Sexual and Reproductive Health

Sensation, Ejaculation and Orgasm

Ejaculation, the process of external semen expulsion, is primarily a sympathetic phenomenon (involving the spinal cord segment between T10-L2). Internally, there is a pathway for sperm to be transported from the testicles with accessory fluids before being expelled out the end of the penile urethra (antegrade ejaculation) (Krassioukov & Elliott 2017). Ejaculatory disorders (most often the lack of both seminal emission and antegrade ejaculation called anejaculation) are highly prevalent (reported at over 90%) so fertility can be a major issue for men with SCI (Elliott 2002). Ejaculation is most likely to occur naturally in men with incomplete conus or cauda equina lesions, and men with lesions higher than T6; ejaculation is least likely to occur naturally in men with complete supraconal lesions (Comarr 1985; Ibrahim et al. 2016). Retrograde ejaculation can also occur, most often in men with sphincterotomy or who have a suprapubic catheter (Ibrahim et al. 2016).

Much of our existing knowledge of ejaculation and orgasmic sexual satisfaction is derived either from self-report surveys or indirectly reported in the fertility literature, thus further research is needed. Not surprisingly, there are no RCT studies in this area, with only one study performing laboratory evaluation of these altered responses in men with SCI (Sipski et al. 2006). Orgasm, in particular, is a phenomenon that is not well defined, either clinically or neurophysiologically, being generated via cerebral, body or genital sources of stimulation, and usually is self-described by participants only in terms of being either similar or different in comparison to their pre-injury experience. Sipski et al. (2006) report that the preservation of light touch and pinprick sensation in the T11-L2 dermatomes is helpful in predicting which people with SCI can achieve psychogenic arousal.

A study by Phelps et al. (1983) found 42% of 50 male veterans with SCI reported orgasm. Alexander et al. (1993) showed in their series that the majority of 38 men with SCI could not ejaculate, with the exception of those with an incomplete paraplegia of whom 75% could ejaculate in some fashion. Despite this, they reported that in the group with complete SCI lesions, 50% of the men with tetraplegia and 25% of those with paraplegia reported that they could have some sort of orgasm, and of those that could, 38% with tetraplegia and 67% with paraplegia reported it was not accompanied by ejaculation. For the men with incomplete SCI lesions, 66% of the men with tetraplegia said they could have orgasm (of which 50% said it was accompanied by ejaculation) and 75% of those with paraplegia reported they could have some kind of orgasm that was always accompanied by ejaculation. There was a significant correlation between the ability to have an orgasm and ejaculation, as was the ability to ejaculate and having an erection firm enough for penetration.

Similarly, a recent laboratory study of 45 men with SCI and 6 able-bodied controls (Sipski et al. 2006) demonstrated that 79% of the men with incomplete lesions and 28% of those with complete lesions achieved orgasm in the laboratory setting (historically, these men reported post-injury orgasmic ability to be 84% and 50%, respectively). Independent significant predictors of orgasm in the laboratory were completeness of injury and prior history of orgasm post-injury. Those men with lower motor neuron lesions affecting the sacral segments (n=4) had no historical or laboratory experience with orgasm. They also reported that although orgasm and ejaculation were likely to occur together, the presence of orgasm was not necessarily connected with presence of ejaculation.

Author Year; Country
Dates included in the
review
Total sample size
Level of evidence
Type of study
Score		 Methods
Databases		 Outcomes
Chéhensse et al. 2013; France
Reviewed published
articles from 1955 to 2012
N=45
Level of evidence
Methodological quality not
assessed
Type of studies
All cross-sectional studies
36 retrospective
AMSTAR=3		 Method: searched for all published articles
examining the occurrence of antegrade
rhythmic forceful or dribbling ejaculation as a
function of the neurological characterization
of the lesion. All levels of evidence were
included.
Databases: MEDLINE, EMBASE,
EBSCOhost, Cochrane Library
  1. Ejaculation occurred in response to (i)masturbation or coitus; (ii) penile vibratory stimulation (PVS) followed by masturbation; (iii)acetylcholinesterase (AchE) inhibitors followed by masturbation in: (i)11.8%; (ii)47.4%; (iii)54.7% of patients with complete SCI (i)33.2%; (ii)52.8%; (iii)78.1% of patients with incomplete SCI
  2. Ejaculation in response to PVS or AchE inhibitors prior to masturbation was rhythmic forceful in 97.9% of patients with complete lesion strictly above segments S2-S4. Complete lesion of the S2-S4 segments precluded the occurrence of rhythmic forceful ejaculation.
  3. Controlling for the number of the injured segments between T12 and L2, the ejaculation rate sharply decreased when the lesion extended to the L3 segment and below.
  4. The spinal sympathetic and parasympathetic centres are crucial for emission and the somatic centre for expulsion.
  5. The spinal segments between L2 and S2 are more than a pathway to connect the ejaculation centres; L3-L5 segments likely harbour a spinal generator of ejaculation.

Author Year; Country
Score
Research Design
Total Sample Size		 Methods Outcome
Overgoor et al. 2013; The Netherlands
Pre-post
Level 4
N=30		 Population: 30 men (SCI n=12, Spina bifida
n=18) with no penile sensation but good
groin sensation.
Treatment: TOMAX (TO MAX-imize
sensation, sexuality and quality of life)
procedure that involved microsurgical
connection of the sensory ilioinguinal nerve
to the dorsal nerve of the penis unilaterally.
Outcome measures: sensitivity testing,
bulbocavernosus testing, Hospital
Depression and Anxiety Scale (HADS),
Symptom Checklist (SCL-90-R), Groninger
Arousability Scale (GAS), Visual Analogue
Scale (VAS).
  1. Participants became more sexually active with their partners and with more satisfaction.
  2. Postoperative (11-24 months) glans sensation increased from absence to having sensations.
  3. All patients retained the preoperative ability to have an erection and ejaculations.
  4. Participants reported having more open and meaningful sexual relationships with their partners.
Courtois et al. 2011; Canada
Cohort
Level 2
N=89		 Population: Men who achieved ejaculation
with (n=50) or without (n=39) experiencing
autonomic dysreflexia (AD).
Treatment: Ejaculation was obtained
through natural stimulation, vibrostimulation
or vibrostimulation combined with midodrine
(5-25 mg).
Outcome measures: Questionnaire
inquiring about the physiological responses
related to orgasm to test the hypothesis that
orgasm is related to AD in individuals with
SCI.
  1. Significantly more sensations were described at ejaculation than with sexual stimulation alone.
  2. Men with SCI who experienced AD at ejaculation reported significantly more cardiovascular, muscular, autonomic and dysreflexic responses than those who did not.
Borisoff et al. 2010; Canada
Pre-post
Level 4
N=3		 Population: 3 males (mean age = 38, range 34-42) with SCI ≥1 year.
Treatment: Sexual self-stimulation while using a novel sensory substitution device that
mapped the stroking motion of the hand to a
congruous flow of electrocutaneous
sensations on the tongue. Erectionenhancing drugs administered as needed.
Outcome measures: Solitary Masturbation
Orgasm Questionnaire (Mah and Binik); SCI
Ejaculation Questionnaire (Courtois et al.);
Sexual Sensations Questionnaire (SSQ).
  1. Each participant reported an increased level of sexual pleasure compared to baseline after a few training sessions.
  2. No difference found on the ejaculation questionnaire scores.
Soler et al. 2008; France
Pre-Post
Level 4
N=158		 Population: 158 participants with SCI who
failed to ejaculate from penile vibratory
stimulation (PVS).
Treatment: Oral midodrine, starting at 7.5mg in participants with tetraplegia and 15mg with paraplegia.
Outcome Measures: Ejaculation; orgasm.
  1. With midodrine, ejaculation was obtained in 102 men (64.6%).
  2. 93 (59%) participants reported orgasm with both midodrine and PVS, compared to 14 patients with only PVS.
  3. Participants with upper motor neuron injury and incomplete lesions experienced significantly more often orgasm.
Courtois et al. 2014
Canada
Retrospective Study
Level 5
N=33		 Population: 34 males (mean age= 41 years,
age range= 19-65 years) with SCI who have
been consulted for sexual dysfunctions over
the past 20 years, lesions varied from L5-S1
and S4-S5, average delay since injury= 10
years
Treatment: None
Outcome Measures: Occurrence of
psychogenic and reflexogenic erection and
ejaculation since injury, and test for perineal
reflexes (bulbocavernosus reflex, anal reflex,
cremasteric reflex)
  1. 31/33 patients maintained natural ejaculations, but 18 complained of premature ejaculation (PE) and five of spontaneous ejaculations.
  2. 14 patients complained of dribbling ejaculation, and 27 of non-climactic ejaculation (13 no sensation, 10 some sensation, 4 painful sensation).
  3. Medical assessments showed absent or diminished anal sensation in 28 patients, absent or diminished anal reflexes in 21, absent or diminished bulbocavernosus reflexes in 20, but 12/13 positive cremasteric reflex.
  4. Urodynamics showed 12/20 areflex and 2/20 hyperactive bladders
Soler et al. 2016;
France
Post test
Level 4
N=33		 Population: 33 males with anejaculation
during sexual stimulation; mean
age=29.0±9.1 years; mean time since the
onset of the neurological disorder was
6.6±6.4 years; 19 have complete motor
lesion (AIS A or B), 1 had incomplete motor
lesion (AIS C).
Treatment: Penile vibratory stimulations were carried out following bladder catheterization
and instillation of a pink buffering medium
(Ferticult) and then PVS. If they failed to
ejaculate, PVS was combined with oral
midodrine 5mg up to 30mg until the patient
ejaculated. The urethra was then milked
manually to ensure that as much semen as
possible was collected. Two-step
catheterization was then performed: a
catheter was inserted through the urethral
sphincter into the prostatic urethra to aspirate its content, and then bladder catheterization was performed to collect the Ferticult. The
procedure was repeated in some patients
after at least 1 week.
Outcome Measures: Type of ejaculation,
quality of sperm, antegrade/retrograde
fraction, prostatic urethra fraction, motility,
viability, and pH of sperm.
  1. A total of 42 trials were obtained from 22 patients. Sperms were found in the prostatic urethra in 21 samples (50%) from 12 patients (11 with spinal cord injury, 1 with diabetes).
  2. The colour of all 21 prostatic urethra sperm samples differed from the Ferticult.
  3. Sperm motility was greater in 8 samples, sperm count was higher in 10 and pH was different in 10, compared with the bladder samples.
  4. The higher overall quality of the sperm allowed cryopreservation in 10 prostatic urethra samples compared with only 5 bladder samples.
  5. Four of the five patients who underwent repeated trials had a reproducible pattern of prostatic urethra ejaculation
  6. The presence of sperm in the prostatic urethra most probably results from ‘ejaculation dyssynergia’, a lack of coordination between bladder neck and external sphincter.
  7. Sperm from the prostatic urethra should be systematically sought to improve the outcome of assisted reproduction.
Leduc et al. 2015;
Canada
RCT
Level 1
PEDRO=8/11
N=20		 Population: 20 men with traumatic SCI (level
C4-T9) of at least one year duration, and
anejaculation.
Treatment: Participants were randomized
into two groups, Group M and Group P
where group M received an oral
administration of flexible sham-midodrine
(7.5-22.5 mg max) followed by PVS, and
group P received oral administration of
(placebo) followed by PVS. Intervention
occurred once a week for a maximum of 3
weeks or until ejaculation occurred.
Outcome Measures: Ejaculation, and
measurement of AD.
  1. Treatment of anejaculation after SCI with midodrine and PVS did not result in a better rate of antegrade ejaculation in 10 men than in 10 men treated with a placebo and PVS.
  2. One participant (10%) from group M reached ejaculation and two participants (20%) from group P reached ejaculation.
  3. Autonomic dysreflexia occurred in three patients (none of which ejaculated) during PVS.
Castle et al. 2014;
United States
Case series
Level 4
N=30		 Population: 30 anejaculatory males with SCI
who were unable to ejaculate by sexual
intercourse or masturbation, level of injury
T10 and rostral.
Treatment: The Viberect-X3 (Reflexonic,
Frederick, MD, USA) was applied to 30
consecutive anejaculatory men with SCI
whose level of injury was T10 and rostral. All
patients received one trial of penile vibratory
stimulation (PVS) with Viberect-X3. All
patients were familiar with PVS and had
been administered one or more previous
trials with an alternate device. Prior to PVS,
participants whose level of injury was T6 or
rostral were administered 10–40mg
nifedipine sublingually to manage autonomic
dysreflexia. Viberect-X3 was administered.
Outcome Measures: Ejaculatory success
rate, time to ejaculation, volume of ejaculate,
blood pressure, adverse events.
  1. The ejaculatory success was 77% (23/30) slightly lower than previously published PVS success rates.
  2. No adverse events occurred, and there were no malfunctions of the device.

Discussion

Microsurgery of the sensory nerves to the penis is one promising treatment for improving senation and orgasm in men (Overgoor et al. 2013). A sensory substitution technology trained patients over 20 sessions to map tongue sensations to sensory perceptions of the genitalia (Borisoff et al. 2010) is one other possible therapeutic avenue for sexual rehabilitation.

One study (Soler et al. 2008) examined the effect of midodrone, an oral selective alpha-adrenoceptor agonist, which is mainly used as a treatment for orthostatic hypotension, on orgasm among 158 individuals with SCI who failed to ejaculate at home and when using penile vibratory stimulation. Soler et al. (2008) found that midodrine combined with penile vibratory stimulation produced orgasm in 59% of participants compared to 9% with vibratory stimulation alone, and orgasm was significantly related (84%) to the presence of either antegrade or retrograde ejaculation. Orgasm was experienced more among individuals with incomplete injuries (vs complete) and among individuals with upper motor lesions (vs lower motor lesions). It is important to note that the sympathomimetic effect results in a significant increase in both systolic and diastolic blood pressure, and caused several patients to develop intense autonomic dysreflexia that required medical attention. It is theorized that orgasmic sensations, with or without ejaculation, are related to somatic responses of vibrostimulation and perceived sensations of autonomic dysreflexia, and that orgasm appears to be a reflex partly under cerebral influence and could therefore be learned and practiced (Courtois et al. 2004; Elliott 2002). In research on the efficacy of the Viberect-X3 for treatment of anejaculation in men with SCI, we conclude that the device is safe and effective for inducing ejaculation in men with SCI.

Conclusion

There is level 4 evidence (Overgoor et al. 2013) that microsurgery of the sensory nerves to the penis may be one treatment for improving sensation and orgasm in men.

There is level 4 evidence (Borisoff et al. 2010) that sensory substitution training may be one therapeutic avenue for sexual rehabilitation.

There is level 4 evidence (Soler et al. 2008) that oral midrodrine may improve orgasm and ejaculation in men with SCI and level 4 evidence that PVS and midrodrine induces ejaculation in anejaculatory males with SCI.

There is level 1b evidence (Leduc et al. 2015) that oral midrodrine and PVS does not result in a better rate of antegrade ejaculation in men with traumatic SCI.

There is level 5 evidence (Courtois et al. 2014) that 53% of patients complained of premature ejaculation and 15% complained of spontaneous ejaculation.

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.

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