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The World Health Organization defines sexuality as “a central aspect of being human throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy and reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors, practices, roles and relationships. While sexuality can include all of these dimensions, not all of them are always experienced or expressed. Sexuality is influenced by the interaction of biological, psychological, social, economic, political, cultural, ethical, legal, historical, religious and spiritual factors.1


Insult to the spinal cord or cauda equina can result in injury to the motor, sensory and autonomic pathways underlying sexual and reproductive function.The effect of a SCI on sexual function and health depends on the level and severity of spinal cord injury, as well as personal attributes such as partnership status, pre-morbid sexual experiences and attitudes, and openness to sexual experimentation.  The level and completeness of spinal cord injury are major determinants of sexual functioning.  Impairments after spinal cord injury (SCI) may include the following:

  • Impairment in libido.
  • Alteration or absent genital orgasm.
  • Impaired psychogenic, but preserved reflexogenic genital engorgement/ lubrication after upper motor neuron (UMN) injury rostral to the T11-L2 spinal segments 
  • Preserved psychogenic and reflexogenic genital engorgement/ lubrication after UMN injury caudal to the T11-L2 segments with sparing of the S2-5 segments
  • Impaired/ absent reflexogenic and psychogenic genital engorgement/ lubrication after lower motor neuron (LMN) injuries affecting the S2-4 cell bodies or nerve roots Inability to ejaculate via intercourse or masturbation for men 


The autonomic nervous system provides significant innervation to the genital organs and is essential to the sexual response.  Simplistically stated, parasympathetic activity is thought to be responsible for achieving sexual arousal, causing genital vasocongestion, erection as well as lubrication, while ejaculation in males is thought to be mediated by the sympathetic nervous system.  However, the interaction of these two systems is quite complex, and poorly understood.2 To understand the impact of cord injury on sexual function, pertinent anatomy will be reviewed.3

  • The sympathetic preganglionic neurons originate from the thoracolumbar segments T11 to L2 in the spinal cord 
  • Sympathetic stimulation causes smooth muscle contraction, reduced arterial blood flow, and flaccidity. However, the sympathetic nervous system can subserve a pro-erectile function, as evidenced by the presence of psychogenic arousal and erection that are “unmasked” following spinal injury.
  • Sexual thoughts can activate theses pathways when connection to the S2-S4 center is disrupted due to a spinal cord injury (termed psychogenic arousal).4 
  • Sympathetic activation is necessary for emission of semen and bladder neck (internal sphincter) closure, which prevents retrograde ejaculation.
  • Parasympathetic nerve fibers originate from the S2-S4 sacral spinal segments and provide innervation to genital erectile tissue resulting in genital (penile and clitoral) vasocongestion (erections) and lubrication.  
  • The parasympathetic nerves release pro-erectile neurotransmitters, the most important being nitric oxide.   
  • Somatic fibers carry sensation from the genitalia of both sexes via the Pudendal Nerve (S2-S4). 
  • Afferent sensory impulses travel from the genital end organs to the somatic sensory cortex.
  • The efferent output causes rhythmic contractions of the bulbocavernosus and ischiocavernosus muscles, which propulses the ejaculate along the urethra in males and mediates pelvic floor contractions in both males and females during orgasm. 
  • At the spinal cord level, the sensory afferents synapse with, and increase activity of parasympathetic nerves, causing reflexive penile and clitoral vasocongestion. Normally this reflex is modulated by tonic inhibitory supraspinal influences. After a spinal cord injury rostral to the S2-S4 segments, this reflex can be triggered by genital stimulation evoking penile and clitoral erections and genital lubrication

Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time) 

Immediately after a spinal cord injury, all reflexes are lost, including sexual reflexes (reflex erections and lubrication). As spinal shock resolves, these reflexes return and can be utilized to augment sexual activity. Once reflexes return, reflexive arousal in men and women (erection in men and vaginal lubrication in women) can be achieved with genital stimulation if the spinal cord injury is rostral to the sacral segments with preservation of the sacral spinal segments and cauda equina. 93% of persons with complete UMN injuries regain reflexogenic erections.

Psychogenic arousal (erections of genitalia and lubrication) can be evoked by erotic thoughts and stimuli, independent of genital stimulation. Psychogenic arousal is thought to be responsible for maintaining erection during sexual intercourse. It occurs with lesions caudal to the thoracolumbar (T10L2) spinal segments and is often lost with injuries to the thoracic and cervical spinal cord).  

Individuals with complete LMN injuries involving either the conus medullaris, or the exiting nerve roots (cauda equina) experience loss or reflexive arousal. Erectile dysfunction in this group of males is less likely to respond to penile vibratory stimulation and generally more difficult to treat.5

Essentials of Assessment


History should include:

  • Medical comorbidities (e.g., diabetes mellitus, hypertension, cardiovascular disease, alcohol/drug use, and impairments in vision or hearing)
  • Sexually transmitted diseases, sexual traumas, and prior sexual dysfunctions.
  • Mental health problems (mood disorders, anxiety, etc.)
  • Medications, especially antispasticity medications, alpha adrenergic antagonists, nitrates, antidepressants and glucocorticoids.
  • History and severity of Autonomic Dysreflexia and triggers.6
  • Pre- and post-SCI sexual experiences, attitudes and orientation, including that of partner(s).
  • Adjustment to SCI and body image.
  • Desire/ libido
  • Partner adjustment/acceptance.
  • Urological management
  • Pregnancy and menses

Physical examination

  • Vital signs, including hypotension or hypertension, and signs of autonomic dysreflexia (AD).
  • General neuromusculoskeletal examination, including components of the International Standards/ASIA exam7 and the International Standards to document residual autonomic function after SCI.8 
  • Neurological examination should include rectal sensation, tone, voluntary contraction, and presence of sacral reflexes (anal wink and bulbocavernosus reflex). Presence of the hip flexion reflex is predictive of preservation of ejaculation reflexes.
  • Detailed sensory examination with specific attention to T11-L2 and S3-5 spinal segments (preservation of sensation, motor function and reflexes mediated by theT11-L2 and S2-S5 spinal segments, corresponding to sympathetic and parasympathetic functions, respectively).5 

Functional assessment

  • Dependence in transfers or bed mobility means that assistance from a partner or caregiver will be required.
  • Mobility and contractures influence positioning options for sexual activity.
  • Upper extremity function, including hand function, affects sexual expression.
  • Assess bowel and bladder management methods and level of social continence.

Laboratory studies

  • Evaluation for testosterone deficiency in men with SCI and reduced libido, decline in strength, fatigue or poor response to phosphodiesterase type 5 inhibitors (PDE5I).
  • Workup for sexual dysfunction includes infection, hyperprolactinemia if concomitant traumatic brain injury, metabolic syndrome, diabetes mellitus.
  • Workup for sexually transmitted infections (STI’s), when indicated.

Supplemental assessment tools

The International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) were developed to describe remaining autonomic function. The autonomic standards rate psychogenic and reflex genital arousal (erection or lubrication), orgasm, ejaculation (in men), and sensation of menses (in women) on a 3-point scale: normal function (2), reduced or altered function (1) and complete loss of function (0). 

Social role and social support system

  • Persons with SCI can resume fulfilling social roles as spouses, partners or parents.
  • Individuals with SCI who are in stable, satisfying relationships, are sexually compatible and have good communication with their partner, experience higher sexual satisfaction.9
  • Married couples with SCI are reported to be as stable and enjoy equal marital satisfaction as able-bodied couples.10
  • Distressed couples with SCI tend to express more dissatisfaction with sexual relations and more negative communication during conflict resolution.11

Professional Issues

  • Sexuality is generally a sensitive topic. Use open-ended questions during discussions.
  • Privacy of the individual with SCI, their family, and partners is paramount.
  • Providers can refer to the PLISSIT model of addressing sexual function: 
    • Permission: Obtain permission to talk about sexual issues
    • Limited information: assess readiness to discuss the impact of SCI on sexual expression
    • Specific Suggestions: make specific suggestions based on a full evaluation of the problem
    • Intensive therapy: Most sexual concerns can be addressed at the limited information & specific suggestion level of intervention, but, occasionally, referral for therapy is required
  • Providers should be sensitive to gender identity issues, sexual orientation and practices.
  • Institutional guidelines should reflect ethical principles to maintain:
    • respect for autonomy and the cultural backgrounds of individuals
    • Professional boundaries between providers, caregivers, and clients
    • Providing guidance to individuals with SCI and their families
      • educating them about risks of sexual abuse
      • regarding use of the internet for relationships and information

Rehabilitation Management and Treatments

Available or current treatment guidelines

Clinical practice guidelines on sexuality and reproductive health have been published.12 In addition, patient-directed materials should be available in each institution with an SCI program of care.

Coordination of care

The interdisciplinary team treats the “whole person” and should elicit information from the patient about whom the patient wants present during clinic visits. Many functions overlap between various providers (e.g., obtaining history, education, coaching) and education is provided through the lens of the clinician’s discipline.


  1. Prescribes medications and devices.
  2. Consults with team members and specialists.
  3. Treats ED and infertility, in conjunction with other specialists


  1. Assesses bowel and bladder programs, skin integrity, medication, supply, and surface needs.
  2. Addresses continence around sexual activity and management of incontinent episodes.

Physical therapist

  1. Assesses safety of equipment (wheelchair, shower chairs, etc.) with respect to sexual activity.
  2. Provides equipment such as bolsters for positioning to reduce pain, accommodate contractures, prevent trauma or skin breakdown, and optimize function during sexual activity.

Occupational therapist

  1. Remediates activities of daily living (ADLs) relevant to sexual activity (e.g., undressing).
  2. Treats sex as an equal ADL.
  3. Provides/fabricates adaptive devices for impaired hand function. A manual of devices has been published.13


  1. Performs individual and/or couples counseling.
  2. Discusses separation of caregiving from intimacy.
  3. May recommend a specialist certified by the American Association of Sexuality Educators, Counselors, and Therapists (AASECT).

Recreation therapist

1. Facilitates community integration, recreation and relationships to support healthy lifestyles.

Treatments for Sexual Dysfunctions

Erectile Dysfunction (ED)

  • Occurs in up to 75% of persons with SCI.
  • Erections may occur but be poorly maintained or unsatisfactory for intercourse
  • Phosphodiesterase inhibitors (sildenafil, vardenafil, tadalafil) are the first line treatment for ED
  • Concomitant use of nitrates for AD or alpha blockers for bladder management may result in life-threatening hypotension.
  • Alprostadil intraurethral suppositories (MUSE®) are poorly effective for motor complete injuries but may help persons with incomplete SCI and mild ED.
  • Vacuum erection devices (VEDs) can be used alone or in combination with medication. Constriction bands should be left in place no longer than 20 minutes. Satisfaction rates are generally low.  

Intracavernosal alprostadil injections with alprostadil (prostaglandin E1) are utilized for men who have inadequate responses to the above. Additional agents such as papaverine and phentolamine can be mixed by compounding pharmacies to create “bi-mix”, “tri-mix” or “quadmix”.

  • Risks of injection therapy include bleeding or priapism. The first injection has to be performed in a clinical, monitored setting. Appropriate counseling is necessary.
  • Anticoagulation, bleeding and clotting disorders are contraindications to VED or injection use.
  • Surgical penile prosthesis implantation is a last resort when other methods are unsuccessful. Older devices had a high infection or erosion rate, which is much less with newer pump implants.14 Satisfaction rates are high with current devices.

Fertility in men with SCI

  • Semen quality in men with SCI is generally poor, characterized by normal sperm concentrations but low sperm motility and viability.15  
  • While the majority of men with SCI can achieve some degree of erection, the percentage who can successfully ejaculate without intervention is very low.
  • Most men with SCI will need assistance with fertility 
  • Penile vibratory stimulation (PVS) is a technique that applies vibratory stimulation to the shaft of the penis that is used to reflexively trigger erection and ejaculation16 High rates of ejaculation are seen with optimized vibration parameters, especially in men with lesions above T10 and intact lower spinal reflexes. The presence of bulbocavernosus reflex and hip flexor reflex predict a favorable response to PVS.16-18  
  • Midodrine19 or abdominal muscle stimulation20,21 can improve responsiveness to vibratory ejaculation.
  • Electroejaculation (EEJ), also called rectal probe electrostimulation (RPE), is a more invasive technique used for sperm retrieval. Electroejaculation utilizes an electrical probe, which is inserted rectally and positioned in contact with the anterior rectal wall adjacent to the prostate gland and the seminal vesicles. The stimulation causes release of semen which usually has to be retrieved with the help of a catheter. Electroejaculation is associated with a high risk for autonomic dysreflexia, tissue burns and must be conducted in a monitored clinical setting. Unlike PVS, which relies on the return of reflexes underlying erection and ejaculation, electroejaculation can be performed in persons with areflexic. Electroejaculation is successful in 95% of men with SCI and in nearly 100% if general anesthesia is used 22
  • Semen quality of spinal cord injured men is better when obtained by penile vibratory stimulation versus electroejaculation
  • Surgical sperm extraction methods (micro epididymal sperm aspiration (MESE), testicular excisional sperm extraction (TESE) should be reserved for those for whom all other methods are ineffective.

Assisted Reproduction

  • Men with SCI and their partners seeking parenthood often require referral to fertility specialists.
  • For men who have safe ejaculation with PVS, intravaginal insemination can be performed at home using a fertility monitor, specimen cup and a needleless syringe. Success rates are lowest with this technique, but there is little cost.
  • Intrauterine insemination (IUI) can be attempted and is less expensive than in vitro fertilization (IVF) but does not overcome the problem of poor motility.
  • IVF is expensive and still requires that spermatozoa have adequate motility and ability to penetrate the ovum
  • Intracytoplasmic sperm injection (ICSI)—a special type of in vitro fertilization, is the most expensive technique, but overcomes sperm motility issues by artificially injecting a single spermatozoon into a single ovum.  This is often performed individually to several ova following superovulation of the female partner and collection of ova via surgical aspiration
  • Overall success rates with IVF in SCI are about 40% and likely higher with ICSI.

Fertility in women with SCI

  • Most women retain normal fertility rates. 50-60% of women have amenorrhea acutely after SCI but 50% return after 6 months, 90% after 1 year.
  • Girls with prepubertal onset of SCI usually have normal onset of menarche

Pregnancy and Lactation

  • Many women with SCI have given birth successfully.  Women with SCI should NOT be counseled against having children merely on the basis of their SCI.
  • AD should be differentiated from pregnancy related hypertension (pre-eclampsia/ eclampsia).  Rehabilitation providers have an important role in educating patients and OB personnel about the risk of autonomic dysreflexia (AD). Such pregnancies should be considered high-risk.12
  • Pregnancy in SCI women is associated with increased risks of urinary tract infection, thromboembolic events, constipation, GERD. Sterile intermittent catheterization should be considered to reduce risk of urinary tract infections.  
  • Women with injuries above T10 may not recognize onset of labor and may have an increased risk of premature cervical dilation.
  • Vaginal delivery is often possible, but Caesarean delivery may be needed if AD, premature dilation or other issues are present.
  • Use of epidural anesthesia may reduce the risk of AD
  • Transfers and wheelchair mobility are usually affected due to changes in maternal weight and center of gravity.  Some manual wheelchair users may need a power wheelchair temporarily. Pregnant patients may warrant an in-depth assessment of ability to perform ADLS, transfers and seating assessment
  • Women with injuries above T4 (T3 or higher) may have impairment in the milk let down reflex.
  • Women with SCI T6 or above may report AD with breastfeeding.23 


  • Studies demonstrate that children of persons with SCI have equal adjustment.
  • Children of mothers with SCI do not perceive their mother as “different”.

Orgasm and Pleasure

  • The neurophysiology of orgasms remains poorly understood
  • Absence of erections or ejaculations does not preclude the ability to experience orgasms.
  • Approximately half of men and women with spinal cord injury can experience orgasms, though the quality of their orgasm may be different.
  • Genital stimulation takes longer to result in orgasm than in able-bodied persons and may be experienced differently. People with no genital sensation may achieve orgasms through fantasy or non-genital exploration.24
  • Some individuals with SCI report pleasurable phenomena in erogenous zones, zones of partial preservation, and other area at or above their injury level
  • Persons with complete lower motor neuron injury affecting their sacral cord (no bulbocavernosus or anal wink reflex, no sensation in S3-S5) are less likely to experience orgasm 
  • Women can experience orgasm after spinal cord injury, even if their spinal cord injury is complete. 
  • Some women with complete SCI C4-T9 report orgasm, awareness of cervical, vaginal stimulation, possibly through a vagus nerve pathway.25
  • Stimulatory devices can be very helpful in achieving sexual pleasure and orgasm, such as vibrators and other sexual toys. 
  • Sex and sexual expression entails encompasses multiple activities beyond penis-vagina intercourse. “Intercourse” and “sex” are not synonymous

Patient & family education

Institutions providing rehabilitation services should incorporate education regarding sexuality after SCI into their rehabilitation curriculum, considering the individual’s life context (cultural, environmental, spiritual, and social) during sexual education and counseling.26 Discussions regarding sexual function should be initiated as early after the SCI as possible and should be broached by the interdisciplinary team members caring for the patient. Discussions regarding sexual function should be held within the continuum of care during and after the initial rehabilitation period. Once permission is obtained, family members and caregivers should be involved in discussions and education.

Provide resources such as:

PleasureABLE Sexual Device Manual for People with Disabilities Naphtali K, MacHattie E.13

Sexuality and Sexual Function after Spinal Cord Injury Model Systems Fact Sheet. Spinal Cord Injury Model System. Sexuality and sexual functioning after spinal cord injury. http://www.msktc.org/lib/docs/Factsheets/SCI_Sexuality.pdf. 

Sexuality and Reproductive Health in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals.27 

“Yes, You Can! A Guide to Self-Care for Persons with Spinal Cord Injury”28

Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills

  • Approach the whole patients when discussing sexuality, using the biopsychosocial model. 
  • Recognize the effects of medications, including antidepressants and antispasticity medications, and the effects of medical illness, such as infections and depression, on sexuality.
  • Utilize the interdisciplinary team.
  • Discussion and education regarding sexual function should not be a single occurrence or conducted by a single provider. Rather, they should be a routine part of the patient assessment both in rehab as well as annually.

Cutting Edge/ Emerging and Unique Concepts and Practice

  • Combinations of ED treatments (e.g., PDE5I with injections or pumps) can be prescribed, with appropriate precautions.
  • Sacral nerve stimulation is a therapy used for treatment of urinary and bowel dysfunctions and its role in the treatment of impaired arousal and erections is under investigation. Although the mechanism of action is not completely understood, the leading hypothesis suggests that stimulating peripheral somatic afferent pathways in the sacral plexus can result in modulating sexual pathways. Currently there is weak evidence suggesting modest favorable effects on male and female sexual function.29  
  • Sensory substitution is being explored as a method of sexual rehabilitation. This is a technique where the sensation in a sensate area (e.g., sensation on the tongue) is mapped onto a lost sensory pathway (e.g., genital stimulation) via neuroplasticity.

Gaps in the Evidence-Based Knowledge

  • Overall, there is little research on sexuality and SCI.  Recommendations for future research have been published.27
  • Much of our knowledge of arousal, ejaculation and orgasm stems from self-reports; further research is necessary to determine the neurologic pathways involved in the sexual responses and how these are altered in spinal cord–injured individuals
  • More research is needed to determine optimal timing, methods and effectiveness of counseling and other techniques for optimizing sexual function and satisfaction.


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  11. Deforge D, Blackmer J, Moher D, et al. Sexuality and reproductive health following spinal cord injury. Evid Rep Technol Assess (Summ). 2004(109):1-8.
  12. Cross LL, Meythaler JM, Tuel SM, Cross AL. Pregnancy, labor and delivery post spinal cord injury. Paraplegia. 1992;30(12):890-902.
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  14. Zermann DH, Kutzenberger J, Sauerwein D, Schubert J, Loeffler U. Penile prosthetic surgery in neurologically impaired patients: long-term followup. J Urol. 2006;175(3 Pt 1):1041-1044; discussion 1044.
  15. Ibrahim E, Lynne CM, Brackett NL. Male fertility following spinal cord injury: an update. Andrology. 2016;4(1):13-26.
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  22. Ibrahim E, Aballa TC, Brackett NL, Lynne CM. Electroejaculation in men with spinal cord injury: a step-by-step video demonstration. Fertil Steril 2021;115:1344-6.
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  27. Consortium for Spinal Cord M. Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals. J Spinal Cord Med. 2010;33(3):281-336.
  28. Burns SP, Hammond MC. Yes, You Can! A Guide to Self-Care for Persons with Spinal Cord Injury.2009; 4th:https://pvasamediaprd.blob.core.windows.net/prod/libraries/media/pva/library/publicatio ns/yes-you-can_digital.pdf.
  29. de Oliveira PS, Reis JP, de Oliveira TR, et al. The Impact of Sacral Neuromodulation on Sexual Dysfunction. Curr Urol. 2019;12(4):188-194.

Original Version of the Topic

Lance L. Goetz, MD. Sexuality and reproductive health after SCI. 6/7/2013.

Previous Revision(s) of the Topic

Lance L. Goetz, MD. Sexuality and reproductive health after SCI. 3/29/2017.

Author Disclosure

Marika J. Hess, MD
Nothing to Disclose