Sexual Functioning After Spinal Cord Injury

Inpatient Physical Therapy Inservice

Author

Affiliations

Chloë Kerstein, B.S., SPT

Doctor of Physical Therapy

B.A. in Neuroscience

Summary

• After a spinal cord injury, it is still possible to enjoy sex!
• The degree of sexual dysfunction will depend on the level of injury, completeness, medications, psychological factors, etc. Currently it is impossible to accurately predict an individual’s potential based on only level/completeness of lesion.
• People with lesions at T6 neurological level and above need to be aware that sexual stimulation (orgasm & ejaculation) and childbirth increase risk of Autonomic Dysreflexia

Male

Definitions

• Reflex erection: from direct stimulation to genital area
• Psychogenic erection: stimulated by sights, smells, sounds, thoughts
• Emission: semen traveling in preparation for ejaculation

Complete Injury above T11-L2 spinal cord level

Reflex Erection possible, not psychogenic. This makes erection possible, but quality/maintaining an erection difficult. If SCI at this level, may preserve both erections. Emission/ejaculation likely impaired Complete Injury between T11-L2 and S2-S4 Psychogenic erection possible Reflexotenic erection possible Emission and ejaculation likely impaired Incomplete Injuries Erection possible, but quality/maintaining an erection may be impaired Ejaculation is rare but more likely to be spared with incomplete than complete SCI.

Treatments for Erectile Function

*Consult with your doctor! Medications Taken by mouth: Viagra, Levitra, Cialis etc Injectables ie) Caverject Vacuum pump w/ penile ring Cylinder placed over penis, drawing blood into penis for erection. Ring placed at base to keep erection for longer. Use < 30 min Surgical implants Is ejaculation still possible? Penile vibratory stimulation (PVS) Vibrator applied to head of penis to stimulate an ejaculation Electroejaculation Done for sperm retrieval when PVS fails. Electrical stimulation probe inserted into rectum so that an ejaculation occurs. Surgical Sperm Retrieval/Prostate massage

Female

Women Definitions: Lubrication: secretion of mucus Vasocongestion: engorgement of erectile tissues in clitoris, vagina, labia Complete injury above T11-L2 More likely to exhibit reflexive arousal, but not psychological arousal. So, more likely in response to manual stimulation in the clitoris region, but not to audio/visual stimuli/thoughts. Many will experience decreased vaginal lubrication Contraction of pelvic musculature likely impaired Complete injury between T11-L2 and S2-S4 More likely to exhibit psychological and reflexogenic arousal Many will experience decreased vaginal lubrication Contraction of pelvic musculature likely impaired Incomplete injuries Lubrication/vasocongestion possible, but may experience decreased vaginal lubrication. Contraction of pelvic musculature is rare but more likely to be spared than in complete injuries. Decreased vaginal lubrication? Use lubricant before sex! Menstrual cycle changes? Menstrual cycle may cease for 3-6 months (or longer in some cases) after SCI then will resume Can I still carry a baby/are there fertility changes? SCI does not change fertility in females SCI does not impact ability to carry babies to full term Vaginal delivery is common, no increased incidence of cesarean sections Risks with pregnancy: Autonomic dysreflexia (T6 and above), anemia, UTI, DVTs, pressure ulcers, respiratory compromise, constipation, premature labor and low birth weight are slightly more common in this population Contraceptives? Oral : increased risk of DVTs IUD: may be unable to feel if it perforates the uterus

Other

Fertility

• While men with SCI have options to assist with semen samples and have normal sperm numbers, SCI affects motility of sperm.
• SCI does not change female fertility
• Medically assisted procedures are available (gamete intrafallopian transfer, in vitro fertilization, intracytoplasmic sperm injection, etc)
• Can be financially/ emotionally taxing

Orgasm

• Does not need to be associated with a physical response, it is a pleasurable, subjective experience
• Climax can be achieved through intense cerebral stimulation or stimulation of areas above level of injury (lowest areas of intact sensation are most sensitive usually)
• More likely if S2-S4 cord segments remain functional. Men with incomplete injuries are more likely to experience orgasm than men with complete injuries. Completeness of injury does not predict orgasm functioning with females.
• Can increase spasticity just before or during orgasm
• After orgasm, spasticity may decrease

Autonomic dysreflexia during sex?

• Can be triggered by sex but not a major threat if handled appropriately
• Especially if you feel a headache starting to occur during sexual stimulation, stop stimulation briefly and this should resolve the headache. When it does, resume activity, avoiding the stimulation that brought headache on.
• What if I have a reflexively functioning bladder/bowel?
• Stimulation of pelvic structures can initiate voiding reflex

Suggestions:

• Empty bladder immediately prior to sex
• Do not drink large amounts of water before
• If it happens, remember what stimulated the voiding and avoid that if it becomes a pattern
• Time it so that sex occurs when bladder function is least likely (depends on daily routine)

Catheters

• Can remove before or keep in place
• Men with urethral catheters can fold along the side of penis, cover it with a condom or leave uncovered and lubricate well
• Women with urethral catheters can lubricate it or tape to abdomen/thigh out of way
• Women with suprapubic catheters can tape it to abdomen

Resources

Groups

SexSci.me Collaborative forum between people with SCI, health practitioners, etc

Sex Aids

Intimate Rider

• Disability Sex Aids for Couples with Limited Mobility

Liberator wedge

• Pillow/Wedge

MSKTC

• Informational page

Dr. Mitchell Tepper

• Sex and paralysis video series