\u003e. 2019;92(15 Supplement):P5.2-089.\u003c/li\u003e\n \u003cli\u003eAfshar B, Amini L, Nabavi S, et al. What effects can expressive writing have on sexual dysfunction in women with multiple sclerosis? A randomized controlled trial. \u003cem\u003eActa Neurol Scand\u003c/em\u003e. 2023. doi:10.1155/2023/6754178.\u003c/li\u003e\n \u003cli\u003eHulter BM, Lundberg PO. Sexual function in women with advanced multiple sclerosis. \u003cem\u003eJ Neurol Neurosurg Psychiatry\u003c/em\u003e. 1995;59(1):83\u0026ndash;6. doi:10.1136/jnnp.59.1.83.\u003c/li\u003e\n \u003cli\u003eSchairer L, Foley F, Zemon V, et al. The impact of sexual dysfunction on health-related quality of life in people with multiple sclerosis. \u003cem\u003eMult Scler J\u003c/em\u003e. 2014;20(5):610\u0026ndash;6. doi:10.1177/1352458513503598.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Multiple sclerosis, Sexual dysfunction, Quality of life, Depression, Help-seeking behavior, Expanded Disability Status Scale, Arizona Sexual Experience Scale","lastPublishedDoi":"10.21203/rs.3.rs-6835200/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6835200/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eSexual dysfunction (SD) is a prevalent but underreported symptom in people with multiple sclerosis (pwMS), significantly affecting quality of life (QoL). Despite its clinical relevance, SD is often overlooked during routine care. This study aimed to determine the prevalence of SD, identify associated risk factors, assess its impact on depression and QoL, and explore help-seeking behaviors among pwMS.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eA cross-sectional study was conducted with 504 pwMS followed at a tertiary MS clinic between November 2023 and May 2024. Data on demographics, disease characteristics, and medications were collected. The Arizona Sexual Experiences Scale (ASEX) was used to assess SD, the Beck Depression Inventory (BDI) for depression, and the Short Form-12 (SF-12) for QoL. EDSS scores were used to evaluate disability. Statistical analyses included t-tests, ANOVA, chi-square, and correlation analyses, with significance set at p \u0026lt; 0.05.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eSD was identified in 69.0% of patients (73.9% of women, 57.6% of men). SD was significantly associated with female gender (p = 0.001), older age (p = 0.006), higher EDSS scores (p = 0.046), and increased depression levels (r = 0.38). SF-12 scores were significantly lower among those with SD (p \u0026lt; 0.001). No significant associations were found between SD and MS type, disease duration, or type of disease-modifying therapy. Only 16.9% of patients with SD reported seeking medical or psychological support.\u003c/p\u003e\n\u003cp\u003eConclusion\u003c/p\u003e\n\u003cp\u003eSD is highly prevalent among pwMS and is closely linked to age, disability, depression, and reduced QoL. Despite this burden, most patients do not seek help. We recommend routine screening and multidisciplinary management approaches are essential for addressing SD in this population.\u003c/p\u003e","manuscriptTitle":"Sexual Dysfunction in Multiple Sclerosis: Prevalence, Risk Factors, and Impact on Quality of Life in a Large Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-06-23 06:33:49","doi":"10.21203/rs.3.rs-6835200/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-08-21T12:31:37+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-16T09:47:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"90760954571700442196735844312192405367","date":"2025-07-29T13:51:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"44766760910980884425754138573908217747","date":"2025-07-28T19:35:31+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-09T00:30:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"56539268763963191201589147422396833880","date":"2025-06-21T23:41:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"27408154902478502986100936269859728948","date":"2025-06-16T15:09:13+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-16T06:51:18+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-06-12T12:59:18+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-06-11T03:21:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-06-11T03:18:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Neurology","date":"2025-06-06T08:24:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-neurology","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"nurl","sideBox":"Learn more about [BMC Neurology](http://bmcneurol.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/nurl","title":"BMC Neurology","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f2df9698-bd4a-4483-a535-a69f202ce00d","owner":[],"postedDate":"June 23rd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-11-17T16:05:13+00:00","versionOfRecord":{"articleIdentity":"rs-6835200","link":"https://doi.org/10.1186/s12883-025-04492-y","journal":{"identity":"bmc-neurology","isVorOnly":false,"title":"BMC Neurology"},"publishedOn":"2025-11-14 15:57:59","publishedOnDateReadable":"November 14th, 2025"},"versionCreatedAt":"2025-06-23 06:33:49","video":"","vorDoi":"10.1186/s12883-025-04492-y","vorDoiUrl":"https://doi.org/10.1186/s12883-025-04492-y","workflowStages":[]},"version":"v1","identity":"rs-6835200","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6835200","identity":"rs-6835200","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}