1. Intimacy Rehabilitation following Spinal Cord Injury Maria van den Heuvel RN.BN.MHealSc(Rehabilitation) Clinical Nurse Specialist BURWOOD SPINAL UNIT 2012

2. The Effects of SCI on Sexual Function Depends on level & completeness of injury Personal & psychological characteristics Men – alteration in erectile quality - ejaculatory function - fertility issues Women – may experience loss of libido - vaginal lubrication - arousal

3. Sexuality Ethical Ideals Religious beliefs Moral opinions and actions Values Cultural Family Neighbors Peers School Marriage Law Custom Media Biological Physiological cycles Physiological changes Growth Development Reproduction Fertility Physical appearance Contraception Sexual arousal Sexual response Psychological Learned attitudes Learned behavior Emotions Experience Self concept Motivation Expressiveness

4. Erections The penis is under both autonomic (parasympathetic/sympathetic) and somatic (sensory/motor) neural regulation Psychogenic: mentally induced Reflexogenic: reflex arc exclusively in sacral spinal cord, touch, rub etc

6. Changes to erection post SCI T6 and above reflexogenic erection preserved,T10 above possible T12-L1 loss of both psychogenic and reflexogenic erection. Sacral injury may have both preserved

7. Erection Quality Often unreliable Often not long enough Often not hard enough for vaginal penetration

8. ORAL MEDICATIONS Can be used safely and effectively for treatment of erectile dysfunction in men with SCI and are recommended as first-line treatment. It can be predicted that men with preserved reflexogenic function will respond better.  Oral medications, such as Phosphodiesterase 5 inhibitors (PDE5i) Viagra, or Cialis. Erection is initiated by smooth muscle relaxation of the corpora cavernosa (erectile bodies) of the penis allowing blood to flow into the penis when stimulated.

9. ORAL MEDICATIONS CONTINUED Different types differ in strengths. Different time frames for achieving erections. NOT TO BE TAKEN WITH NITRATES – as a combination may cause a potentially dangerous decrease in blood pressure. Avoid taking a PDE 5 inhibitor for at least 48 hours after a severe episode of dysreflexia. Must not use GTN if Sildenafil (Viagra) has been take in the last 24 hours for AD. Must not use GTN if Tadalafill (Cialis) has been taken in the previous 4 days. NEVER exceed the prescribed dose.

10. Intracaversonal Injection Therapy 95% success rate with prostaglandins (papaverine, phentolamine, prostaglandin E1) Lack of vascular diseases in SCI population hence very effective, needs less dosage as well. Priapism, ecchymosis, autonomic dysreflexia

11. Priapism- erect penis that does not return to its flaccid state, despite the absence of both physical & psychological stimulation, within 4 hours A MEDICAL EMERGENCY Oral pseudo-ephedrine Cold shower Medical Detumesence

12. Topical medication and intraurethral Prostaglandin suppositories MUSE (Medicated urethral system of erection) intra urethral delivery of prostaglandin E1 suppositories. Success rate poor in SCI population Orthostatic hypotension serious side effect

13. Vacuum Erection Device Potential to achieve an erection adequate for vaginal penetration Premature loss of erection Ecchymosis, petechiae, skin edema, abrasion Penile skin necrosis

14. Penile Prosthesis Risks Infection rate Mechanical failure Extrusion Haematoma formation

15. Sexual Function in Women with SCI Acute physical and psychological trauma usually causes amenorrhea lasting 4-5 months on average. ‘Normal’ pattern returns & fertility is then unaffected Oral contraceptives may be considered if no history of DVT/PE or other medical indications. Increased UTI, Candida Reduced lubrication

16. SEXUAL RESPONSE Significant impairment in arousal and orgasm. Less likely to achieve orgasm than able-bodied women, and time to orgasm is significantly increased compared to able-bodies controls (Sipski et al. 2001). Following SCI women may attain genital sexual arousal through a psychogenic and/or a reflex pathway. Studies – manual & vibratory clitoral stimulation, Sildenafil to partially reverse subjective arousal difficulties, comprehensive gynaecological services to improve women’s health behaviours.

17. MENOPAUSE – little published re- SCI No significant differences in the menopausal symptoms of women with SCI and those without SCI Clinical evidence shows that within the SCI population, women with incomplete injuries tend to have more night sweats than women with complete injuries and women with paraplegia have reported more bleeding. Many of the indications of menopause tend to mimic or mask the physical symptoms commonly associate with SCI. This may result in delay in treatment for SCI- related conditions if a woman mistakenly believes her symptoms are a result of menopause rather than injury.

18. Sexuality Counselling & Education Maintain an open discussion and provide access to education about sex in both formal and informal settings throughout the treatment continuum. Providing assurance and basic information about sexuality should preferably occur during the acute rehabilitation phase. Discussing the subject of sexuality should be in a straightforward and nonjudgmental manner. Maintain a nonjudgmental attitude regarding sexual orientation, gender identity and individual difference.

19. Sexuality Counselling Consider using the PLISSIT framework for sexual counselling for determining both the clients needs and the professional’s level of skills in regard to provision of sexual health care: P = Permission Li = Limited Knowledge SS = Specific Suggestions IT = Intensive Therapy

20. Special Concerns SKIN CARE Discuss ways to avoid injuring skin or exacerbating existing pressure sores. After sexual activity inspect insensate skin surfaces, particularly around the genitalia and buttocks as these areas may have received excessive friction or tears. LUBRICATION Decreased lubrication may result in irritation Recommend artificial water-soluble lubricant

21. Special Concerns BLADDER Ensure is empty Spigot/tape catheter Restrict fluid intake 3-4 hours prior to sexual activity Men with IDC – fold it back along the penis & hold in place with a condom ISC if possible BOWEL Reliable routine (accidents unlikely if bowel a reflex type) Flaccid – may experience some leakage so emptying bowel & hour prior to sexual activity is suggested

22. Special Concerns AUTONOMIC DYSREFLEXIA For those with spinal cord damage at T6 and above: - Sexual activity, especially ejaculation may trigger an episode If individual starts experiencing the symptoms – advise they stop activity, sit upright, treat as advised NOTE – DO NOT USE GTN Spray for AD if Viagra has been taken in the last 24 hours or Cialis in the previous four days. SPASM Involuntary muscle spasms can interfere or assist with movement & positions during sexual activity If interfere – may be hip adductor spasm – try warm shower, medications, passive movements If assist – a possible advantage

23. Special Concerns POSITIONS Teach the person with SCI optimal positioning & bed mobility in accordance with his or her injury Encourage individuals to learn about the safety limits of their particular chairs. Experiment, think creatively Use pillows Consider unconventional locations for sexual activity Discuss the use of adaptive equipment (vibrator wands etc) and assistive devices – Intimate Rider

24. The Intimate Rider

25. Positions

26. Safe Sex after Spinal Cord Injury Communication Encourage open discussion to occur with partner regarding intimacy, sexuality, and fertility. Provide opportunities for partners together with individual with SCI to ask questions. Possible discomfort - Focus more on sensuality than sexuality, both partners may need to work through their anger and grief about the impact SCI has on their sexual relationship. Set aside regular times to establish/rebuild a sensual relationship together without focus on performance. Advise the individual to ‘stay in charge’, be aware that alcohol and recreational drugs tend to weaken good judgment.

27. Enhancing Sexual Pleasure with the use of Sexual Aids Especially useful for tetraplegics who have limited use of their hands and body movement. Can assist in sexually pleasing a partner or partner pleasing individual with SCI. Many different types available to purchase at adults shops or on-line. Advise against using the same vibrator for both vaginal and anal use. Unwise to share sexual aids and these should be washed and cleaned after each use.

28. Sexually Transmitted Infections Important to educate patients with SCI that they remain at risk for acquiring or transmitting sexually transmitted infections (STIs) Condoms correctly applied offer the best protection against STIs. Viral Sexuality Transmitted Infections include: Genital Herpes (HSV), Human Papillovavirus (HPV), Hepatitis, Human Immunodeficiency Virus (HIV) Non-Viral Transmitted Infections include: Candidiasis, Chlamydia, Gonorrhoea, Non Specific Urethritis (NSU), Trichomonas vaginalis and Syphilis.

29. Following Spinal Cord Injury

30. Orgasm Orgasm – a subjective experience for all Some people with SCI may achieve Orgasmic ‘transference” – explore erogenous zones

31. SCI and spermatogenesis Physical factors Testicular hyperthermia Decreased blood flow within 3 days post SCI

32. Ejaculation Seminal emission: T10-L2 sympathetic, hypogastric nerve: transport. L1-L2 sympathetic input via hypogastric Functional closure of bladder preventing retrograde ejaculation Propulsatile ejaculation: pelvic nerve, parasympathetic S2,S3,S4

33. SPERM RETRIEVAL Vibro ejaculation above T10 Bulbocavernous reflex if present, better success Superior quality of sperms High amplitude 100Hz,2.5 mm vibration stimulation Ejaculate within 1-5 min 4-6 cycles before giving up

35. Electro-Ejaculation Empty bladder,neutralise urine for retrograde ejaculation Nifedipine if AD possible Normally need between 4v-15v Continuous increasing current till antegrade ejaculation occurs Intermittent turn on 5 sec and turn off 5 sec, increase by 2V each time turned on till antegrade ejaculation occurs Preferred method as better sperm count

38. Operative techniques Removal from Vas deferens, epidydimis or testes MESA(micro epididymal sperm aspiration) PESA(percutaneous epididymal sperm aspiration) TESE(Testicular sperm extraction)

39. PREGNANCY – is usually normal; increase in complications Bladder & kidney infections Thrombosis & leg oedema Difficulty in transfers Potential for pressure areas Postural hypotension Autonomic dysreflexia Premature labour Difficulty in self care eg - ISC

40. Pregnancy cont/ Labour – usually progresses to normal vaginal delivery (may require forceps) First symptom of labour may cause severe autonomic dysreflexia in those with lesions above T6 Epidural anaesthesia – best control for this Post partum concerns – healing of perineum. Women above T5 may have difficulty breastfeeding due to impaired ‘let-down-reflex’ Baby-care – may need nanny/assistance

41. Sexuality Scenarios - discussion Nurse fails to cover female patient appropriately when pushing in shower chair down corridor to bathroom Physio laughs at patient when he tells her he is worried that his penis is flaccid and he will never get a girlfriend now? Patient asks physio “How will I be able to satisfy my partner ever again” Patient says to nursing student “I find you very attractive, Will you go out with me?

42. Sexuality Scenarios- discussion “I guess if I cannot ejaculate I don’t need to wear a condom” “What say my bowels open when we are having sex”? And what do I do with my catheter? “Will I ever have an orgasm again? “Where can I get information regarding sexuality issues”? Who can I talk to? “I’m so embarrassed, I keep getting erections, and I’m not even thinking that way” “Can I get pregnant? Can I use tampons?

43. RESOURCES Back on Track book ABC Library holds a variety of reading material & Videos regarding sexuality www.sexsci.me is a NZ interactive website. This forum is a available to individuals with SCI, their partners and health professionals as a place to get advise and discuss sexuality issues following SCI. www.sexsci.me

44. REFERENCES Consortium for Spinal cord Medicine (2010). Sexuality and Reproductive Health in Adults with Spinal cord Injury: A Clinical Practice Guideline for Health-Care Professionals. Paralysed Veterans of America website: www.pva.org Middleton, J., Wolf, A., Cameron, I., Elliot, S., McBride, K., Breen, S & Abramson. (2010). Sexual Health Following Spinal Cord Injury. SCRIRE website: www.scireproject.com.www.scireproject.com Sexual Health Team Sir George Bedbrook Spinal Unit. (2002). Information Guide for Men. Edition 1, Royal Perth Hospital.