1. Female and Male Sexual Function after Spinal Cord Injury International Symposium of SCI November 24, 2007 Humlebaek, Denmak Stacy Elliott, MD Sexual Rehabilitative Medicine Clinical Professor Department of Psychiatry and Urology University of British Columbia, Canada

2. Vancouver, British Columbia, Canada Faculty Disclosure: No affiliation with any mechanical devices or use of medications for BP control discussed in this presentation

3. Dr. Mark Nigro Urology Colleagues in Sexual Medicine since 1986 with SCI Dr. George Szasz Prof. Emeritus Sexual Health Clinicians GF Strong Rehab Centre 2007 Vancouver Sperm Retrieval Clinic

4. Is sex really that important following SCI? Anderson (2004). Targeting recovery: priorities of the spinal cord-injured population J. Neurotrauma 21(10):1371-1383.

5. Sexual Satisfaction after SCI Generally lower in both sexes, but ¾ satisfied Predictors: higher education, higher income and lower age, fewer medical conditions Factors in involved in sexual rehabilitation: - bladder and bowel - mobility and sensory capacities - sexual self esteem - relationship issues May be the primary sexual barrier(s) !

6. What happens to womens sexual functioning after traumatic SCI ?

7. Sexual Activity Changes after SCI Less penetrative sexual intercourse ( ~70%) Noncoital activities increase More use of breast, nipple, vibrator stimulation ¼ will experience penetrative anal intercourse after injury White et al 1993 : Jackson and Wadley 1999

8. Sexual Intercourse Difficulties after SCI 1.Positioning during foreplay ( 72%) and intercourse (77%) 2. Vaginal lubrication ( 65%) 3. Spasticity ( 63%) 4. Dysparunia ( 18%) White et al 1993 : Jackson and Wadley 1999

9. Common problems for women with SCI Arousal difficulties sense of subjective arousal may or may not be present: objective arousal dependant on neurology +/- sensory preservation Orgasmic difficulties* 50% may experience orgasm indistinguishable in description from pre-injury but takes longer and requires higher stimulus * Papers: Marca Sipski, Beverly Whipple, Cindy Meston

10. What happens to mens sexual functioning after traumatic SCI ?

11. Common problems for men with SCI Arousal difficulties - 2/3-3/4 can obtain but not necessarily maintain erections: ED complaint common Ejaculatory difficulties - anejaculation biggest problem - priority is pleasure, not fertility Orgasmic difficulties* - 40-50% may experience orgasm * Papers: Alexander, Sipski, Anderson, Elliott

12. Psychogenic Pathway Reflexogenic Pathway Genital arousal Non injured SC

13. Cervical Injury Reliant on sacral reflex Genital arousal

14. Sacral Injury Genital Arousal Reliant on mental arousal

15. Spinal Mediation of Vasocongestion Sipski ML, Alexander CJ, Rosen R., et al 2001, 2006 and 2007 Preservation of light touch and pinprick sensory function in the T11-L2 dermatomes is associated with psychogenically mediated genital vasocongestion. Reflex lubrication possible with complete UMN lesions

16. Changes to Erection Functioning After SCI Men with incomplete and/or UMN injuries have a better prognosis for erection as compared to those with complete and LMN injuries respectively Underlying medical factors can also contribute to the erection problem

17. ? Ejaculation and/or Orgasm Is reflexogenic component key to orgasm after SCI ?

18. Summary Orgasm for Women with SCI 90% pre-injury: 30 -50% post-injury orgasmic predictors were greater sexual knowledge and higher sex drive Sipski: 59% above S2-S5 17% with S2-S5 Incomplete > complete regardless of LOI Thoracolumbar and thoracic > cervical

19. Orgasm = more than a reflex Whipple et al., 1996b; 1996c; 1997 Complete injury T-10 and/or above theoretically should not be able to perceive sexual response from cervical or vaginal stimulation Capable of experiencing orgasm from either/or both vaginal self- stimulation and cervical self- stimulation. Also reported experiencing menstrual discomfort. Tepper ISSWSH 2002 Hypogastric Plexus T10 to L2 Carries Psychogenic Messages

20. fMRI and PET-Imaging 4 women with compete SCI > T10 Vaginal –cervical stimulation to orgasm resulted in activation of the inferior region o the nucleus tractus solitarii (NTS),the region of the medulla oblongata to which the vagus nerves project Whipple 2002, Komisaruk 2004

21. Summary Orgasm for Men with SCI Men LOI not so predictive majority orgasmic are ejaculating but not all improved erections may enhance the chance of ejaculation, i.e. sometimes the use of PDE5i can be helpfulimproved erections may enhance the chance of ejaculation, i.e. sometimes the use of PDE5i can be helpful Both sexes: reports of orgasm with recruitment of sensate areas

22. Orgasm Neurophysiology Still unclear Better definition: genital and non-genital? Pinprick to genitalia + voluntary anal contraction predictive of genital orgasm Afferent signals can be from brain alone ( ie Tantric practices, sleep) may provide neurohormonal element for orgasm May be AD variant : autonomic/visceral interpretation ( F. Courtois, S.Elliott)

23. Relearning Signals Use sexual software to expand the potential when the neurological hardware is disrupted Concept of neuroplasticity

24. Dr. Jaimie Borisoff Neil Squire Foundation, Vancouver, BC New research : Sensory Substitution PI: Dr.Gary Birch

25. What therapies are there for men with SCI when they have… Low libido Improve sexual payoff R/O biological factors Erection dysfunction Erection enhancement Delayed ejaculation Vibrostimulation (VS) No ejaculation VS or EEP Poor sensation Erogenous recruitment Orgasmic sensation Male Kegel exercises Autonomic dysreflexia Preventative: use of antihypertensive?

26. Treating Erection Dysfunction after SCI For men, there are many options Oral : Phosphodiesterase V inhibitors (PDE5i) 80% Penile Injections 95% Vacuum devices and rings: effective but less attractive Intraurethral and topical : not effective Surgical implants : last resort

28. Oral Medications Treating Male Sexual Dysfunctions after SCI

29. Acetylcholine Parasympathetic Nerves Nitric Oxide Erection Smooth Muscle Cell NANC Endothelial cells guanylate cyclase

30. Acetylcholine Parasympathetic Nerves Nitric Oxide Erection Smooth Muscle Cell NANC Endothelial cells guanylate cyclase enhanced with PDE-5is

31. PDE5i Tx in Men with SCI S ildenafil (Viagra) treatment was associated with significant improvements in satisfaction with sexual intercourse ( the frequency of ejaculation, the frequency of orgasm, and overall sexual satisfaction were improved but were not statistically significant) Vardenafil (Levitra) also improved erection and was recently noted to significantly double the ejaculation rate in men with SCI ( 19% with vardenafil vs.10% for placebo) Giuliano et al, Annals of Neurology 1999;46:15 – 21 Giuliano et al, RESPITE study, Bayer presented October 2004

32. PDE5i in Men with SCI Dosing reliant on NO source so start low with : - young man - reflexogenic but unreliable erection - hypotensive - liver or kidney dysfunction Increase the dose ( need > 6 tries) Be sure to outline the correct timing and why Prescribe for efficacy and cost

33. Pharmacokinetic Properties of PDE5 Inhibitors Porst H. Int J Impot Res 2002;14 Suppl 1:S57 Cialis and SCI??? 05101520 Tadalafil Sildenafil Vardenafil Hours t max t½t½ 0.66 1.16 2.0 3.9 17.5 3.82

34. Treatment of Sexual Dysfunctions Following SCI: Phosphodiesterase inhibitors (PDE5) Advantages oral noninvasive safe for most men negligible risk of priapism lifetime use may help retain natural function Disadvantages hypotension facial flushing confusion with AD less effective with lower injuries rigidity not as good as with injections No nitrate use

35. Oral MedicationsPenile Injections Treating Male Sexual Dysfunctions after SCI

36. Prostaglandin E1 Erection Smooth Muscle Cell adenylate cyclase enhanced with PGE1

37. Treatment of Sexual Dysfunctions Following SCI: Intracavernosal Injections Advantages small doses rarely need Bi-Trimix reliable best rigidity may be painless Disadvantages priapism risk long term invasive therapy fibrosis

38. Oral MedicationsPenile Injections Intraurethral Pellet Treating Male Sexual Dysfunctions after SCI

39. Treatment of Sexual Dysfunctions Following SCI: Intraurethral Micropellet of PGE1 Advantages less invasive catheter familiarity Disadvantages poor responsiveness Actis ring necessary hypotensive possibility may have urethral stricture

40. Oral MedicationsPenile Injections Vacuum device Intraurethral Pellet Treating Male Sexual Dysfunctions after SCI

41. Treatment of Sexual Dysfunctions Following SCI: Vacuum devices and Constrictor Bands Can be beneficial to those men who cannot tolerate medications constrictor band can only remain on for 30 minutes - SCI may not feel a band that remains on watch anticoagulation therapy bands alone can maintain a reflex erection

42. Treating Erectile Dysfunction with Surgical Methods Rarely used now, but improved technology

43. Ejaculation potential: Borrow from Sperm Retrieval Techniques Sperm Retrieval Vibrostimulation & Electroejaculation

44. Various vibrators can be used to assist pleasure via ejaculation / orgasm for men with SCI

45. What to do about the specific female sexual problems Sexual disinterest Improve payoff Poor lubrication* H20 based lubricants Genital insensitivity * Recruit sensate areas Weak pelvic floor Kegel exercises, Vacuum device, vibrators? Orgasmic difficulties Vibrators ( clitoral and cervical) Dysparunia manage source Autonomic dysreflexia Preventative: use of antihypertensive? *Use of Viagra, Levitra or Cialis (PDE5i)

46. Treating Womens Arousal Dysfunction after SCI PDE5i may assist ? For women, there are no drugs on the market effectively enhancing arousal or orgasmic capacity

48. AN ICORD COURTSHIP BCIT VSD Design Team GF Strong Sexual Health Rehab Service

49. Prototype of BCIT/ICORD 2007 FEMALE and MALE VSD

50. What are the risks to sexual activity after SCI?

51. Spinal Cord Injury Uninjured Spinal Cord Peak BP 220/140 mmHg Peak BP 170/110 mmHg Greatest CV risk at orgasm

52. Examples of Objective and Subjective CV Responses in ICORD 2005 study Subject level and completeness Resting HR BP Peak HR BP SSR preservation of descending pathways Symptoms at Ejaculation C7 ASIA A Complete Quad 72129 84 76229 139 none severe T4 ASIA A Complete Para 63138 73 65221 125 none below level of injury mild C5 ASIA C Incomplete Quad 6797 64 54214 136 Partial preservation of SSR in both arms moderate

53. Dr. John Steeves Director, ICORD Rick Hansen Dr.Andrei Krassioukov Research Champions

54. Treatment of Sexual Dysfunctions Following SCI Three principles of rehabilitation 1. Maximization of physiology 2. Adaptation to limitations 3. Positive outlook on future potential

55. Sexual Rehab: focusing on what you can do vs what you cant! Thank you!

57. Reproductive Issues Compared to men with SCI, fertility in women with SCI is not an issue Birth control is more challenging (40 – 75%) Pregnancy and childbirth have more complications than pre-injury The perception of being able to be a mother suffers after SCI Babies are often of lower birth weight

58. Oral MedicationsPenile Injections Vacuum device Intraurethral Pellet Treating Male Sexual Dysfunctions after SCI

59. Changes to ejaculation following spinal cord injury Chance of ejaculation with sexual activity: incomplete > complete LMN > UMN BUT may not be the same with sperm retrieval