Abstract
BACKGROUND:
Spinal Cord Injury (SCI) causes neurological impairment with resultant neurogenic sexual dysfunction which can compound preexisting psychological and medical sexual concerns. Understanding these concerns is important in managing the lifelong needs of persons with SCIs.
OBJECTIVES:
To provide an overview of the impact of SCI on sexuality along with a framework for treatment of sexual concerns. To briefly review male infertility and its treatments and pregnancy in females after SCI.
METHODS:
Interdisciplinary literature review and synthesis of information.
RESULTS:
The average age at SCI is increased, thus persons with SCIs may have preexisting sexual concerns. Sexual activity and satisfaction are decreased after SCI. Psychogenic sexual arousal is related to remaining sensation in the T11-L2 dermatomes. Orgasm occurs in approximately 50% of persons with SCIs with all injuries except subjects with complete lower motor neuron (LMN) injuries affecting the lowest sacral segments A structured approach to treatment including assessing preinjury function, determining the impact of injury, education, assessing and treating iatrogenic sexual dysfunction and treatment of concomitant problems is recommended. Basic and advanced methods to improve sexual arousal and orgasm are discussed and treatment of anejaculation and issues associated with pregnancy and SCI are reviewed.
CONCLUSIONS:
Sexual satisfaction is impaired after SCI; however, education and new therapies can improve responsiveness. Future research is warranted to improve sexual function and fertility potential in persons with SCIs.
Keywords
Introduction
Spinal cord injuries (SCIs) are an uncommon but devastating disorder. Data indicate a prevalence of 282,000 with over 50% of persons single at injury (NSCIS, 2016). Average age at injury has increased from 28 to 42; however, gender distribution is consistent at 80% male and 20% female. Tetraplegia occurs in 60% of persons with 20% of these injuries complete while 50% of persons with paraplegia have complete injuries.
Sexuality is one of the greatest concerns of persons with SCIs (Anderson, 2004) and it is an important factor in quality of life. However, sexual concerns are common and have both psychologic and physiologic etiologies. Thus, the practitioner must consider issues not only related to SCI but also issues related to sexuality in the general population. These include psychologic concerns such as depression and body image related to aging and disability and physiologic concerns such as the natural and iatrogenic impacts of other medical problems and their treatments. Because the age at injury is increasing persons with SCI are more likely to have preexisting sexual problems. Treatment of these problems in conjunction with those related to SCI has not been concisely addressed in the literature. Therefore, the goal of this paper is to provide an overview of the psychologic and physiologic issues regarding sexuality that persons with SCI may experience in conjunction with with a framework for treatment. Additionally, a brief review of reproductive concerns will be presented. Finally recommendations are made for areas of future research.
Methods
This unstructured review was undertaken by an interdisciplinary group of professionals from the fields of neurology, physical medicine and rehabilitation and urology. Articles were reviewed from Pub Med using the topics sexuality, sexual dysfunction, erectile dysfunction, ejaculation, sexual response, orgasm, fertility, infertility, menstruation, pregnancy and spinal cord injury with the most relevant and recent papers selected for review. Additionally, the topics diabetes, hypertension, cardiac disease and urinary tract dysfunction and the topic sexual dysfunction was searched and the most recent and relevant papers were reviewed. Appropriate relevant papers were also obtained based upon the references of articles and the author’s knowledge.
Results
Psychological concerns
Sexual arousal is usually initiated in the brain in response to a variety of sensory stimuli including visual, auditory, olfactory, tactile, and from spontaneous memory; therefore, a person’s overall psychological status and mood impacts sexual desire, arousal, and orgasmic capacity. Spinal cord injury has a profound impact on the body and its function and many associated psychological problems occur including altered body image due to muscle wasting, spasticity and loss of sensation, fear about the inability to control one’s bladder and bowel function and shame about unwanted smells, a protuberant abdomen, pressure sores or unattractive undergarments. The inability to walk, quickly get in and out of a car, eat independently or move around in bed the same way the individual did prior to SCI can also contribute to psychologic distress impacting sexuality. There may be also dyadic issues as the relationship with their partner may shift with the partner reacting to the SCI or the person may feel inadequate with regards to dating or meeting new sexual partners. With the inability to move in bed or exit an uncomfortable situation, the person with SCI is also more vulnerable to abuse during sexual activity and relationships, such as having the partner take away the person’s wheelchair or forcing the injured individual to participate in excessive or unwanted sexual activities. Individuals with sexual orientation and gender concerns also require unique care to address their emotional issues but have received minimal attention in the SCI literature.
Other common psychologic concerns in the general population and the subset of persons with SCIS such as depression and anxiety contribute negatively to sexual function from their existence and from the iatrogenic effects of treatment. Harrison, Glass, Owens and Soni (1995) noted anxiety was present in 31% of 78 SCI women and depression was present in 11%. Anxiety was correlated with current sexual dysfunction while depression was related to general body dissatisfaction. Substance use disorders are also common in the general and SCI population and can also impact negatively on overall sexual participation. In addition, there may be a nocebo effect with providers, other individuals with SCIs or able-bodied friends having given patients and their partners negative misinformation regarding their sexual potential.
The sum of these problems is that the general psychologic impact of SCI on sexuality is similar to other neurologic disabilities such as stroke or multiple sclersosis. Sexual desire has been reported unchanged in one report post SCI (Cardosa et al., 2009) while others (Alexander et al., 1993; Kreuter et al., 2011; Phelps, Albo, Dunn, & Joseph, 2001) noted decreased desire SCI. Regardless of desire, both men and women are less sexually active after SCI then prior to injury (Otero-Villaverde et al., 2015; Kreuter, Taft, Siosteen, & Biering-Sorensen, 2011; Alexander, Sipski, & Findley, 1993; Cardosa, Savall, & Mendes, 2009; Ferreiro-Velasco et al., 2005) and reasons can include lack of desire but also lack of a partner or a partner that wants to be sexually active. Sexual satisfaction also decreases after SCI (Alexander et al., 1993; Kreuter, Sullivan, & Siosteen, 1996); however, men with paraplegia report greater satisfaction with their sex lives than men with tetraplegia (Dahlberg, Alaranta, Kautianinen, & Kotila, 2007).
Decreased sexual activity may result from lack of access to partners; however, depression, anxiety and fatigue may also contribute. Other issues such as neuropathic pain and bladder and bowel dysfunction may cause secondary decreased interest and satisfaction due to overall bother. Spasticity can result in sexual problems due to positioning or pain and treatment with baclofen can also cause sexual dysfunction (Calabro et al., 2014). In contrast stimulation of ejaculation through penile vibratory stimulation (PVS) is known to result in a decrease in spasticity in men and rectal probe electoejaculation (EEJ) has been shown to decrease spasticity in both men and women (Laessoe, Nielsen, Biering-Sorensen, & Sonksen, 2004; Halstead et al., 1993). Although the overall reasons for change in interest and behavior with regards to sexual activity after SCI have not been delineated, patient counseling and rehabilitation is consistently recommended in the literature (Otero-Villaverde et al., 2015; Kreuter et al., 2011; Ferrero-Velasco et al., 2005). This counseling generally begins with basic psychological education about the impact of SCI on an individual’s emotional and sexual function, participation in clinician or peer led group education classes and also recommendation of consumer materials to patients. For a more detailed discussion of these possibilities, the clinician is referred to the Consortium of Spinal Cord Medicine Guidelines “Sexuality and Reproductive Health in Adults with Spinal Cord Injury: A Clinical Practice Guideline for Health-Care Professionals (Ducharme et al., 2010.).
Physiology of sexual response
Recent research has provided support for the belief that sacral autonomic input is all sympathetic (Espinosa-Medina et al., 2016) and if further research supports this concept, our overall understanding of sexual physiology may dramatically change. Keeping this in mind, we will provide a classical description of sexual anatomy and the impact of SCI.
In males, the sympathetic, parasympathetic and somatic nervous systems work together to produce genital arousal, ejaculation and orgasm. Sympathetic outflow from T11-L2 is responsible for psychogenic erections, seminal emission, and bladder neck closure during ejaculation. Parasympathetic outflow from S2-S4 controls the initiation of reflexogenic erections. Somatic nerves from S2-S4 control rhythmic contraction of the periurethral muscles and projectile ejaculation. The dorsal nerve of the penis provides sensory input to the S2-S4 spinal segments.
In females, sympathetic efferents from T10-T11 innervate the ovaries and smooth muscle of the fallopian tubes and uterus, while parasympathetics (S2-4) supply the fallopian tubes and vagina. Afferent information from the cervix and tubal region is transmitted to T11-12 segments through the pelvic nerves. In females, psychogenic sexual arousal with resultant vaginal lubrication and clitoral enlargement is thought to be mediated through thoracolumbar sympathetic fibers. Reflexive sexual arousal relies on afferent fibers of the pudendal nerve (S2-4) and parasympathetic efferents (S2-4) which are activated by descending influences and by afferent sacral synapses.
The degree and location of a person’s SCI determines whether psychogenic arousal and orgasm are maintained. Studies in SCI show that psychogenic arousal in females and males are mediated through the sympathetic nervous system. Therefore, injury to the thoracolumbar spinal cord results in a decreased ability to achieve psychogenic arousal. As measured by the International Standards for the Neurologic Classification of SCI (ISNCSCI), the ability to perceive pinprick plus light touch sensation at T11-12 significantly correlates with the ability to experience psychogenic genital vasocongestion in women and increased penile circumference in men (Sipski, Alexander, & Rosen, 2001; Sipski, Alexander, Gomez-Marin, & Spalding, 2007), regardless of the level of injury. With regards to reflex erection and lubrication, those individuals without anal sensation and with lower motor neuron (LMN) type sacral function (e.g. lack of the bulbocavernosus and anal wink reflexes) have an inability to achieve reflex arousal. Those persons with absent anal and sacral sensation and reflexes but retention of thoracolumbar sensation can often have some type of the psychogenic genital arousal; however, there is a subgroup of individuals with complete damage to both the psychogenic and reflex pathways that are unable to achieve any type of genital arousal. Orgasm is generally considered the peak of sexual experience. Orgasm was studied in a controlled laboratory based analysis of 62 women with SCI and 21 able-bodied (AB) women (Sipski et al., 2001). A significant decrease in the ability of women with complete LMN dysfunction affecting their sacral cord to achieve orgasm was found as compared to women with all other levels and degrees of SCI. Similar findings were found in a study of 45 men with SCI and 16 AB controls (Sipski et al., 2006); that is, those with LMN dysfunction affecting their sacral segments were significantly less likely to achieve orgasm than men with all other levels and degrees of SCI.
In association with the decreased incidence of orgasm, time to orgasm was significantly increased in women with SCI as compared to AB women. Although there was a trend toward increased time to orgasm in men, this did not reach significance. Blood pressure and heart rate readings were similar between SCI and AB individuals. Furthermore, in this laboratory based analysis no dysreflexia was noted in conjunction with orgasm, despite having a protocol for treatment. This finding of no clinical hypertension or dysreflexia in persons with SCI is in contrast of claims of frequent dysreflexia in other reports (Phillips, Elliott, & Krassioukov, 2016). Furthermore, it is noted that studies defining dysreflexia as purely a 20 mmHg increase in blood pressure may be overdiagnosing the problem (Alexander & Courtois, 2017).
More recently, imaging has been used to document the spinal and brain activity associated with arousal and orgasm (Kozyrev et al., 2012; Alexander et al., 2016; Alexander, Kozyrev, Figley, & Richards, 2017; Georgiadis, Simone Reinder, Paans, Renken, & Kortekaas, 2009; Komisaruk, Whipple, Crawford, Liu, Kalnin, & Mosier, 2004). In AB and SCI men and women, evidence of thoracolumbar and sacral activation has been found via functional magnetic resonance imaging (fMRI) assessment of cord activity during arousal and orgasm (Kozyrev et al., 2012; Alexander et al., 2016; Alexander et al., 2017). Positron emission tomography (PET) and brain fMRI scans have shown increased cerebellar activity and deactivation in the left ventromedial and orbitofrontal cortex during orgasm in AB men and women (Georgiadis et al., 2009). Women with SCI have shown evidence of paraventricular nucleus, nucleus cuneatus and nucleus tractus solitarii activation in conjunction with orgasm and this finding has been attributed to the vagus nerve conveying impulses from the spinal cord to the brain. However, the overall autonomic signs occurring with orgasm include increased sympathetic activity with elevated heart rate, blood pressure and respiratory rate during orgasm followed by a parasympathetic response including return to baseline heart rate, blood pressure and respiratory rate during the resolution phase. Thus, it has been proposed that local increases in sympathetic outflow may travel in an anterograde and retrograde fashion (Alexander & Marson, 2017) with activation of the central pattern generator for ejaculation (Chehensee et al., 2016) causing the repetitive involuntary sacral and lower extremity muscular contractions associated with orgasm. Additionally, neuroplasticity has been demonstrated in sympathetic pathways following SCI (McLachlan, 2007) and it has been proposed sympathetic neuroplasticity allows retrograde transmission of neurologic impulses bilaterally up the sympathetic chain with resulting activation of the paraventricular nucleus and nucleus cuneatus and ultimately in response, the nucleus solitarus (Alexander & Marson, 2017).
Treatment of sexual dysfunction after SCI
To effectively treat sexual concerns after SCI, sexuality should be a part of lifelong followup visits with the clinician. In this situation it is useful to follow the Guidelines to Promote Sexual Sustainability post SCI (Alexander, Courtois, Elliott, & Tepper, 2017) as a framework to diagnose and treat sexual dysfunction. Key points in this approach include establishing communication with the individual by asking open-ended, nonjudgmental questions and encouraging routine practice and follow through regarding sexual concerns at all clinician visits. A thorough preinjury sexual and medical history must be obtained as sexual dysfunction is common in the general population. If there is evidence of sexual abuse, preexisting sexual dysfunction, or recent relationship problems, a referral for counseling is suggested. Cultural and religious issues must also be considered, as these may prevent the individual with SCI or their partner from fully participating in sexual activities, especially if a change in sexual roles is necessary because of the SCI.
A detailed neurologic examination according to the ISNCSCI (Kirshblum et al., 2011) in addition to determination of the presence of the bulbocavernosus reflex is necessary to accurately counsel SCI persons with regards to their sexual potential. The combined sensory score to pinprick and light touch in the T11-L2 dermatomes should be determined. This score ranges from 0–32 and individuals with a sensory score greater than 24 are significantly more likely to retain capacity for psychogenic erection or lubrication (Sipski et al., 2001, 2007). Moreover, the clinician should check for preservation of deep and surface anal sensation and the presence of the bulbocavernosus and anal wink reflexes. Those individuals with the preservation of reflex function are more likely to have reflex genital arousal while those individuals with complete absence of sensation and complete LMN injuries affecting the sacral segments are significantly less likely to experience orgasm (Sipski et al., 2001, 2006). Once the neurologic examination is completed, documentation of the status of the person’s sexual function after SCI in a systematic fashion is important. For this reason, the use of the International Standards for the Assessment of Autonomic Function after SCI is recommended to document the presumed basic impact of the SCI on sexual response including reflex and psychogenic arousal, orgasm, ejaculation and menstruation (Alexander et al., 2009). The International Spinal Cord Injury Basic Male Sexual Function and Female Sexual and Reproductive Function Data Sets can also serve as a valuable resource to document effects of treating sexual dysfunction or to monitor the effects of various interventions to improve sexual function in the medical record (Alexander, Biering-Sorensen, Elliott, Kreuter, & Sonksen, 2011a,b; Alexander, New, Biering-Sorensen, Courtois, Del Popolo, Elliott, Kiekens, Vogel, & Previnaire, 2017). These data sets provide a format to document interest in discussing sexual issues, sexual orientation, sexual issues unrelated to the spinal cord lesion, sexual dysfunction related to spinal cord lesion, psychogenic genital arousal, reflex genital arousal, orgasmic function and menstruation.
Once the baseline neurologic examination is completed and the persons specific sexual potential is determined, it is recommended the clinician educates the patient and, if present, their partner, about their sexual potential, and recommends practice of sexual activities. It is beneficial to encourage patients to masturbate if this is physically feasible or if not to instruct their partner to stimulate the person with SCI to learn how the SCI has impacted their sexual response. Individuals with SCIs should be educated it will generally take increased time for orgasm to occur along with a discussion of the need to empty the bladder and bowel prior to sexual activity and issues related to spasticity, positioning and the potential for friction or pressure sores. This is also a good time to discuss such basic issues related to sexuality as body image and the potential for positive feelings throughout the body as opposed to just the genitals, the use of techniques other than intercourse for sexual stimulation and the need for birth control in women. Persons with SCIs at T6 and above must also be made aware of the potential for dysreflexia and told that if a headache develops during sexual activity, they should stop stimulation, sit up and check their blood pressure if possible. Moreover, if it is extremely elevated or a recurrent problem they should discuss potential causes or need for prophylaxis against dysreflexia with their SCI practitioner. However, the practitioner is also cautioned from overemphasizing this risk (Alexander & Courtois, 2017) and the potential for a noceboeffect.
Iatrogenic considerations
If an individual with SCI reports sexual concerns, it is recommended that the patient explore their natural sexual potential before any treatment changes or addition of new medications In order to do this, at all visits the provider should follow-up and ask whether there are sexual concerns. If problems exist, the provider should assess for discrepancies between anticipated sexual responses based upon injury pattern versus actual sexual responses. Any physical, psychological or iatrogenic issues that are negatively impacting the individuals’s sexual function can then be treated. At this time, issues may come up related to spasticity, pain, transfers, bladder and bowel function, or a fearful or uninterested partner. Medications commonly used after SCI often cause sexual problems and adjustment may resolve sexual concerns. Amongst medications commonly used after SCI, antispasmodics especially baclofen, medications used for neurogenic pain management especially gabapentin or pregabalin, alpha-blockers, antidepressants and opiates often cause sexual dysfunction and adjustment of the dosage and timing of these can often resolve the problem (Kaufman & Struck, 2011; Calabro, DeLuca, Pollicino, & Bramanti, 2013; Welliver, Butcher, Potini, & McVary, 2014; Segraves & Balon, 2014; Dalal & Zhou, 2008; Yee, Loh, Hisham, & Ng, 2014).
Treatments for erectile and orgasm dysfunction in men
If education and changes in the patient’s medications are unsuccessful, further treatments can be explored. Some type of erectile function is present in 85% of men within two years of injury; however, these erections are often inadequate for intercourse (Hess & Hough, 2012; Lombardi et al., 2015; Brackett, Lynne, Ibrahim, Ohl, & Sonksen, 2010). Thus, most men with SCI complain of some degree of erectile dysfunction.
For those males who are able to attain reflex erections but not maintain them, the use of a silicon or rubber ring placed at the base of the penis can help maintain an erection. A vacuum constriction device coupled with a penile ring (Lombardi, Musco, Wyndaele, & Del Popolo, 2015) can also be used to treat erectile dysfunction; however these devices are associated with low satisfaction because the appearance of the penis is less natural and there may also be erectile failure during intercourse. Both of these techniques may be used for up to, but no longer than 30 minutes due to the risk of ischemia and skin erosion. Alternatively, some men with SCIs prefer to stuff their penis into a hollowed out dildo that can be strapped to the body during sexual activity.
With regards to medical therapies, treatment with Phosphodiesterase-5 (PDE-5) inhibitors are considered first line to promote erection in men (Jia, Shuang, Cheng, Jia, & Zhang, 2016; Soler et al., 2007, 2016). PDE5 inhibitors work by preserving cyclic guanosine monophosphate (cGMP) and prolonging the cavernous smooth muscle relaxation that leads to erection (Derry et al., 1998). Because men with SCI have intact peripheral penile innervation and vasculature, these medications can be effective at the same dose as non-injured men. Data shows PDE5 inhibitors are safe and effective for treatment of erectile dysfunction in men with SCIss (Giuliano et al., 2006; Giuliano et al., 2007; Lombardi, Macchiarella, Cecconi, & Del Popolo, 2009); however, the subgroup of men with SCIs and no ability to achieve erection is unresponsive to PDE5 inhibitors (Khorrami et al., 2010). In addition to the use of PDE 5 inhibitors, low testosterone is common after SCI and use of testosterone may be considered as part of treatment (Gannon & Walsh, 2016).
Other treatments for erectile dysfunction may require referral to a specialized provider. Second line medical management options include intracavernous injections (ICI) and intraurethral suppositories (Cochina et al., 2016; Conejero, Munoz, Sarrias, & Ramirez 2002; Bodner, Haas, Krueger, & Seftel, 1999). ICI medications include prostaglandin E1 (alprostadil), phentolamine and papaverine (Bimix), or phentolamine, papaverine and prostaglandin E1 (Trimix). ICI of aprostadil is FDA approved for erectile dysfunction in men with SCI and tends to be more effective in younger men with incomplete lesions. Some men with SCIs may, however, lack the manual dexterity required for self-injection and they may need assistance from a partner. Alprostadil may also be administered intrauretherally, though erections are less rigid than achieved by ICI and some individuals with SCIs may experience hypotension. A meta-analysis of ICI in males with SCIs found successful erections in 93% of men using phentolamine and papavarine and 80% using alprostadil (Watanabe et al., 1999). Risks of these medications include priapism and hematoma (Moemen et al., 2008). When priapism occurs in the setting of prostaglandin treatment, treatment with oral midodrine can be effective (Soler, Previnaire, Mieusset, & Plante, 2009).
Despite advances in medical management, the use of a penile prosthesis continues to be an important treatment for a small percentage of men with SCIs. When used in men with SCIs, inflatable and malleable penile prostheses have infection rates ranging 5–8% with satisfaction rates at around 80% (Kim, Yang, Lee, Jung, & Shim 2008). Malleable prostheses have a higher rate of perforation suggesting that inflatable prostheses may be safer (Zermann, Kutzenberger, Sauerwein, Schubert, & Loeffler, 2006).
In addition to erectile dysfunction, many men with SCI suffer from orgasmic dysfunction. As part of treatment, it is important to make men aware that orgasm can occur without ejaculation. Unfortunately, most studies in men with SCIs focus on ejaculation rather than orgasm and few treatments exist for orgasm dysfunction in men with SCIs. Promising results have, however, been obtained with the combination of vibratory stimulation and midodrine with the majority of men reporting orgasm (Soler, Previnaire, Plante, Denys, & Chartier-Kastler, 2008). Regardless of the technique used or the purpose of treatment, because of abnormalities in sensation, special attention must be made to ensure there is no damage to the penis during sexual activity in men with SCI.
Treatment of arousal and orgasm dysfunction in women
Although there may be more information available regarding female sexual response after SCI than male sexual response, little attention has been paid to the changing sexual concerns of women who are older before their SCIs or who age with SCIs. Arousal and orgasm disorders are common in women; however, there is an overall lack of FDA approved therapies for women. Thus the first line treatments for women with arousal and orgasm dysfunction after SCI are truly limited to lubricants, sex toys and vibrators.
With regards to prescribed treatments, flibanserin is now the only therapy approved for premenopausal females with hypoactive sexual desire. Unfortunately, flibanserin’s use is not recommended with alcohol and it is only approved for hypoactive sexual desire unrelated to medical or psychologic causes. Thus, with a SCI unless the hypoactive sexual desire is premorbid it is difficult to determine the exact etiology and off-label use is likely the only possible way to use the medication in women with SCIs. Other possibilities for treatment of desire and arousal problems are the use of off- label testosterone to treat desire or orgasmic dysfunction or the use of off-label sildenafil for arousal dysfunction. Low testosterone and poor libido are common in post menopausal women and testosterone patches have been approved to treat sexual arousal disorder in association with menopause in Europe. However, testosterone is not FDA approved for use in women in the US. Despite positive results in a laboratory study documenting increased arousal in women with SCI (Sipski, Rosen, Alexander, & Hamer, 2000), in a large multicenter trial both placebo and sildenafil groups showed similar increases in frequency of sexual activity and successful sexual encounters (Alexander, Rosen, Steinberg, & Hultling, 2011). These results should be interpreted with caution; however, because the primary outcome measures (Alexander & Marson, 2017) included frequency of successful sexual intercourse or masturbation, intercourse or oral sex resulting in orgasm, not increased sexual arousal or orgasm (Alexander & Marson, 2017). Successful sexual intercourse could mean different things to different people, thus results are not conclusive and careful off label use of sildenafil may be considered. Another problem that can negatively impact female sexual function is that of dyspareunia. Dyspareunia is common after menopause because of atrophied vaginal tissues and is commonly treated with lubricants and estrogens. Recently, ospemifene a non-estrogen was FDA approved for treating dyspareunia in post menopausal women and its use may be considered in SCI; however there are risks blood clots associated with its similar to the use of estrogen so these issues must be taken into account when treating women with SCIS.
For women who are anorgasmic after SCI the use of a clitoral vacuum suction device or vibratory stimulation may be beneficial (Alexander, Bashir, Marson, Alexander, & Rosen, 2017; Sipski, Alexander, Gomez-Marin, Grossbard, & Rosen, 2005). For women with complete LMN injuries affecting their sacral spinal segments, the use of alternative places for stimulation is suggested (Alexander et al., 2017). Additionally, the use of mindfulness techniques (Brotto et al., 2012) is recommended.
Medical comorbidities (and their treatments) which can impair sexual function
Preexisting and post injury medical conditions often impact sexuality. Specifically, cardiovascular disease, diabetes, urinary tract infections and other chronic illnesses are risk factors for sexual dysfunction. Mood disorders such as depression, anxiety and substance abuse are also known to have an impact on sexuality. These conditions need to be identified, assessed, and treated, before (or in parallel with) initiating specific sexuality interventions.
Hypertension is correlated with sexual dysfunction. In one study of 417 women, sexual dysfunction was found in 42.1% of hypertensive women compared to 19.4% of women without hypertension (Foy et al., 2016). Hypertension is also known to result in erectile dysfunction in men (Pallangyo et al., 2016; Rew & Heidelbaugh, 2016) and antihypertensive medications are correlated with decreased sex drive (Tedla & Bautistista, 2016). Many antihypertensive medications including thiazide class diuretics, beta-blockers, and centrally acting sympathetic blocking agents can contribute to sexual dysfunction and treatment guidelines often do not expressly discuss this problem (Al Khaja & Sequiera, 2016). The clinician caring for persons with SCI and hypertension must therefore consider this issue in persons that are sexually active.
Cardiovascular disease can also cause sexual dysfunction and erectile dysfunction often precedes symptomatic cardiac disease (Hackett et al., 2016). In women a trend has been noted towards greater sexual dysfunction with more significant cardiac disease. However, in a study of women undergoing angioplasty, 76% had sexual dysfunction and only age was independently related to the presence of sexual dysfunction (Megiddo et al., 2009; Oren, Megiddo, Banai, & Justo, 2016).
Impaired sexual function is also common in persons with diabetes and metabolic syndrome. Erectile, arousal and orgasmic dysfunction can be related to vascular causes and autonomic neuropathy. Recent publications suggest that interventions for carefully managing the underlying conditions, such as use of insulin pumps and the Mediterranean diet are correlated with preservation of sexual function (Maiorino et al., 2016a, 2016b).
Incontinence and urinary tract infections are common in individuals with SCIs. The same neurological pathways impact bladder dysfunction and sexual dysfunction. As a result, it is important to examine the effect of bladder symptoms directly on sexuality. The European Association of Urology Guidelines state “the greatest physical barrier to sexual activity in female neurological patients is urinary incontinence” though this appears to represent clinical consensus rather than an evidence based conclusion (Groen et al., 2016). There is an established association between benign prostatic hyperplasia with lower urinary tract symptoms and erectile dysfunction (Glina et al., 2015). The use of tadalafil along with finasteride has recently been shown to have greater improvements in sexual functioning with this condition than with placebo and finasteride, though long term efficacy has yet to be confirmed (Brasure et al., 2015).
Reproductive concerns
Over 90% of men with SCI have abnormal semen and natural conception is only seen in about 10% of couples with an affected male partner (Kafetsoulis et al., 2006; Ibrahim, Brackett, & Lynne, 2016). Despite normal sperm quantity, men with SCI have poor sperm motility and viability. Abnormalities including hypothalamic-pituitary-testicular axis dysfunction, disruption of sympathetic nerve activity to the epididymis and vas deferens, increased reactive oxygen species and leucocytes in the seminal fluid, abnormal seminal fluid, and sperm ultrastructure defects (Patki, Woodhouse, Hamid, Craggs, & Shah, 2008) may all contribute to poor sperm quality.
Lifestyle factors such as scrotal hyperthermia, techniques of bladder management, and infrequent ejaculation show little relationship with semen qualilty (Brackett, Lynne, Weizman, Bloch, & Padron, 1994). Clean intermittent catheterization did however tend to show improved sperm motility and quality over reflex voiding and indwelling catheters (Rutkowski, Middleton, Truman, Hagan, & Ryan, 1995). Repeated procedures to stimulate ejaculation do not improve the quality of results (Das et al., 2006; Sonksen et al., 1999; Hamid, Patki, Bywater, Shah, & Craggs, 2006) and there is no change in sperm motility based upon time post SCI (Brackett, Ferrell, Aballa, Amador, & Lynne, 1998).
As a consequence of ejaculatory dysfunction, most men with SCI require medical assistance to produce sperm. Options for this include PVS with and without midodrine, EEJ, prostatic massage, and sperm extraction.
PVS has been shown to be easy to use, safe and pleasurable in that it has been discussed in relation to orgasm (Soler et al., 2007). Success rates range from 19–96% in achieving anterograde and or retrograde ejaculation in men with SCIs (Weider, Brackett, Lynne, Green, & Aballa, 2000; Bird, Brackett, Lynne, Aballa, & Ferrell, 2001). Current approved devices include Ferticare (Multicept A/S, DK, Frederiksberg C) and Viberect X3 (Reflexonic, Frederick, MD, USA). Predictors of response to PVS include injury at or above T10 and the presence of a bulbocavernosus reflex. The use of a 100 Hz frequency and 2.5 mm amplitude stimulation has been shown optimal to produce ejaculation (Sonksen, Biering-Sorensen, & Kristensen, 1994). PVS technique includes applying the vibrator to the dorsum, frenulum, or sides of the penis for 2-3 minute cycles for up to 15 minutes and placing a sterile cup for collection of the specimen. If PVS alone is not successful, the addition of midodrine, PDE5 inhibitors and abdominal electrical stimulation can help promote ejaculation (Giuliano et al., 2008; Courtois et al., 2008; Leduc et al., 2015; Kafetsoulis et al., 2006; Soler, Previnaire, Plante, Denys, & Chartier-Kastler, 2007). Most recently, Chehensse et al. (2013) performed a meta-analysis of anejaculation and showed that those individuals with complete spinal cord lesions from T12-L2,S2-S4 or of all the spinal ejaculation centres T12-S5 were unable to achieve ejaculation via PVS and that the spinal segments between L2 and S2 likely harbour the spinal generator for ejaculation in the L3-L5 spinal segments.
If PVS fails, despite the use of midodrine, EEJ can be considered. The EEJ probe is placed into the lower rectum with an electrode facing the prostate and seminal vesicles. The current is gradually increased or administered as pulses with a step wise increase (Ibrahim, Lynne, & Brackett, 2016). One study suggests that using the interrupted current technique provides superior antegrade ejaculatory volumes (Brackett, Ead, Aballa, Ferrell, & Lynne, 2002). A retrospective study of 500 men showed success in over 85% of individuals with SCI at or above T10 with PVS and a success rate of more than 90% in men with EEJ (Brackett, Ibrahim, Iremashvili, Aballa, & Lynne, 2010). Examining fertility outcomes in men with SCIs, there were no significant differences between PVS and EEJ (Kathiresan et al., 2011). Men with SCIs at or above T6 are at risk for developing autonomic dysreflexia during PVS and EEJ. Autonomic dysreflexia has been defined as a 20 mm Hg increase above baseline blood pressure; however, it can also manifest as severe hypertension, headache, sweating, and goose flesh, and can be seen during any assisted ejaculation procedure. All men with SCI undergoing EEJ should have vital signs carefully monitored and physicians should consider pretreatment with nifedipine. Furthermore, those men with injuries above T6 who are using PVS have also been shown to have blood pressure elevations indicating dysreflexia and pretreatment should also be considered in this population. If severe symptomatic dysreflexia occurs, stimulation should immediately be discontinued.
For men with SCIs who fail PVS and cannot tolerate EEJ (or have rectal lesions precluding its use), prostate massage to manually produce sperm may be considered. This technique has shown some, albeit modest, success (Arafa, Zohdy, & Shamloul, 2007). Because PVS and EEJ have high success rates and are generally able to produce a sufficient number of sperm for intravaginal or intrauterine insemination, the use of testicular sperm extraction which requires costly and invasive intracytopasmic sperm injection is rarely necessary. Surgical sperm retrieval can be beneficial in men with SCIs who fail PVS and EEJ or for whom these treatments are not tolerated or available. Surgical sperm retrieval can be performed by open or percutaneous testicular biopsy, testicular or percutaneous epidydymal sperm aspiration, and microsurgical testicular sperm extraction. To date there is no comparison of the various techniques among men with SCIs and it is difficult to extrapolate from AB men given that the abnormalities are generally different between men with SCIs and AB men. A single center study of conventional testicular sperm extraction in men with SCI related anejaculation who had failed PVS showed successful sperm retrieval in 42/52 men (80.7%). Moreover, of 37 cases where intracytoplasmic sperm injection was performed, pregnancy was achieved in 32 (86.5%) with a take home baby rate of 70.2% (Iwahata et al., 2016).
Fertility and pregnancy for women with SCI
A complete discussion of this topic is beyond the scope of this paper thus the reader is referred directly to the references for more information. For women, SCI affects menstruation and pregnancy, but does not create a specific inability to conceive or create a direct impact on fertility. The menstrual cycle is often temporarily interrupted (Jackson & Wadley, 1999); however, age at menarche has not been shown to substantially change in adolescent girls with SCI (Anderson, Mulcahey, & Vogel, 1997). In light of this, women with SCIs must be cautioned of the need for birth control.
A recent study of the model SCI database noted pregnancy rates after SCI are similar to that of the nondisabled population (Iezzoni, Chen, & McLain, 2016). Women who are younger when they sustain their SCIs have a higher pregnancy rate (Bughi, Shaw, Mahmood, Atkins, & Szlachcic, 2008). Furthermore, in the model systems report, amongst the women with SCIs who were pregnant, there were higher functional abilities than those women who were not pregnant (Ieazzoni et al., 2016).
Special considerations for the pregnant SCI female include monitoring for related medical complications. Urinary incontinence is aggravated, and it is necessary to guide the woman with SCI about hygiene and to monitor closely for urinary infections and skin problems. Antibiotic choices must be made with the goal of protecting the fetus. Pregnancy can also aggravate the neurogenic bowel and bowel impaction must be avoided, because its treatment could lead to premature labor. The enlarging uterus will put pressure on venous structures, and venous stasis can lead to peripheral edema and venous thrombosis. Similarly, the enlarged uterus can decrease ventilatory capacity, leading to atelectasis and other respiratory complications (Bertschy, Boston, Meyer, & Pannek, 2016; Sterling, Keunen, Wigdor, Sermer, & Maxwell, 2013; Pereira, 2003).
Preparing for a more difficult pregnancy, labor, delivery and post-partum period is advised for women with SCIs. Before and throughout pregnancy, care should be provided from an obstetrician with specific knowledge about the medical complications of SCI, and the impact of SCI on pregnancy, labor and delivery. Additionally advice regarding pregnancy can generally be obtained from SCI centers if an experienced provider is unavailable. Labor and delivery issues are quite different for the woman with lumbo-sacral injury versus high thoracic or cervical cord injury. With lumbo-sacral injuries, autonomic dysreflexia is quite rare, while for women with SCIs at T6 and above, monitoring for autonomic dysreflexia must go on throughout pregnancy, particularly during labor and delivery. Care must be taken as dysreflexia has been confused with preeclampsia and both the patient and provider must be aware of the signs and appropriate therapies.
Discussion
After SCI, sexuality is impacted both from a psychological and medical perspective. As a result there is decreased frequency and satisfaction with sexuality after SCI. Recent research in women and men has shown predictable alterations in sexual arousal and orgasm and there are effective treatments available for these problems. In order to maximize sexual satisfaction after SCI it is recommended the clinician use a progressive protocol to treat individuals with SCIs including assessment of preinjury and concomitant medical concerns and educating the individual about the impact of their injury on psychosocial issues and sexual response. After encouraging the individual with SCI to practice, it is recommended the practitioner address iatrogenic causes of sexual dysfunctions and provide basic treatments before starting medication management. Frequent practice by the individual with SCI is emphasized and if problems persist it is recommended first line therapies to improve arousal and orgasm problems are considered. If these treatments are unsuccessful it is recommended the individual with SCI is referred to a subspecialist for further therapies.
With regards to fertility issues, the use of PVS in conjunction with midodrine will generally produce ejaculation in males and if this is unsuccessful, referral can be considered for EEJ. For women menstrual irregularities may occur in the immediate post injury period; however, successful pregnancy is possible provided attention is paid to possible complications, particularly the possibility for autonomic dysreflexia.
Challenges remain in our ability to treat sexual dysfunction in persons with SCIs. The reality that sexual function has both physiologic and psychologic components makes the performance of research complicated. The small size of the SCI population makes prospective clinical trials difficult. The preponderance of the literature related to treatment is for male erectile and ejaculatory dysfunction and contains retrospective data and/or small sample sizes. There is minimal literature addressing treatment of arousal disorders in females and orgasm dysfunction in males and females with SCI.
While meta-analyses may be helpful, as shown by Chehensse et al. (2013), it can be difficult to compare studies with persons from diverse levels and degrees of SCI and variations in treatment strategies. Further standardization through the use of the autonomic standards and the international data sets and collaboration in multi center trials will be helpful to allow performance of meta-analyses. More data are needed to determine optimal treatment strategies to promote sexual satisfaction and to determine the benefits of improved sexual function on quality of life. Research evaluating the impacts of various medication combinations on causing and treating erectile dysfunction and comparative trials of mechanical and medical means to treat erectile dysfunction after SCI with longer follow up would be beneficial. More studies focusing on improving female sexual arousal and treatment of orgasm in both men and women are necessary. Further neuroimaging studies in persons with specific levels and degrees of SCIs to understand the neurophysiology of sexual response and mechanisms for treatments of sexual dysfunction are warranted. Moreover, the use of new formats for treatment such as mindfulness, and new methods for treatment delivery such as telemedicine and internet based therapies are fertile areas for future clinical research.
In memorium
In preparing this article it was noted the physical medicine and rehabilitation specialist and scientist Clement Chehensse had passed away at an untimely age. He made valuable contributions to the understanding of the ejaculation in men with SCIs and the human spinal ejaculation generator in a short time. He would have made many more in the future.
Conflict of interest
None to report.