Abstract
W
The researchers have failed to take into account a number of issues and thus overestimate the risk of dysreflexia during sexual activity post-SCI. First, the initial definition of dysreflexia, hypertension, and emergency hypertension was developed based upon intermittent BP readings using regular BP cuffs, not continuous readings. At least one study comparing BP in SCI and able-bodied subjects was not included. 2 The researchers do not consistently take into account the N of subjects in the studies they quote. 3 –10 It appears that at least two 6,7 and possibly three 8 of the articles that the team of researchers wrote and quoted included the same subjects and, in fact, may have been the same research trials. Finally, the researchers seem to overemphasize the clinical significance of brief elevations in BP that they find, and they do not discuss the possibility of contributing factors to hypertensive readings in the case reports they bring up.
We opine that the original definition of dysreflexia published in 2007 11 was based upon clinical consensus and based upon intermittent BP readings. In light of this fact, the transference of a 20-mm Hg increase in systolic BP based upon continuous BP monitoring as the definition for dysreflexia may not be valid. We believe a relook at the determination of the diagnosis of dysreflexia needs to be considered given that an asymptomatic 20 mm Hg is likely more of a research finding as opposed to a clinically significant finding.
With regard to data that are not adequately addressed, the researchers fail to include the publication of Sipski and colleagues. 2 In this study, BP was monitored every 3 min in 68 SCI subjects and 21 able-bodied subjects during a 78-min protocol assessing arousal. Moreover, in the same study, it was also monitored in a 75-min protocol evaluating orgasm in 27 SCI subjects and 21 able-bodied subjects in which BP was measured every 3 min and at the moment of orgasm. In the arousal study, there was not a significant difference in BP during baseline, audiovisual, and audiovisual combined with manual or manual stimulation alone. Additionally, there were no increases in BP over 20 mm Hg. Further, in the orgasm study, the BP readings at baseline and orgasm were statistically similar between able-bodied and SCI subjects and there was no evidence of dysreflexia. The researchers also compare the data of Courtois and colleagues 3 (n = 62) who measured BP before, at, and following ejaculation, and Soler and colleagues 4 (n = 158) who measured BP every 1 min during the protocol with other much smaller studies, a technique that is not scientifically optimal. In the smaller studies, they include Brown and colleagues 5 (n = 10) with theirs, including Ekland and colleagues 6 (n = 13), Claydon and colleagues 7 (n = 13, with all patients appearing identical to those in Ekland and colleagues), Sheel and colleagues 8 (n = 13, with 12 patients appearing identical and 1 different to the studies of Ekland and colleagues 6 and Claydon and colleagues 7 ), and Elliot and Krassioukov 9 (n = 3, with 1 possibly being identical to the Ekland and collegaues 6 and Claydon and colleagues 7 patients given that their level and degree of injury and age appear identical and BP listed is identical at ejaculation). These data give the reviewer the impression that there are many individual studies documenting dysreflexia during vibratory stimulation. In fact, however, in detailed review of the tables in the original articles, it appears that the subjects of the Ekland and collegaues 6 and Claydon and colleagues 7 studies are identical and the Sheel and colleagues 8 article only has 1 subject that is different. Moreover, it appears that they are possibly discussing the exact same trials of ejaculation in the different articles, and it appears that the corrected N for these studies combined is only 16 total.
Finally, the researchers quote the BP of recordings of a case study of a patient by McBride and colleagues 10 with extremely elevated BP. While this is certainly a dangerous and significant situation, it does not appear that all cardiac or systemic issues that could have contributed to the situation were ruled out in this case.
We believe it is important that the risk of autonomic dysreflexia during sexual activity versus vibratory ejaculation is portrayed accurately. From these results, it appears that there is less of a risk with routine sexual activity than with vibratory stimulation. However, in addition to this, we believe the risk of dysreflexia with sexual dysfunction appears to be overestimated and exaggerated in the article of Davidson and colleagues. 1