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by Stanley Ducharme, Ph.D.

Reprinted from: The Rehabilitation of People With Spinal Cord Injury, Second Edition, Blackwell Science Publishers, Boston, 2000

With longer life expectancies following SCI, the emphasis in rehabilitation over the past decade has gradually shifted to improved quality of life. Toward this goal, issues related to sexuality must be addressed by the rehabilitation team in both the acute and chronic stages of SCI. Providing sexual education to patients and their partners is best accomplished by an interdisciplinary team approach in which medical and psychological issues can be addressed.

Erectile and ejaculatory function are complex physiological activities that require the interaction between the vascular, nervous and endocrine systems. Erections are controlled by the parasympathetic nervous system.

In the simplest of terms, erection is controlled by a reflex arc that is mediated in the sacral spinal cord. A reflex involves an afferent and efferent limb. The afferent limb consists of somatic afferent fibers from the genital region that travel through the pudental nerve into the sacral spinal cord. These fibers travel through the cauda equina and exit via the S2 to S4 nerve roots. The post-ganglionic parasympathetic fibers secrete nitric oxide, which causes relaxation of the smooth muscle of the corpus cavernosum and increases blood flow to the penile arteries. Consequently, the vascular sinusoids of the penis become engorged with blood and the result is an erection. This reflex is modulated by higher brainstem, subcortical and cortical centers. In addition, erectile function is influenced by hormonal factors such as testosterone.

Ejaculation signals the culmination of the male sexual act and is primarily controlled by the sympathetic nervous system. Similar to the sympathetic innervation of the bladder, these fibers originate in the thoraco-lumbar spinal cord and travel into the sympathetic chain. These fascicles then travel through the splanchnic nerves into the hypogastric plexus. After synapsing in the inferior mesentericganglion, postganglionic fibers travel through the hypogastric nerves to supply the vas deferens, seminal vesicles and ejaculatory ducts in the prostate.

The physiology of the female sexual act has not been studied as well as the male sexual act. However, female sexual satisfaction is dependent on a complex interaction of the endocrine and nervous systems. Sexual excitation is the result of psychogenic and physical stimulation. This arousal is manifested by vaginal lubrication and tightening of the interoitus. Stimulation of the genital region including the clitoris, labia majora and labia minora causes afferent signals to travel via the pudendal nerve into the S2 to S4 segments of the spinal cord. These fibers interact with efferent parasympathetic fibers that project through the pelvic nerve. The result is dilation of arteries to perineal muscles and tightening of the interoitus. In addition, the parasympathetic fibers cause the Bartolin’s glands to secrete mucus, which aids in vaginal lubrication.

Female orgasm is characterized by the rhythmic contraction of the pelvic structures. Female orgasm also results in cervical dilation, which may aid in sperm transport and fertility.

A simplified sexual history should be part of the initial clinical assessment. Key elements include physical capabilities, past sexual activities and current sexual function. In addition, the clinician should inquire into the partner’s availability, partner satisfaction, sexual orientation, behavioral repertoire and past sexual abuse. Open ended questions will facilitate better communication. Topics of a more sensitive nature should be reserved for later in the interview when a therapeutic relationship has been established.

Adaptation to an SCI is a gradual process that extends over a prolonged period of time. Successful sexual adjustment is influenced by many factors such as age at time of injury, quality of social supports, physical health, gender and severity of the injury. Losses need to be mourned so that the remaining strengths can be nurtured and developed. To achieve satisfying sexual adjustment, a person with an SCI will have to learn their new sexual abilities, as opposed to recapturing the past.

After a traumatic injury, individuals typically go through a period of reduced sexual drive. Although libido is not affected by SCI, it may be diminished by depression, trauma of the injury or medications. Initially after injury, some persons with SCI may deny the importance of sexual issues. Other individuals may be reluctant to discuss issues related to sexuality due to cultural or personal reasons. Other patients may go through a period of sexual “acting out” (i.e., unacceptable sexually explicit language, inappropriate unwanted physical contact with staff, etc.) while on the rehabilitation unit.

During the acute rehabilitation phase, a sensitive discussion regarding sexuality is appropriate. The person with SCI may inquire about issues such as dating, attractiveness, relationships, parenthood and physical appearance. Other topics of interest may include erections, lubrications, sensation, orgasm, ejaculation and fertility. Many individuals will inquire about sexuality as it related to bladder and b function. Even if the patient does not initiate discussions about these topics, it is important for members of the rehabilitation team to provide basic information.

Men and women with SCI often lack sensation at traditional erogenous areas such as the genitals and nip. As such stimulating these areas may result in penile erections or vaginal lubrication but not necessarily sexual pleasure. However, other areas, sometimes not normally recognized as erogenous areas, such as the ears, eyelids and neck, can be stimulated to provide sexual arousal. Some individuals find the skin surface around the neurological level to have heightened tactile sexual response.

Men with SCI may obtain reflexogenic or psychogenic erections. Reflex erections are secondary to manual stimulation of the genital region. Psychogenic erections are the result of erotic stimuli that result in cortical modulation of the sacral reflex arc. In general, erections are more likely with incomplete injuries (both upper and lower motor neuron), than complete injuries. Many times, men with SCI can only maintain an erection while the penis is stimulated and the quality of the erection is insufficient for sexual satisfaction. As such, the erection must be augmented with devices, medications or a penile implant for satisfactory sexual function.

In men with SCI, the ability to ejaculate is less common than the ability to obtain an erection. The rate of ejaculation varies depending on the nature and location of the neurological injury. In complete upper motor neuron lesions, the ejaculation rate is estimated at 2 percent. In incomplete upper motor neuron lesions, the ejaculation rate is estimated to be somewhat higher at 32%. Many men who are able to ejaculate experience retrograde ejaculation into the bladder, some may experience dribbling of semen.

The experience of orgasm in men with SCI is variable. Some individuals describe a primarily emotional event. Others experience generalized muscle relaxation or a pleasant sensation in the pelvis or at the sensory level. Other men report orgasm to be non-existent following the injury.

Sildenafil (Viagra) was approved by the FDA in 1998, and may have a significant role in the treatment of erectile dysfunction for men with SCI. Sildenafil is a type 5 phosphodiesterase inhibitor that prevents the intracorporal breakdown of cyclic GNP. It is rapidly absorbed after oral administration and is taken approximately 60 minutes before anticipated sexual activity. It is most effective for men who are capable of achieving reflex erections. It can assist the man in gaining further rigidity and in sustaining the erection for penetration. Sildenafil is contraindicated in men taking nitrates due to the risk of profound hypotension. Many men with SCI have low baseline blood pressure and this agent should be prescribed with caution. In addition, this drug is not recommended for those individuals with cardiac disease. Side effects noted in this otherwise well population include facial flushing, dyspepsia, headache and visual disturbances.

Intracavernosal Injection Therapy

Therapy with intracavernosal injection of papaverine, alprostadil and phenotolamine is an accepted treatment of erectile dysfunction. Initiating this therapy necessitates a referral to a urologist. Initially, individuals are given small doses of the pharmacological agent and the dose is increased until a satisfactory erection is obtained for intercourse. Sometimes, a mixture of agents is prescribed. Erections should not persist beyond four hours. Many tetraplegics have impaired hand function and will require a cooperative partner to perform the injection. In some cases a commercially marketed penile autoinjector can be easier to manipulate. Priapism is a possibility; therefore, both partners should be properly trained. Some individuals with incomplete injuries may experience pain at the injection site.Penile fibrosis is also a potential risk of intracavernosal therapy.

Recently, transurethral delivery systems for administering agents that result in erections have been approved. The medication delivered is usually alprostadil. This treatment is generally not as effective as intracavernosal therapy. Many men are not satisfied with the rigidity of the erections obtained.

These devises create a vacuum around the penis. As a result, blood isdrawn into the corporal spaces. A band is then slipped off the plasitic cylinder around the base of the penis to maintain penile tumescence. Ejaculation may be retarded due to the constriction of the urethrea. However, newer models are available with constricting bands that are less likely to diminish ejaculation.

Vacuum devices are non-invasive, economical and efficacious. Howver, these devices require some degree of manual dexterity. For many men with tetraplegia, the partner must be willing to assist with the procedure. In addition, men must transfer out of the wheelchair and be in a recumbent position to obtain a good vacuum seal at the base of the penis. Individuals with incomplete injuries may experience pain, discoloration and coldness at the base of the penis. Constriction rings should not remain in placefor more than 30 minutes. Longer time periods may be associated with potential skin breakdown. Vacuum devises are more accepted by men in more established sexual relationships. Some men use vacuum devices to augment erections obtained with oral medications. Vacuum devises are commonly used in underdeveloped nations where phramacotherapy is unavailable or not affordable.

Penile implants are considered when other treatments have been unsuccessful, especially if trauma has disrupted the penile vascular system. It also may be indicated is severe Peyronie’s disease is a factor. Implants are not considered in the first year post injury so that persons with SCI can make emotional adaptations to the injury and explore less invasive options for sexual activity. There are a number of different devises, ranging from the simple malleable prosthesis to more complex hydraulic prostheses. Generally, the choice of prosthesis is related to individual preference and financial constraints.

The ability to father a child correlates with the frequency of ejaculation. Successful pregnancy rates range from 10 percent to 35 percent. In general, men with incomplete lesions (both upper and lower motor neuron) are more likely to become fathers than those with complete lesions. Conditions that may contribute to infertility include retrograde ejaculation, repeated urinary tract infections and altered testicular temperature. Newer methods of obtaining semen samples include rectal electroejaculation or penile vibroejaculation. Both of these techniques may precipitate autonomic dysreflexia.

Most women with SCI can achieve some level of vaginal lubrication. This lubrication can be mediated by reflexogenic or psychogenic factors. Individuals with incomplete (both upper and lower motor neuron) injures are more likely to have satisfactory lubrication. If vaginal lubrication is unsatisfactory, then a water soluble lubricant can be recommended. Sildenafil may be of value in women with SCI by increasing blood flow to the perineum and increasing vaginal lubrication. , which may improve sexual satisfaction. However, there are no controlled studies on the female SCI population.

Immediately after injury, 44 percent to 58 percent of women suffer from temporary amennorhea. Menstruation usually returns within 6 months post injury. Neither the level nor the completeness of the injury appear to be associated with the interruption of menstrual cycles. In a small percentages of women with SCI, there are also changes in cycle length, duration of flow, amount of flow and amount of menstrual pain. Most women with SCI are fertile.

The issue of birth control can be somewhat problematic for women with SCI. Condoms provide contraception as well as diminish the risk of transmission of sexually transmitted diseases. A diaphragm may be another acceptable option if the individual has adequate hand dexterity or a cooperative partner. Oral contraception is associated with increased incidence of thromboembolism and must be prescribed with caution in women with SCI. Oral contraceptives that contain only progesterone may be safer than medications that contain both estrogen and progesterone. IUD may be associated with increased incidence of pelvic inflammatory disease . Untreated PID may lead to autonomic dysreflexia. In addition, women with SCI may not be able to perceive if the devise has migrated out of the cervix.

Pregnant women with SCI have an increased risk of urinary tract infections, leg edema, autonomic dysreflexia, constipation, thromboembolism and pre-mature birth. Since uterine innervation arises from the T10 to T12 levels, patients with lesions above T10 may not be able to perceive uterine contractions or fetal movements. It may be difficult to differentiate between pregnancy induced hypertension (pre-eclampsia) and autonomic dysreflexia. Autonomic dysreflexia may be the only clinical manifestation of labor. During the second and third trimester, pregnant women may have difficulty in performing functional tasks that were previously completed independently. Transfers may require the assistance of a caregiver and a power wheelchair may be necessary for mobility. Locating an obstetrician and anesthesiologist with a supportive attitude, an accessible office and experience in SCI can be difficult in many areas.

Urinary and fetal incontinence at inopportune times and subsequent social rejection are major fears of some people with SCI. A bladder or bowel accident may occur at any time during courtship, sexual activity or during social events. The embarrassment, shame and humiliation associated with incontinence create undue anxiety and are often regarded as a major reason for social isolation or the termination of a relationship.

To minimize untimely episodes of incontinence, the bladder should be emptied prior to sexual activity. Foley catheters, if present, can be taped to the side of the penis with a condom placed over the catheter. Females can engage in sexual intercourse despite the presence of a Foley catheter by taping the catheter to the abdomen. Despite the best management program, sexual stimulation can cause urinary and or fecal incontinence . Embarrassing passage of gas from the vagina, bowel or ostomy bag can be avoided by gentle thrusting, coital positioning and a careful diet. Fluids should be limited during the hours preceding sexual activity. Towels should be available to manage episodes of urinary or fecal incontinence.

Sexual adaptation after an SCI is a gradual process that involves psychological and physical adjustments. The availability of new medications, devices and procedures have greatly enhanced the possibility of having a satisfactory sexual life after an SCI. Toward this end, the rehabilitation team has a responsibility to provide sexual information and counseling during the acute and chronic stages of SCI.

Boller, P. and Frank, E. Sexual Dysfunction in Neurologic Disorders, New York, Raven Press; 1982.

Ducharme, S. and Gill, K. Sexuality After Spinal Cord Injury, Baltimore, MD, Paul Brooks Publishing Company; 1997.

Leyson, J. Sexual Rehabilitation of the Spinal Cord Injured Patient. Clinton, NJ; Humana Press, 1991.

Sipski, M. and Alexander, C. Sexual Function In People With Disability and Chronic Illness. Gaithersburg, MD; Aspen Publications; 1997.

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