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Maintaining a healthy sex life after spinal cord injury is an
important priority to many people. Fortunately, over the past
few years a large amount of research has begun to be performed
in this area. Whereas in the past our knowledge about the field
of spinal cord injury was exclusively focused on males and
erectile function, recent work has begun to illustrate the
impact of spinal cord injury on female sexuality. Moreover,
recent gains in the study of infertility after spinal cord
injury have allowed professionals to approach the care of newly
injured patients with optimism for their potential in sexual
functioning. this article provides a basic review of what is
known about sexual functioning after spinal cord injury and the
impact on patients. Today sexual disfunction in SCI males can
sometimes be treated with new medications such as viagra, of
course a lot depends on exactly how the sexual function has been
affected
Sexual Response
The effect of spinal cord injury on sexual response is generally
discussed based upon the degree of completeness or
incompleteness of the patient's injury and whether the
neurologic damage affecting the individual's sacral spinal
segments is an upper or lower motor neuron injury. Whether a
spinal cord injury is considered complete or incomplete is
determined by whether they have voluntary rectal contraction and
whether they have the ability to perceive sensation around their
rectum. As males have external genitalia, questionnaire studies
have been utilized to determine the impact on erections and
ejaculations, depending on their extent of injury. In males with
complete spinal cord injuries and upper motor neuron injuries
affecting their sacral segments, there is a loss of psychogenic1
erectile function in conjunction with maintenance of reflex1
erectile functions (Bors & Comarr, 1960). In those males with
incomplete upper motor neuron injuries, there is still
maintenance of reflex function; however, some of these males may
be able to have psychogenic erectile function. For those males
with lower motor neuron injuries affecting their sacral spinal
segments, it has been shown that approximately 25 percent of
males will have psychogenic erectile function, whereas none of
these males will have reflex erectile function. With incomplete
lower motor neuron injuries affecting the sacral spinal
segments, over 90 percent of the population will be able to have
some type of erectile function.
Previous reports have hypothesized that female sexual function
would be affected similarly to male sexual function in that
psychogenic and reflex lubrication will be maintained in a
comparable fashion to males, depending on the level and degree
of the woman's spinal cord injury. Recent laboratory-based
research performed has supported the hypothesis that women with
complete spinal cord injuries and upper motor neuron injuries
affecting the sacral spinal segments will maintain the capacity
for reflex lubrication while losing the capacity for psychogenic
lubrication (Sipski and Alexander, 1995a). Moreover, in those
women with incomplete injuries and upper motor neuron injuries,
research indicates the preservation of the ability to perceive
pinprick sensation in the T11-L2 dermatomes may be able to be
used as a predictor for the ability of psychogenic lubrication.
Further research to confirm the effects of spinal cord injury on
women with injuries below the level of T6 is planned for the
future.
Ejaculatory function is markedly decreased in men with spinal
cord injuries. This is most likely due to the fact that
coordinated neurological impulses from the sympathetic,
parasympathetic, and somatic nervous systems are necessary for
ejaculation to occur. For instance, the rate of ejaculation in
men with complete upper motor neuron injuries can be as low as 4
percent (Bors and Comarr, 1960). Furthermore, many times men
with spinal cord injuries have ejaculation which goes back into
the bladder instead of coming out of the penis. Treatment of
this inability to ejaculate has recently been used successfully
to help men who suffer from infertility.
Treatment of Sexual Dysfunction
Treatment of male sexual dysfunction has been focused at the
treatment 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 be
helpful to maintain an erection. These rings may be used for up
to 30 minutes, but should not be used on a longer basis due to
the risk of insufficient blood flow to the penis causing
ischemia and subsequent complications. If a male is not able to
have an erection, a vacuum suction device may possibly be used
effectively to produce the erection, followed by the placement
of a similar ring. Again, this device should not be used for
more than 30 minutes due to the risk of ischemia. Recently, FDA
approval has been obtained to allow for self-administered
injections of prostaglandin E1 into the penis. This is followed
by an erection which occurs in approximately 5 minutes.
Potential complications from prostaglandin include the
development of priapism, a condition whereby an erection will
not go down; therefore, emergency instructions must be available
to the patient, and a system for appropriate treatment for
priapism must be in place. Intraurethral insertion of medication
is now also on the horizon as another mechanism to treat
erectile dysfunction. Drugs now commonly available such a viagra
have been shown to help prolong erections in incomplete injuries
too.
Other male sexual dysfunctions such as inability to have an
orgasm, decreased sexual desire, and premature ejaculation have
not been well-studied in the male population. Questionnaire
studies have revealed that approximately 50 percent of males
with spinal cord injuries can have orgasms and that the ability
to have orgasms is not related to the degree of spinal cord
injury. Furthermore, it has been documented that both sexual
satisfaction and frequency of sexual activity decrease after
spinal cord injury. As the focus changes from merely production
of an erection to improving the quality of feeling in male
sexual response, the reasons for the ability of some males to
attain orgasms and others not to will need to be elucidated.
Furthermore, treatment protocols for other male sexual
dysfunctions will need to be developed.
Similar to male sexual functions, females with spinal cord
injury have been shown to have the capacity to achieve orgasm
approximately 50 percent of the time, and this has not been
found to be related to the degree of injury. This has also
recently been confirmed via laboratory-based research (Sipski &
Alexander, 1995b). Similar to males, women with spinal cord
injury have been shown to have decreased sexual satisfaction in
addition to decreased frequency of sexual activities post spinal
cord injury. Treatment of inability to have orgasms, decreased
sexual desire, and arousal disorders has not been attempted in a
standardized fashion in women after spinal cord injury. Because
some women with spinal cord injury may be able to be orgasmic,
the use of sex therapy techniques similar to those utilized in
the non disabled population may be an appropriate treatment in
the future for women with spinal cord injuries.
Treatment of Male Infertility
As ejaculation is greatly decreased after spinal cord injury, it
follows that infertility can become a problem (Sipski &
Alexander, 1992). In addition to the inability to ejaculate,
males with spinal cord injury have decrease in the quality and
quantity of sperm which occur in the first few weeks
post injuries. Production of ejaculation via electroejaculation
(electrical stimulation in the area of the prostate which
produces ejaculate) followed by either
in utero insemination (insertion of the semen in the woman's
uterus),
in vitro fertilization,2 or
intracytoplasmic sperm injection3
has emerged as a viable option for treatment of male infertility
after spinal cord injuries. Whereas the use of these techniques
has been able to produce pregnancies in the partners of men with
spinal cord injuries, these techniques must be performed in a
clinic setting and can be somewhat costly. An alternative method
to remediate male infertility has been the use of
electrovibration applied to the penis. Due to the risk of
autonomic dysreflexia,4 this technique is initially performed in
a clinic setting, but may also be performed at home, and has
been done so in Europe and other countries around the world.
Electrovibration, similar to electroejaculation, is coupled with
artificial insemination of the female.
Women with spinal cord injuries suffer from temporary loss of
their menstrual periods after their injuries. After this, there
is generally resumption of periods, which most times return
similar to their previous fashion. Menstrual pain is still
present after spinal cord injury and there is generally not a
decrease in the ability of a woman with a spinal cord injury to
conceive. For this reason, the need to use birth control must be
emphasized with women who have spinal cord injuries.
For those women who become pregnant after spinal cord injury, it
is important that their gynaecologist is aware of the potential
complications associated with pregnancy and spinal cord
injuries. These can include anemia, problems with transfers due
to weight gain, urinary tract infections, pressure sores, and,
most significantly, autonomic dysreflexia, which frequently
occurs during labor in women with injuries above the level of
T6. Unfortunately, confusion of autonomic dysreflexia with
preeclampsia5 still occurs and the gynaecologist who works with a
woman with spinal cord injury must be able to differentiate
between these two conditions in order to properly treat
dysreflexia in the woman with spinal cord injury. Some studies
have shown an increased risk of caesarean section in women with
spinal cord injuries; however, more recent works have not shown
this increased incidence.
Conclusion
Sexual activity and the ability to remain a sexual being
persists in both males and females after spinal cord injuries.
As such, it is important to provide the patient with information
about how their sexual response and sexual functioning can be
affected after spinal cord injuries and for healthcare
professionals to know where to refer patients who are in need of
further information. In our rehabilitation hospital, this
information is supplemented by the presentation of our patient
education video, "Sexuality Reborn" (Alexander & Sipski, 1993).
The video includes various couples speaking about their sexual
functioning after spinal cord injury and demonstrating various
sexual techniques. Building upon these two instructional
presentations, the patient may also be referred to a sexuality
clinic for further information about their sexual potential or
remediation of problems which may occur. It is important that in
this time of change in the healthcare system, the need to
maintain healthy sexuality in persons with spinal cord injury
not be ignored. Recent advances in our understanding of this
area can be utilized to educate and counsel patients and
optimize their level of sexual health
References
1. Alexander, C.J., & Sipski, M.L. (Co-Producers). (1993).
Sexuality Reborn: Sexuality Following Spinal Cord Injury.
Videotape. Kessler Institute for Rehabilitation, West Orange, NJ.
2. Bors, E., & Comarr, A.E. (1960). Neurological disturbances of
sexual function with special reference to 529 patients with
spinal cord injury. Urology Survey, 110, 191-221.
3. Sipski, M.L., Alexander, C.J. (1992). Sexual function and
dysfunction after spinal cord injury. Physical Medicine and
Rehabilitation Clinics of North America (pp. 811-828).
Philadelphia: WB Saunders Company.
4. Sipski, M.L., Alexander, C.J., & Rosen, R.C. (1995a).
Physiological parameters associated with psychogenic sexual
arousal in women with complete spinal cord injuries. Archives of
Physical Medicine and Rehabilitation, 76, 811-818.
5. Sipski, M.L., Alexander, C.J., & Rosen, R.C. (1995b). Orgasm
in women with spinal cord injuries: A laboratory-based
assessment. Archives of Physical Medicine and Rehabilitation,
76, 1097-102.
6. Sipski, M.L., Alexander, C.J., & Rosen, R.C. (1996)
Physiologic parameters associated with the performance of a
distracting task and genital self-stimulation in women with
complete spinal cord injuries. Archives of Physical Medicine and
Rehabilitation, 77, 419-424.
Notes
1. In the able-bodied male there are two pathways for erection,
both of which result in increased engorgement of blood in the
penis. With a psychogenic erection, the person is aroused in his
brain by seeing something or hearing something. With a reflex
erection, the person is aroused by touching in the genital
region/area.
2. With in vitro fertilization, the male's sperm and the
female's egg are put together outside of the woman's body. After
the sperm fertilize the eggs the embryos are placed into the
women's uterus.
3. With intracytoplasmic sperm injection, an individual sperm is
used to fertilize an individual egg outside of the woman's body.
The embryo is then placed in the woman's uterus.
4. Autonomic dysreflexia is an abnormal reflex which occurs in
people with spinal cord injuries at the level of T6 and above. A
noxius stimulus such as bladder distention causes a chain of
reflexes which can lead to dangerously elevated blood pressure,
sweating, headache, and other symptoms. The condition is treated
by removing the offending stimulus and giving the patient
medication.
5. Preeclampsia is a medical condition which results in
hypertension and can result in seizures which can occur during
pregnancy.
Source
Marca L. Sipski, M.D.
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