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 |
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| 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). |
|
| 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. |
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| 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). |
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| 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. |
|
| 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) |
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| 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. |
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| 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. |
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| 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. |
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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.
