Sensation, Orgasm, and Ejaculation in Men with Spinal Cord Injury

A spinal cord injury impairs the nervous system’s ability to transmit messages between the brain and the body, including many types of sensation (NINDS, 2026). Problems may result from impaired neural transmission that directly limit someone’s sexual response, including the ability to have an orgasm (Lombardi et al. 2015). Orgasm is a complex neurophysiological phenomenon, but it is generally driven by a massive autonomic nervous system response inducing involuntary pelvic floor muscle contractions and a release of neurohormones, experienced as ‘sexual release, climax, intense pleasure, and ensuing deep relaxation’ (Hess & Hough 2012; Rosenthal 2012). Researchers have reported 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 (i.e., erection in men or vaginal lubrication in women), whereas reflexogenic orgasm is more often preserved in people with injuries above T11 and generally requires the presence of an intact sacral reflex arc (Alexander & Marson, 2018; Hess & Hough 2012; Sipski et al. (2006).

After SCI it is common for men to be unable to ejaculate without medical assistance (Sinha et al. 2017; Chéhensse et al. 2013). 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 enhanced with accessory fluids before being expelled out the end of the penile urethra; this is referred to as antegrade ejaculation (Krassioukov & Elliott 2017). Retrograde ejaculation, a condition where semen travels backward into the bladder instead of exiting through the penis during orgasm, resulting in a “dry orgasm,” can also occur most often in men with sphincterotomy or who have a suprapubic catheter (Ibrahim et al. 2016a). Anejaculation is when there is a lack of seminal emission and antegrade ejaculation. Ejaculatory disorders are highly prevalent (reported at over 90%) thus fertility can be a major issue for men with SCI (Elliott 2002). Ejaculation is more likely to occur naturally in men with incomplete conus or cauda equina lesions, and men with lesions higher than T6 if vibratory stimulation is used. Ejaculation is least likely to occur naturally in men with complete supraconal lesions (Comarr 1985; Ibrahim et al. 2016a).

Discussion

Most functioning for people with SCI is determined by the level and completeness of injury (World Health Organization, 2024). Sexual function is innervated lower in the spinal cord, so experts recommend taking physical/sexual history in addition to neurological examination, paying specific attention to the T11-L2 and S3-5 spinal segments when assessing sexual sensation, orgasm, and ejaculation (Alexander et al. 2017).

Most research in men’s sexual health is focused on male erectile function and fertility, however, sexual pleasure and orgasm are often cited as top priorities for recovery in people with SCI (Borisoff et al. 2010; Albright et al. 2015). A recent review reported that approximately 50% of sexually active men and women retain orgasmic ability after SCI, though time to orgasm may be longer in people with SCI than in the general population (Alexander & Marson, 2018).

Sensation

De Moura et al. (2020) found that men reported decreased sensation and sexual response after SCI, specifically, decreased sensation at the penis and testicles following injury (p=0.02). Other areas of the body, however, did become more sensate, such as the mouth, neck, and ears. Researchers and clinicians suggest that individuals should explore their bodies and use multiple senses to discover areas that are most sensual and pleasing (Hess & Hough 2012; Elliott, 2006). Different parts of the body, especially at the level of injury, can become sexually pleasurable; stimulation to the nipples, earlobes, or inner thighs may be perceived as erogenous and even evoke genital awareness in the absence of genital sensation, thus exploring sexual and responses in the SCI population should take a head-to-toe approach (Hess & Hough 2012; Elliott, 2006).

In one of the more novel studies we found, Borisoff et al. (2010) used a sensory stimulation replacement protocol whereby participants masturbated and received electrocutaneous stimulation on the tongue as a form of sensory substitution designed to improve the sexual experience. All participants reported orgasmic feelings early in the training, but these feelings were not replicated in later sessions. Though preliminary and with few participants, this study is the first to show promise for sensory substitutions as a possible therapeutic avenue for sexual rehabilitation in people with SCI.

We found one study that used a microsurgical surgical procedure to connect the sensory ilioinguinal nerve to the dorsal nerve of the penis unilaterally (Overgoor et al. 2013). In the post-operative period (11-24 months), 24/30 patients (80%) gained overall groin sensation that transformed into real glans sensation in 11 patients (33%); these patients reported better overall sexual function (p=0.022) and increased satisfaction (p=0.004).

Orgasm

Sipski et al. (2006) found in a study of 45 SCI and 16 non-SCI controls, 79% of the men with incomplete lesions and 28% of those with complete lesions achieved orgasm in the laboratory setting using erotic videos and self-stimulation (p<.001). In the past, this group of men reported post-injury orgasmic ability to be 84% and 50%, respectively. None of the men with complete lower motor neuron dysfunction affecting their sacral segments achieved orgasm in the laboratory, vs. 55% of men with all other types of SCI (P=.04). 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.

A few medicines used in SCI treatment have been tested to see if they influence arousal and orgasm. In one of the few RCTs in this area, Cardenas et al (2014) demonstrated that fampridine-SR had superior effects to a placebo on both erectile function and orgasmic function in 213 men with SCI. Midodrine, an oral selective alpha-adrenoceptor agonist that is mainly used as a treatment for orthostatic hypotension, is also often used to enhance orgasm and ejaculation in SCI patients. Soler et al. (2008) found that midodrine combined with PVS produced orgasm in 59% of participants compared to no orgasm in 41% of participants (p<.01). Orgasm was also experience more in men with incomplete injuries and upper motor lesions 93% of participants with upper motor neuron injuries had somatic responses vs. 26% of participants with lower motor neuron injuries (p<.01). Injury at or below T10, LMN lesions, and no somatic responses during stimulation were significantly related to the absence of orgasm.

It is important to note that midodrine significantly increases systolic and diastolic blood pressure and caused several patients to develop intense autonomic dysreflexia (AD) 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 AD and orgasm appears to be a reflex partly under cerebral influence and could therefore be learned and practiced (Courtois et al. 2004; Elliott 2002).

Ejaculation

Chéhennse et al. (2016) reviewed 30 years of medical charts in men with SCI who used PVS in the clinical setting, and found that 47% could ejaculate. In determining who could or could not ejaculate, they found that ejaculation success with PVS was higher when any of the C5–T6 spinal segments was injured (50-67% success). Ejaculation success with PVS decreased when lesions were more caudal, reaching a minimum for the subsample (2.6%) with complete L4 injury versus a minimum of 12% when any of the sacral segments (complete S3) was injured. In a study assessing sexual function 10-45 years post-SCI, Biering-Sorenson et al. (2012) found that 44% of men with SCI reported that they could ejaculate with 56% of those using assistive aids to achieve ejaculation. The mean age for those reporting being able to achieve versus not achieve ejaculation was significantly different (46 years vs. 54 years; p < 0.0001).

Methods commonly used to treat erectile dysfunction have also been tested in studies attempting to provoke ejaculation (i.e., PDE5i, penile vibratory stimulation [PVS]). In a recent double‐blind, randomized, placebo‐controlled study found no improvement in ejaculation success rates by PVS combined with midodrine vs. a placebo (Leduc et al. 2015). Soler et al. (2008) found that midodrine combined with PVS produced orgasm in 59% of participants compared to 9% with vibrostimulation alone; participants with incomplete upper motor neuron injuries had the highest rates of ejaculation.

We found a few studies that tested different PVS devices, at different frequencies, and with or without medication to mitigate risk of blood pressure spikes or drops that can accompany sexual activity in people with SCI. Castle et al. (2014) found that the Veberect-X3 was successful in provoking ejaculation in 77% of their participants (N=30). In a small study, Ibrahim et al. (2021) found that the Ferticare 2.0 was safe and effective for men with SCI, resulting in orgasm in 93% of participants using various settings (2.5mm, 4.0mm, or 2 devices at 2.5mm). Vibrostimulation or penile vibrostimulation (PVS) is a non-invasive and generally effective method used to provoke ejaculation for fertility or for pleasure, though precautions should be taken to prevent autonomic dysreflexia (blood pressure spikes) particularly in men with SCI at T6 or above (Previnaire et al. 2022; Alsseril et al. 2021; Courtois et al. 2011). Precautions could include the pre-PVS administration of nifedipine, a blood pressure control medication (Courtois et al. 2011; Elliott et al. 2017). Previnaire et al. (2022) found that ejaculation induced by PVS had increases in urethral pressure particularly patients with UMN lesions.

For more results on ejaculation as it relates to fertility in men with SCI, visit our Sperm Retrieval page in this chapter.

Conclusion

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

There is level 1 evidence (Cardenas et al. 2014 that fampridine-SR is superior to placebo in improving erectile and orgasmic function in 213 men with SCI

There is level 2 evidence (Ibrahim et al. 2021) that PVS with Ferticare 2.0 resulted in pleasure and ejaculation in most participants.

There is level 2 evidence (Sipski et al. 2006) men with SCI were less likely than controls to achieve orgasm, and that men with incomplete SCI were more likely to achieve orgasm than those with complete SCI in a laboratory setting using video and self-stimulation.

There is level 2 evidence (Soler et al. 2008) that midodrine plus penile vibratory stimulation (PVS) was superior to midodrine alone in provoking orgasms and/or ejaculation.

There is level 3 evidence (Courtois et al. 2011) that men who could be stimulated to ejaculation reported more autonomic and cardiovascular responses, regardless of completeness of their injuries.

There is level 4 evidence from a 30-year case series (Chéhennse et al. 2016) showing that approximately 50% of men with SCI could ejaculate using penile vibratory stimulation (PVS).

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 organism in men.

There is level 4 evidence (Previnaire et al. 2022) that PVS-induced ejaculation increases urethral pressure and ejaculation follows the relation of EUS.

There is level 4 evidence (Borisoff et al. 2010) that a sensory substitution device was successful in provoking orgasm in early sessions but not in later sessions in men with SCI.

There is level 5 evidence (Ayaz et al. 2018) that people with incomplete injuries have more ejaculations post-injury.

There is Level 5 evidence (De Moura et al. 2020) that pleasurable sensations increase at the neck and decrease at the penis and testicles following SCI.