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Sexuality after SCI William McKinley MD Associate Professor PM&R

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Presentation on theme: "Sexuality after SCI William McKinley MD Associate Professor PM&R"— Presentation transcript:


2 Sexuality after SCI William McKinley MD Associate Professor PM&R
Director SCI Rehab Medicine Virginia Commonwealth University

3 Objectives Describe & contrast male & female sexual response following SCI Identify options for management of sexual dysfunction following SCI Discuss the impact and approach to sexuality following SCI

4 Demographics of SCI: “Who are we talking about?”
8, ,000 traumatic SCI / year (MVA, violence, falls) men (4:1), ages years complete = incomplete Non-traumatic SCI (33% of SCI admits) (spinal stenosis, cancer, ischemia, infection) male = female, older ages incomplete > complete

5 Sex vs Sexuality Sexuality: an expression of maleness & femaleness through body, personality and behavior involves: physical, emotional, social affects sense of well-being, self image, self esteem, partner relationships & quality of life (QOL)

6 Overview of Human Sexual Response (HSR)
Masters & Johnson: 4 Phases of HSR Excitement Plateau Orgasm Resolution

7 Normal Sexual Function in Females

8 HSR in able-bodied Females
Excitement Phase afferent stim of genitals (via pudendal N) increase in blood flow vasocongestion and tumescence of external genitalia (mons pubis, labia, clitoris, vagina) vaginal lubrication “Reflex (S2-4) “Pschogenic” (T10-L2)

9 HSR in a-b Females (cont)
Plateau Phase vasodilation in vagina uterine & cervical elevation sexual flush (seen in 75%) secretions from Batholin’s gland (analogous to “emission phase” in male ejaculation) increase in breast size, nipple erection increase in RR, pulse rate, BP

10 HSR in a-b Females (cont)
Orgasm Rhythmic contractions of uterus, outer 1/3 of vagina & anal sphincter studies suggest orgasm is an S2-4 sacral reflex Resolution Phase gradual loss of vasocongestion & tumescence (unlike males, during resolution, may return to orgasm phase…)

11 SCI & Female sexual function

12 Terminology “Complete” SCI = no motor/sensory sparing
“Incomplete” = sparing of motor/sensory Upper Motor Neuron (UMN) = descending sp cord tracts affected, caudal reflex arcs intact Lower Motor Neuron (LMN) = non-functional reflex ability (consider “spinal shock” period)

13 SCI & HSR in Females In “Complete UMN” SCI In “Complete LMN” SCI
maintenance of reflexic (S2-4), but not psychogenic (T10-L2) vaginal lubrication PP at T11-12 predictive of Psych lubrication Orgasms reported even with complete SCI T-9 & above In “Complete LMN” SCI No reflexic, but 25% psychogenic lubrication

14 Females & Intercourse after SCI
67% report IC post injury (87% prior) Predictive info: years post SCI - 50% yr 1, 75% > 10 yrs LOI - 62% cerv, 70% thor, 82% L/S Complete = Incomplete Problems reported: lubrication, decreased enjoyment… positioning (40%), spasticity(26%), bl incont (17%), AD (11%)

15 Female Sexual activity post SCI
Most individuals who were sexually active prior to SCI remain so. Positive sexual adjustment is reported in majority (by 6 mo p-injury)

16 Female sexual activity (cont)
Orgasm reported in 54% took more time and more intensity relocation of erogenous zones reported 71% reported “pleasure” above LOI Favorite sexuality activities Pre- SCI : intercourse Post-SCI: kissing, hugging, touching

17 Impact of SCI on Female Fertility
No adverse impact on female fertility Amenorrhea (seen initially in 60%) returns by 6 mo (50%), by 12 mo (90%) Once menses returns = Fertile! No increase in spontaneous abortions noted

18 Female Contraception p-SCI
Oral pills - contraindicated w/ h/o DVT low dose progestin has lower risk Implants (levonorgesterol) - appear safer Cerv diaphram/caps/sponges - not rec’s due to dec. uterine sensation, inc risk PID Barrier method (male contraception) - may be safest!

19 Prenatal & Perinatal Pregnancy Issues
constipation (decreased gastric motility) UTI’s (? abx choice, change to sterile IC) decreased mobility in 3rd trimester vital capacity decreases (uterine elevation) DVT risk (dec venous return & mobility) Autonomic dysreflexia (T-6 & above) Pressure ulcers Spasticity

20 Pregnancy Issues (cont)
Perinatal SCI above T-10 do not feel onset of uterine cont (labor pains) small increase in premature delivery & low birth weights delivery before 37 weeks (30-40%) vaginal delivery is preferred episiotomy rx w/nonabsorb sutures (breakdown) AD in 90% (HTN confused w/ pre-eclampsia) Rx - epidural anesthesia

21 Parenting Issues in Females
Most did NOT feel well informed 70% satisfied with post-SCI sexual exp. breast feeding not contra (dec milk w/sci >T6) Felt family roles/relationships similar to before more division of HH & child care tasks children did not perceive mothers differently partners did not perceive undue burden Divorce rate higher, especially when married prior to SCI

22 Normal Sexual Function in Males

23 HSR in able-bodied Males
Excitement phase Erection -vasocongestion & penile tumescence vasodilation of penile arts w/i corpus cavernosum (nitrous oxide / cGMP-mediated) influx of blood flow compression of venous outflow by non-distensible Tunica Albuginea (maintains erection)

24 Neuro-innervation of erection
Psychogenic erection - SNS (T12-L2) via hypogastric N Reflexogenic erection - PNS (S2-4) via Pelvic N penile sensation - pudendal N.

25 HSR in a-b Males (cont) Plateau phase
testicular elevation & enlargement secretions from bulbourethral (Cowpers) glands sexual flush (seen in 25%) increase in RR, pulse rate

26 HSR in a-b males (cont) Orgasm Phase = Ejaculation (2 phases)
1. Emission - SNS innervation (T12-L2) contraction of vas def, seminal vesicle & prostate sends emissions to posterior urethra closure of bl. neck prevents retrograde ejaculation 2. Ejaculation - PNS & Somatic innerv.(S2-4) contraction of Bulbospongiosum & Ischiocavernosum pelvic floor m’s opening of external urethral sphincter - anterograde projectile ejaculation

27 HSR in a-b males (cont) Resolution Phase
contraction of sinusoidal smooth muscle entrapped blood flows out thru emissary veins decreased rigidity, de-tumescence males are refractory from “repeat” orgasm

28 SCI and sexual function in Males

29 Overview: SCI & male HSR
1. Erectile dysfunction UMN > LMN, incomplete > complete 2. Ejaculatory dysfunction LMN > UMN, incomplete > complete anejaculation retrograde ejaculation 3. Poor semen quality

30 SCI & Male HSR: Overview (cont)
Complete UMN SCI 90% reflex erections (lesions above T-10), poorly sustained no psychogenic erections (above T-10) 40% “successful” for intercourse 5-10% ejaculation Complete LMN SCI 25 % erections psychogenic 10-25% “successful” for intercourse 15-20% ejaculate (many retrograde due to dec opening of ext sph. & dec closure of bl neck)

31 Erectile Dysfunction (ED): Treatment options
1. Penile implants / prosthesis 2. Vacuum devices, constriction rings 3. Intracavernous injections 4. intraurethral / topical meds 5. Oral medications (Viagra)

32 Erectile Dysfunction: Treatment
1998 Viagra

33 Erectile Dysfunction (ED): Treatment Options
Penile implant (within corp cavernosum) types: rigid, semi-rigid, inflatable* advantages: spontaneity, duration, (external catheter) disadvantages: invasive surgical option high complication rate (erosion, infection, mechanical failure, removal (10-30 %)

34 ED treatment (cont) venous constriction band- maintains rigidity
Vacuum pump - tube w/ constriction rings negative pressure to inc bl flow 90% successful disadvantages: dec spontaneity, discomfort, bruising, necrosis flaccid proximal to ring (“pistoning”) rec’d usage < 30 minutes at a time relative contraindications - anticoag,

35 ED treatment (cont) Intracaverous Injections (90% success)
Papaverine 2-5 mg(sm m relaxant) & Phentolamine (alpha-adren antag) Prostoglandin E ug (vasodil & sm m relax)(Alprostadil) erection in 10 min, lasting 30 min-6 hours…(avg = 2 hours) SE: scarring, infection, pain, priapism Rec’d usage: 1-2 per week

36 Priapism: management Priapism (abnormally sustained erection):
Can be a potentially emergent situation requiring: aspiration from corpus cav. Alpha-agonist injection (ephedrine) oral terbutaline 5mg

37 ED treatment (cont) Intraurethral meds Topical agents
instillation of protoglandin (Alprostadil, MUSE) erection in 5-10 min, lasting min less rigidity (may need constriction band), dec satisfaction SE: hypotension (drop 20/10), pain, bleeding Topical agents NTG paste, minoxidil, prostoglandins not approved by FDA

38 Sildenafil (Viagra) Sildenafil (Viagra) Pathophysiology:
originally studied as angina Rx FDA approved (1998) as 1st oral ED med Pathophysiology: inhibits CGMP phosphodiesterase type 5 (ie: increases cGMP) (inc’d conc of PDE-5 in penis) increases smooth m relaxation in corpus cav.

39 Viagra: outcome studies
75-80% success (vs 7% in placebo) accepted as 1st line Rx for ED Useful in both UMN & LMN efficacy depends on sparing of either sacral (S2-4) or T-L (T10-L2) segments absence of both seems to exclude success

40 Viagra: (cont) Dosage: 25-100 mg Contraindications: Viagra + nitrates
given min PTA, requires stimulation Contraindications: Viagra + nitrates (both inc c-GMP) CVD is NOT a contraind. (NO signif inc in CV events) SE’s: hypotension (10/7 drop), HA, dyspepsia, dizziness, blurred vision, rhinitis, diarrhea, rash (no AD or priapism)

41 ED: Associated Factors to consider
Smoking HTN, DM, CVD Depression Chronic ETOH Medications: (anti-hypertensives, anti-depressants, anti-arrhythmics)

42 Treatment Recommendations for ED
Review asso factors / meds Satisfactory reflex erections may enhance with constriction band Viagra * Injections or vacuum device (patient choice) intraurethral meds

43 Ejaculatory Dysfunction: treatment options
1. Injected meds 2. Penile vibratory stimulation 3. Electro-ejaculation 4. sperm aspiration

44 Ejaculatory Dysfunction (cont)
Intrathecal neostigmine (cholinesterase inhibitor) & sub-Q physostigmine SE: severe HA, N/V, AD NOT approved! NOT recommended!

45 Penile Vibratory Stim. activate ejaculatory reflex via dorsal penile N. (10-45 min) 90% success w/newer settings (high amp 2.5cm, freq 100Hz), UMN > LMN Predictors: hip flexion reflex & BC reflex primarily anterograde ejaculate SE: AD (10%), superficial trauma

46 Electroejaculation 85% success rate (UMN > LMN, but both possible)
electric probe placed in contact w prostate & Sem ves min) anterograde & retrograde ejac cath prior, instill sperm-friendly medium, cath post SE’s: discomfort, AD (monitor BP), rectal injury, spasticity generally tol’d (5% require sedation/anesth)

47 AD: management Autonomic Dysreflexia = “uncontrolled sympathetic hyperactivity” in SCI above T6 potentially life-threatening stimuli include: sexual activity, masturbation, semen retrieval tech’s, bladder… Rx: education, prevention, pre-activity medications (nifedipine, nitropaste, clonidine)

48 Sperm aspiration Sperm aspiration from: testes vas deferens epididymis

49 Conclusion: Ejaculatory Dysfunction Rec’s
PVS / self administration EEJ (if PVS failure) IUI or IVF Sperm aspiration

50 SCI and Male Fertility Significantly decreased fertility rate (1% with sexual intercourse alone…ie: w/o assistive options) secondary to: Erectile dysfunction Ejaculatory dysfunction anejaculation retrograde ejaculation Poor sperm quality

51 Semen Quality after SCI

52 Semen Quality (cont) Poor sperm motility (in spite of nl #)
20% motile (vs 70% in a-b males) factors: recurrent UTI, epididymitis, scrotal hyperthermia, meds, stasis of prostatic fluid, retrograde ejaculation, chronic denervation, change in hormones (test, FSH, LH) future research necessary! Should semen be frozen? Not recommended semen quality does not decline (freezing may decrease motility by 50%) semen quality is better with PVS vs RPE

53 Insemination 1. Home insemination 2. Intrauterine 3. In-vitro
4. Intracytoplasmic 5. Gamete fallopian transfer

54 Insemination Home insemination with PVS prophylactic nifedipine
non-spermacidal collection container 10 ml syringe for vaginal self-insem. Multiple trial cycles timing, sx, body temp, “kits” 25-60% successful

55 Assisted Reproduction Technology (ART)
Fertility success rate 90% w/ ART Intrauterine insemination (IUI) 10-15% success lad-collected sperm sep’d from semen fluid good for “motile” sperm In-vitro fertilization (IVF) 25% success, Usually asso w fertility drugs (inc # eggs) again, good for motile sperm

56 ART (cont) Intracytoplasmic Sperm inj. (ICSI) - inj of single sperm directly into ovum (can be used if poor motility) inc rate of multiple births, premature delivery, miscarriage no inc in birth defects Gamete intra-fallopian transfer (GIFT) egg & sperm placed in fallopian tube

57 Parenting issues in Males w/SCI
Children of males w/SCI well adjusted Sexual readjustment individual persons wishes experience pre-injury sexual habits

58 Related Practical Issues
positioning bladder / bowel skin breakdown prevention AD spasticity

59 Sexual history & intervention
“ENIGMA” E = engage in conversation N = normalize sexuality I = inform & educate G = guide & suggest M = maximize abilities A = assess & reassess

60 Sexual Intervention (cont)
“PLISSIT” model of sexual therapy a spectrum of interventional areas that can be addressed in part by each member of the interdisciplinary team P = permission LI = limited information SS = specific suggestions IT = intensive therapy

61 Summary: Female & Male Sexual function after SCI

62 Summary: Female post-SCI
Lubrication present or easily enhanced Enjoyment / orgasm are key issues Fertility essentially normal

63 Summary: male post-SCI
“Succesful” Erection/intercourse in 33% Oral meds (Viagra) has enhanced efficiency Poor unassisted ejaculation / orgasm / fertility With assistance, fatherhood very possible

64 Successful Sexuality after SCI
Education! Preparation! Communication!


66 Q & A

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