Sexuality incorporates personal and biological factors (including the effects of illness or injuries), and reproductive capabilities. It encompasses “one’s sense of self, biological makeup, interpersonal relationships, moral and cultural beliefs, as well as the way in which individuals relate to their surroundings and our society.”1
Insult to the spinal cord or cauda equina results in impairments in sexual and reproductive functions. Sensorimotor deficits depend upon location and severity of injury. Impairments after spinal cord injury (SCI) may include the following:
- Impaired psychogenic, but preserved reflexogenic, penile erection, after upper motor neuron (UMN)/reflexic injury.
- Impaired reflexogenic penile erection and altered or absent psychogenic erection after lower motor neuron (LMN)/areflexic injuries.
- Inability to ejaculate via intercourse or masturbation.
- Impaired psychogenic, but preserved reflexogenic, blood flow, with resulting engorgement and lubrication of genital and erogenous structures (breasts, labia) after UMN injury.
- Impaired or absent reflexogenic engorgement and lubrication of genitalia after LMN injury.
In men and women:
- Impairment in libido.
- Alteration or absence of genital orgasm.
After SCI, volitional control of sexual structures is reduced or absent.
- Erectile function in men and genital lubrication in women is mediated primarily via the parasympathetic pelvic nerves (S2-4).
- Ejaculation is mediated primarily by the sympathetic nervous system via spinal cord sympathetic tract segments T10-L2. Activation is necessary for emission of semen and bladder neck (internal sphincter) closure, which prevents retrograde ejaculation.
- The pudendal nerve originates from S2-4 spinal segments and innervates pelvic muscles such as the ischiocavernosus and bulbocavernosus, which contract during ejaculation and cause propulsion of semen. The pudendal nerve also innervates the external urethral sphincter, which is normally relaxed during ejaculation.
- Rhythmic contractions of genitalia and pelvic floor musculature during orgasm in women are mediated by sympathetic and pudendal innervated structures, respectively.
Disease progression including natural history, disease phases or stages, disease trajectory (clinical features and presentation over time)
- Return of reflexogenic erections and lubrication occurs in UMN injury as spinal shock resolves.
- 93% of persons with complete UMN injuries regain reflexogenic erections. However, erection may be poorly maintained.
- Complete LMN injuries lose reflexogenic erections, and only 26% maintain ability to have psychogenic erections. However, 90% of incomplete LMN injuries regain erectile abilities. 2
2. 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 AD and triggers.3
- Pre- and post-SCI sexual experiences, attitudes and orientation, including partner(s).
- Adjustment to SCI and body image.
- Partner adjustment/acceptance.
- Vital signs, including hypotension or hypertension, and signs of autonomic dysreflexia (AD).
- General neuromusculoskeletal examination, including components of the International Standards/ASIA exam4 and the International Standards to Document Residual autonomic function after SCI.5 Neurological rectal examination including sensation, tone, voluntary contraction, sacral reflexes (anal wink and bulbocavernosus reflex).
- Assessment of the hip flexion reflex, whose presence is predictive of preservation of ejaculation reflexes.
- Detailed sensory examination with specific attention to preservation/absence of sensation in T11-L2 and S2-S5 dermatomes (corresponding to sympathetic and parasympathetic functions, respectively).5
- Contractures, painful or hypersensitive dermatomes, skin breakdown, and presence/type of urinary catheter.
- 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.
- 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(STIs), when indicated.
Supplemental assessment tools
The International Index of Erectile Function (IIEF) is a self-report scale commonly used in clinical studies.
Social role and social support system
- Persons with SCI can resume fulfilling social roles as spouses, partners or parents.
- Individuals who marry after SCI report better life satisfaction than those married pre-injury.6
- Married couples with SCI are reported to be as stable and enjoy equal marital satisfaction as able-bodied couples.7
- Distressed couples with SCI tend to express more dissatisfaction with sexual relations and more negative communication during conflict resolution.8
- Sexuality is generally a sensitive topic. Use open-ended questions during discussions.
- Privacy of the individual with SCI, their family, and partners is paramount.
- Permission must be obtained from individuals before discussing information with any other party.
- 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
3. REHABILITATION MANAGEMENT AND TREATMENTS
Available or current treatment guidelines
Clinical practice guidelines on sexuality and reproductive health have been published.18 In addition, patient-directed materials are available.
Coordination of care
The interdisciplinary team treats the “whole person.”
- Obtains sexual history
- Prescribes medications and devices.
- Consults team members and specialists.
- Explains anatomy, physiology and function.
- Treats ED and infertility, in conjunction with other specialists
- Assesses bowel and bladder programs, skin integrity, medication, supply, and surface needs.
- Addresses continence around sexual activity and management of incontinent episodes.
- Assesses safety of equipment (wheelchair, shower chairs, etc.) with respect to sexual activity.
- Provides equipment such as bolsters for positioning to reduce pain, accommodate contractures, prevent trauma or skin breakdown, and optimize function during sexual activity.
- Remediates activities of daily living (ADLs) relevant to sexual activity (e.g., undressing).
- Treats sex as an equal ADL.
- Provides/fabricates adaptive devices for impaired hand function. A manual of devices has been published.9
- Performs individual and/or couples counseling.
- Discusses separation of caregiving from intimacy.
- May recommend a specialist certified by the American Association of Sexuality Educators, Counselors, and Therapists (AASECT).
- Facilitates community integration, recreation and relationships to support healthy lifestyles.
Treatments for Sexual Dysfunctions
- Occurs in up to 75% of persons with SCI.
- Erections may occur but be poorly maintained or unsatisfactory for intercourse
- PDE5 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 side effects such as 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. Satisfaction rates are low for persons with SCI as the penis may have the tendency to “pivot” on the constriction band. Constriction bands should be left in place no longer than 20 minutes.
- 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 quad-mix”.
- Risks of injection therapy include bleeding or priapism; 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.10 Satisfaction rates are high with current devices.
Fertility in men with SCI
- Semen quality in men with SCI is generally poor, due to reduced motility and low
- Methods to obtain semen
- Utilize a protocol approach11 in the following order:
- Masturbationis rarely successful in motor complete SCI but should be attempted
- Penile vibratory stimulation(PVS) with optimized parameters12
- Recommended to perform in office setting to monitor for, treat AD
- Can be done in the home setting if safe
- Higher injuries, presence of bulbocavernosus reflex and hip flexor reflex predict response to PVS1312
- Midodrine14or abdominal muscle stimulation 1516 can improve responsiveness to vibratory ejaculation.
- Electroejaculation (EEJ),also called rectal probe electrostimulation (RPE)
- Semen quality of spinal cord injured men is better when obtained by penile vibratory stimulation versus electroejaculation
- Electroejaculation has a success rate nearing 100%17 and is generally effective even for persons with areflexic/LMN injuries
- Risks AD, tissue burns
- Surgical sperm extractionmethods (MESE/MESA, TESE/TESA) should be reserved for those for whom all other methods are ineffective.
- 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
- Long term fertility is generally intact. 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 clinical from pregnancy related hypertension (pre-eclampsia/eclampsia). Rehabilitation providers should educate patients and OB personnel when needed, Pregnant women with SCI and risk of AD should be considered high-risk pregnancies.18
- Increased risks—UTI, DVT, constipation/neurogenic bowel, GERD. Consider sterile intermittent catheterization. Consider pregnancy-related medication restrictions.
- Women with injuries above T10 may not recognize 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.
- Transfers and wheelchair mobility are usually affected. Some manual wheelchair users may need a power wheelchair temporarily. ADLS, OT PT
- 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 19
- 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
- Sexual desire is often reduced after SCI. However, desire is highly complex, highly individualized, and may be affected by potentially reversible health factors.
- Some women with complete SCI C4-T9 report orgasm, awareness of cervical, vaginal stimulation, possibly through a vagus nerve pathway.20
- In one study 44% of women with SCI T6 below reported orgasm but only 17% of those with complete LMN injuries.21
- Sildenafil may increase subjective arousal in women with SCI21
- Specialized stimulatory devices such as the NuGyn Eros can assist some women.
- In men, orgasm is typically linked with ejaculation and most men with complete SCI do not report either in the traditional sense.
- Some men with SCI report pleasurable phenomena in erogenous zones, zones of partial preservation, and other area at or above their injury level
- Some men with complete SCI report pleasurable genital sensations with simulation.
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.1 Involve significant others as allowed by the client.
Provide resources such as:
- Sexuality and Reproductive Health Consumer Guide (www.pva.org) 22
- “Yes, You Can!” manual (www.pva.org)23
- Moderated videos or group discussions
- Books about sex and disability.
Translation into practice: practice “pearls”/performance improvement in practice (PIPs)/changes in clinical practice behaviors and skills
- 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.
4. CUTTING EDGE/EMERGING AND UNIQUE CONCEPTS AND PRACTICE
Combinations of ED treatments (e.g. PDE5I with injections or pumps) can be tried if needed, with appropriate precautions.
Sensory substitution is being explored as a method of sexual rehabilitation.
5. GAPS IN THE EVIDENCE-BASED KNOWLEDGE
- Overall, there is little research on sexuality and SCI. Recommendations for future research have been published.1
- More research is needed to determine optimal timing, methods and effectiveness of counseling and other techniques for optimizing sexual function and satisfaction.
- Sexuality and Reproductive Health in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Washington, D.C.: Consortium for Spinal Cord Medicine, Paralyzed Veterans of America; 2010.
- Comarr E. Neurological disturbances of sexual function with special reference to 529 patients with spinal cord injury. Urol Surv. 1960;10:191-222.
- Acute Management of Autonomic Dysreflexia: Individuals with Spinal Cord Injury Presenting to Health-Care Facilities. 2nd ed. Washington D.C.: Consortium for Spinal Cord Medicine, Paralyzed Veterans of America; 2001.
- International Standards for Neurological Classification of Spinal Cord Injury. Atlanta, GA: American Spinal Injury Association; 2011.
- Krassioukov A, Biering-Sørensen F, Donovan W, et al. International standards to document remaining autonomic function after spinal cord injury. J Spinal Cord Med. 2012;35(4):201-210. doi:10.1179/1079026812Z.00000000053.
- Crewe NM, Krause JS. Marital status and adjustment to spinal cord injury. J Am Paraplegia Soc. 1992;15(1):14-18.
- Yim SY, Lee IY, Yoon SH, Song MS, Rah EW, Moon HW. Quality of marital life in Korean spinal cord injured patients. Spinal Cord. 1998;36(12):826-831.
- 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.
- Naphtali K, MacHattie E, Elliott S. Pleasure ABLE Sexual Device Manual for Persons with Disabilities. Vancouver: ICORD; 2010. http://www.dhrn.ca/files/sexualhealthmanual_lowres_2010_0208.pdf.
- Zermann D-H, 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. doi:10.1016/S0022-5347(05)00344-7.
- Ibrahim E, Lynne CM, Brackett NL. Male fertility following spinal cord injury: an update. Andrology. 2016;4(1):13-26. doi:10.1111/andr.12119.
- Ohl DA, Menge AC, Sønksen J. Penile vibratory stimulation in spinal cord injured men: optimized vibration parameters and prognostic factors. Arch Phys Med Rehabil. 1996;77(9):903-905.
- Bird VG, Brackett NL, Lynne CM, Aballa TC, Ferrell SM. Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury. Spinal Cord. 2001;39(10):514-519. doi:10.1038/sj.sc.3101200.
- Soler JM, Previnaire JG, Plante P, Denys P, Chartier-Kastler E. Midodrine improves ejaculation in spinal cord injured men. J Urol. 2007;178(5):2082-2086. doi:10.1016/j.juro.2007.07.047.
- Goetz LL, Stiens SA. Abdominal electric stimulation facilitates penile vibratory stimulation for ejaculation after spinal cord injury: a single-subject trial. Arch Phys Med Rehabil. 2005;86(9):1879-1883. doi:10.1016/j.apmr.2005.03.023.
- Kafetsoulis A, Ibrahim E, Aballa TC, Goetz LL, Lynne CM, Brackett NL. Abdominal electrical stimulation rescues failures to penile vibratory stimulation in men with spinal cord injury: a report of two cases. Urology. 2006;68(1):204.e9-e11. doi:10.1016/j.urology.2006.01.074.
- Rutkowski SB, Geraghty TJ, Hagen DL, Bowers DM, Craven M, Middleton JW. A comprehensive approach to the management of male infertility following spinal cord injury. Spinal Cord. 1999;37(7):508-514.
- Cross LL, Meythaler JM, Tuel SM, Cross AL. Pregnancy, labor and delivery post spinal cord injury. Paraplegia. 1992;30(12):890-902. doi:10.1038/sc.1992.166.
- Dakhil-Jerew F, Brook S, Derry F. Autonomic dysreflexia triggered by breastfeeding in a tetraplegic mother. J Rehabil Med. 2008;40(9):780-782. doi:10.2340/16501977-0250.
- Whipple B, Komisaruk BR. Brain (PET) responses to vaginal-cervical self-stimulation in women with complete spinal cord injury: preliminary findings. J Sex Marital Ther. 2002;28(1):79-86. doi:10.1080/009262302317251043.
- Sipski ML, Alexander CJ, Rosen R. Sexual arousal and orgasm in women: effects of spinal cord injury. Ann Neurol. 2001;49(1):35-44.
- Sexuality and Reproductive Health in Adults with Spinal Cord Injury: What You Should Know. A Guide for People with Spinal Cord Injury. Washington D.C.: Consortium for Spinal Cord Medicine, Paralyzed Veterans of America; 2011.
- Yes, You Can! A Guide to Self-Care for Persons with Spinal Cord Injury. 2nd ed. Washington, D.C.: Paralyzed Veterans of America; 2009. www.pva.org/site.
Original Version of the Topic
Lance L. Goetz, MD. Sexuality and reproductive health after SCI. 06/07/2013.
Lance L. Goetz, MD
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