Key Points
After an SCI it is still possible to have and enjoy sex.
The degree of sexual dysfunction varies significantly among people with SCI and depends on the level and the severity of injury.
People with lesions at T6 and above must be aware that sexual stimulation, especially orgasm and ejaculation, as well as childbirth increases the risk of developing Autonomic Dysreflexia (AD).
Assessment
There is no one measurement tool that adequately assesses the complex issue of sexual health and satisfaction after SCI. For an assessment to be comprehensive, neurological bases for sexual health dysfunction are necessary (such as The International Standards of Neurological Classification of Spinal Cord Injury (ISNCSCI) or The International Standards to Document Remaining Autonomic Function after SCI (ISAFSCI).
Sexual and Reproductive Health in Men With SCI
In general, the majority of men can attain an erection after SCI either through the psychogenic (T11-L2) or reflexogenic (S2-S4) pathways, depending on the level and completeness of injury.
Phosphodiesterase Type 5 Inhibitors (PDE5i – e.g., Viagra®, Cialis®) can be used safely and effectively for treatment of erectile dysfunction (ED) in men with SCI and are recommended as first-line treatment.
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. Medically sanctioned vacuum erection devices (VED), penile rings, perineal training, mechanical devices, and penile prostheses all may be effective in enhancing erectile function in men with SCI. Surgical options should be reserved for cases where other ED treatments fail.
Sperm retrieval can be problematic after SCI. Semen quality in men with chronic SCI is reported to have decreased motility and viability, although total numbers of sperm tend to remain high.
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). PVS is most successful in men with SCI above T10.
Sexual and Reproductive Health in Women With SCI
Multiple laboratory-based studies have documented the presence of sexual arousal and orgasm in women with SCI.
Generally, women with SCI are less likely to achieve orgasm than able-bodied women, and time to orgasm is significantly increased compared to able-bodied controls. The ability to achieve orgasm, however, seems unrelated to the pattern or degree of neurological impairment in women with lesions down to T5 level.
Amenorrhea may occur immediately following injury, lasting 4-5 months on average, but fertility is generally not affected once regular menstrual cycle resumes.
Women with SCI are able to conceive, carry and deliver a baby; however, there is an increased frequency of complications during pregnancy, labour and delivery, including AD, bladder problems, spasticity, pressure sores, and problems with mobility.
Sexual Behaviour/Activity/Satisfaction After SCI
Frequency of sexual activity, desire for sexual activity and sexual satisfaction all tend to decrease after SCI in both men and women.
A 2004 survey of 681 people with SCI found that regaining sexual function was rated the highest priority for the majority of people with paraplegia, and the 2nd highest priority for those with tetraplegia, after restoration of hand and arm function.
Bladder and bowel management problems (incontinence/UTI’s) have a negative impact on sexual activity and satisfaction in both men and women after SCI. Continent urinary diversion in women with tetraplegia may result in improved self-image, quality of life, and greater sexual satisfaction.
For both men and women with SCI, psychological barriers to engaging in sexual activity include: feeling unattractive, low self-esteem, low sexual desire, lack of confidence in sexual ability and ability to satisfy a partner, lowered body image, and difficulty meeting a partner.
Education and Counselling
Surveys of people who have completed rehabilitation after SCI have expressed a need for more education and counselling on sexual health concerns. Some recent research reported that few people with SCI receive information or are satisfied with the levels of education about pregnancy or sexual health.
Research shows that patients expect their health care professionals to bring up sexuality and sexual health, but health care professionals can be reluctant to do so because of their lack of knowledge, fear of offending the patient, or discomfort in asking questions that address sexual concerns.
A number of studies in this area show that training in sexual health can make a positive difference in knowledge, attitudes, and willingness to bring up sexual health issues in health care professionals.
As sexual health can be complex and multi-faceted, the authors present a Sexual and Fertility Rehabilitation Framework – a multidisciplinary approach to addressing the multi- faceted needs of people after SCI.
