Marca L. Sipski, M.D.  

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. In this article, I will provide a basic review of what is known about sexual functioning after spinal cord injury and the impact on patients.

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 at our institution 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 neurologic 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.

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 postspinal 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 nondisabled population may be an appropriate treatment in the future for women with spinal cord injuries.