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

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Presentation on theme: "Sexuality after SCI William McKinley MD Associate Professor PM&R Director SCI Rehab Medicine Virginia Commonwealth University."— 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 l (MVA, violence, falls) l men (4:1), ages years l complete = incomplete §Non-traumatic SCI (33% of SCI admits) l (spinal stenosis, cancer, ischemia, infection) l male = female, older ages l incomplete > complete

5 Sex vs Sexuality §Sexuality: an expression of maleness & femaleness through body, personality and behavior l involves: physical, emotional, social l 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 l Excitement l Plateau l Orgasm l Resolution

7 Normal Sexual Function in Females

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

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

10 HSR in a-b Females (cont) §Orgasm l Rhythmic contractions of uterus, outer 1/3 of vagina & anal sphincter l studies suggest orgasm is an S2-4 sacral reflex §Resolution Phase l gradual loss of vasocongestion & tumescence l (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 l maintenance of reflexic (S2-4), but not psychogenic (T10-L2) vaginal lubrication PP at T11-12 predictive of Psych lubrication l Orgasms reported even with complete SCI T-9 & above §In Complete LMN SCI l No reflexic, but 25% psychogenic lubrication

14 Females & Intercourse after SCI §67% report IC post injury (87% prior) §Predictive info: l years post SCI - 50% yr 1, 75% > 10 yrs l LOI - 62% cerv, 70% thor, 82% L/S l Complete = Incomplete §Problems reported: l lubrication, decreased enjoyment… l 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% l took more time and more intensity l relocation of erogenous zones reported l 71% reported pleasure above LOI §Favorite sexuality activities l Pre- SCI : intercourse l Post-SCI: kissing, hugging, touching

17 Impact of SCI on Female Fertility §No adverse impact on female fertility §Amenorrhea (seen initially in 60%) l 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 l low dose progestin has lower risk §Implants (levonorgesterol) - appear safer §Cerv diaphram/caps/sponges - not recs due to dec. uterine sensation, inc risk PID §Barrier method (male contraception) - may be safest!

19 Prenatal & Perinatal Pregnancy Issues §Prenatal: l constipation (decreased gastric motility) l UTIs (? abx choice, change to sterile IC) l decreased mobility in 3rd trimester l vital capacity decreases (uterine elevation) l DVT risk (dec venous return & mobility) l Autonomic dysreflexia (T-6 & above) l Pressure ulcers l Spasticity

20 Pregnancy Issues (cont) §Perinatal l SCI above T-10 do not feel onset of uterine cont (labor pains) l small increase in premature delivery & low birth weights delivery before 37 weeks (30-40%) l vaginal delivery is preferred episiotomy rx w/nonabsorb sutures (breakdown) l 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. l breast feeding not contra (dec milk w/sci >T6) l Felt family roles/relationships similar to before more division of HH & child care tasks l children did not perceive mothers differently l 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 l 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 l testicular elevation & enlargement l secretions from bulbourethral (Cowpers) glands l sexual flush (seen in 25%) l increase in RR, pulse rate

26 HSR in a-b males (cont) §Orgasm Phase = Ejaculation (2 phases) l 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 l 2. Ejaculation - PNS & Somatic innerv.(S2-4) contraction of Bulbospongiosum & Ischiocavernosum pelvic floor ms opening of external urethral sphincter - anterograde projectile ejaculation

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

28 SCI and sexual function in Males

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

30 SCI & Male HSR: Overview (cont) §Complete UMN SCI l 90% reflex erections (lesions above T-10), poorly sustained no psychogenic erections (above T-10) l 40% successful for intercourse l 5-10% ejaculation §Complete LMN SCI l 25 % erections psychogenic l 10-25% successful for intercourse l 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) l types: rigid, semi-rigid, inflatable* l advantages: spontaneity, duration, (external catheter) l 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 l negative pressure to inc bl flow l 90% successful l disadvantages: dec spontaneity, discomfort, bruising, necrosis flaccid proximal to ring (pistoning) recd usage < 30 minutes at a time relative contraindications - anticoag,

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

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

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

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

39 Viagra: outcome studies §75-80% success (vs 7% in placebo) l 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 l absence of both seems to exclude success

40 Viagra: (cont) §Dosage: mg l given min PTA, requires stimulation §Contraindications: Viagra + nitrates (both inc c-GMP) –CVD is NOT a contraind. (NO signif inc in CV events) §SEs: 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 l 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) l electric probe placed in contact w prostate & Sem ves min) l anterograde & retrograde ejac cath prior, instill sperm-friendly medium, cath post l SEs: discomfort, AD (monitor BP), rectal injury, spasticity generally told (5% require sedation/anesth)

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

48 Sperm aspiration §Sperm aspiration from: l testes l vas deferens l epididymis

49 Conclusion: Ejaculatory Dysfunction Recs §PVS / self administration §EEJ (if PVS failure) l 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: l Erectile dysfunction l Ejaculatory dysfunction anejaculation retrograde ejaculation l 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 l prophylactic nifedipine l non-spermacidal collection container l 10 ml syringe for vaginal self-insem. l Multiple trial cycles timing, sx, body temp, kits l 25-60% successful

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

56 ART (cont) l 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 l 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 l individual persons wishes l experience l 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 l 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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