AA

Key Points

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General

  • Common barriers to sexual satisfaction include bladder and bowel problems, as well as other SCI-related impairments (e.g., spasticity, lack of mobility).
  • Continent urinary diversion in women with tetraplegia may result in improved self-image, quality of life, and greater sexual satisfaction.

Men with SCI

  • Phosphodiesterase Type 5 Inhibitors (PDE5i) can be used safely and effectively for treatment of erectile dysfunction (ED) in men with SCI and are recommended as first-line treatment. A lesion above the sacral spinal tract and a higher reflexive erection are predictable favorable parameters for a positive response to all PDE5i.  Men with tetraplegia or high-level paraplegia should be cautioned about the possibility of experiencing postural hypotension for several hours after use.
  • Intracavernosal (penile) injectable medications (ICI) are very effective for the treatment of ED in men with SCI and may be used with careful dose titration and some precautions.
  • Topical agents are not effective for treatment of erectile dysfunction in men with SCI.
  • Intraurethral preparations are not effective for treatment of erectile dysfunction in men with SCI.
  • Medically sanctioned vacuum erection devices (VED) and penile rings may be used for treatment of erectile dysfunction in men with SCI.
  • Penile prostheses may be effective for treatment of erectile dysfunction in men with SCI, however, should generally be reserved for situations where all reversible erectile dysfunction treatments have failed.
  • Perineal training may enhance erectile function in men with SCI who have some voluntary pelvic floor muscle contraction.
  • The use of PDE5i for treatment of ED in men with SCI is effective, safe and popular, followed by the more invasive but highly effective method of intracavernosal injection.
  • The use of mechanical devices may be effective but are less popular, and surgical options should be reserved for cases where other ED treatments fail.
  • Promising options (but with limited evidence) exist for improving the chance of reaching orgasm in men with SCI include microsurgery of the sensory nerves to the penis and sensory substitution training. The use of oral midrodrine to encourage ejaculation may also improve chance of orgasm.
  • Implantation of an intrathecal baclofen pump, while effective in managing spasticity, may cause difficulties with erection and sexual function.
  • Prostatic massage alone is a safe and easy alternative way to retrieve semen in some men with SCI above T10.
  • The least invasive sperm retrieval method should be tried first (i.e. penile vibrostimulatory stimulation (PVS) in the clinic setting to monitor for autonomic dysreflexia) followed by the more invasive of electroejaculation procedure (EEP). Sperm aspiration can also be performed in either a clinic or operating room setting.
  • PVS is most successful in men with SCI above T10. EEP can be done on men with any level of SCI but may require anesthetic.
  • Midodrine may be an effective and safe adjunct to PVS in men not responding to PVS alone who are not at risk for significant autonomic dysreflexia.
  • PVS results in better sperm quality than that obtained by EEP.
  • Balloon catheters to tamponade the bladder neck may be effective in securing antegrade ejaculate samples.
  • Antegrade samples have better sperm motility than that found in retrograde samples.
  • Electroejaculation with interrupted current produces better sperm motility than with continuous current.
  • Bladder management with clean intermittent catheterization may improve semen quality over indwelling catheterization, reflex voiding or straining.
  • SCI sperm quality improves by processing in able-bodied seminal plasma.
  • Aspirated sperm has better motility following sperm retrieval procedures than ejaculated sperm which is more exposed to the toxic seminal vesicle components.
  • Sperm motility may improve by neutralizing receptors to various cytokines in semen.
  • Use of ejaculated sperm or aspirated sperm for reproductive purposes requires a cost- benefit analysis.
  • Botox injections to the overactive bladder may reduce semen volume, but increase semen quality.
  • Men with SCI should have realistic expectations of becoming a biological father.  Depending on semen quality and female factors, a progression from intravaginal insemination to assisted techniques such as intrauterine insemination, in vitro fertilization (IVF) to IVF plus intracytoplasmic sperm injection (ICSI) is recommended.
  • At home intravaginal insemination has revealed pregnancy rates of 40-50%.

Women with SCI

  • Sildenafil does not appear to result in clinically meaningful benefits in women who have sexual arousal disorder as a result of SCI.
  • Manual and vibratory clitoral stimulation may increase genital responsiveness in women with SCI.
  • Limited evidence exists which suggests that comprehensive gynaecologic services may improve women’s health behaviors.
  • Adequate anesthesia (spinal or epidural if possible) is needed for vaginal, Cesarean, or instrumental delivery.
  • Epidural anesthesia is preferred and effective for most women with AD during labour and delivery.

Education and counselling

  • Interactive educational workshops can improve clinician knowledge and attitudes towards sexual health counselling, as well as improve their ability to respond appropriately to the sexual concerns of patients.
  • There is some evidence, although limited, that exists to show participation in sexual health programs improves sexual health outcomes.