Sexual Response in Women With SCI
Women with SCI are less likely to achieve orgasm than non-SCI women, and time to orgasm is significantly increased compared to the general population (Sipski et al. 2001). The ability to achieve orgasm, however, seems unrelated to the pattern or degree of neurological impairment in women with lesions down to T5 level (Sipski et al. 1995). On the other hand, women with LMN lesions affecting S2-S5 segments were less likely to achieve orgasm compared with women who had other types of SCI lesion (Sipski et al. 2001).
Multiple laboratory-based studies have documented the presence of sexual arousal and orgasm in women with SCI (Whipple & Komisaruk 2002; Komisaruk et al. 2004, Sipski et al. 1995b, 2000, 2004, 2005). Following SCI, women may attain genital sexual arousal through a psychogenic (i.e., through mental stimulation) and/or a reflex (i.e., through direct physical touch) pathway. Preservation of T11–L2 sensory dermatomes is associated with psychogenically-mediated genital vasocongestion (i.e., vaginal lubrication; Sipski et al. 1997; Sipski et al. 2001). The ability to achieve reflexogenic genital congestion and orgasm depends on the presence of an intact sacral reflex arc (Sipski et al. 1997; Sipski et al. 2001). The vagus nerve has also been hypothesized to serve as a pathway that bypasses the spinal cord and thereby may facilitate those responses (Komisaruk et al. 2004).
Discussion
Women with SCI have significantly higher levels of sexual dysfunction compared to women in the general population; Haijiaghababaei et al. (2014) found that 88% of SCI patients reported at least 1 type of sexual dysfunction, whereas only 37% of non-SCI controls reported sexual dysfunction. Lack of vaginal lubrication was reported more frequently in SCI patients and is related to age (p<0.05) and lower level of injury below T6 (p=0.003) (D’andrea et al. 2020a). Women with SCI reported a significantly higher level of sexual distress compared with non-SCI women (Hajiaghababaei et al. 2014).
An interview study of women with SCI reported that the lack of bowel and bladder control was especially problematic for women who were developing new intimate relationships (Fritz et al. 2015). Lemos et al. (2022) found that after laparoscopic implantation of neuromodulation electrodes 20 of 28 patients reported improvement in genital sensitivity, the number of female patients was not specified (p<0.0001). However, FSFI did not significantly change between T10 and T12 as sexual function had a short-term reduction after the operation and returned to pre-operative levels. Moreover, Shackleton et al. (2023) found that with epidural stimulation, there was a 3.2 (13.2%) increase in FSFI, and improvements were seen in the sub-domains such as desire, arousal, orgasm, and satisfaction. Following epidural stimulation, there was a clinically meaningful change of 14 points in the ISNCSCI (Shackleton et al. 2023).
A vibratory and manual clitoral simulation in women with SCI improved sexual arousal (Sipski et al. 2005). Small studies (Sipski et al. 2000b) have evaluated the use of sildenafil (Viagra) 50mg in women with SCI and reported promising increases in subjective arousal especially when combined with manual and visual stimulation. However, a larger study (Alexander et al. 2011b) with a sample size of 126 found that sildenafil lacked clinically meaningful benefits for women with SCI, as found similarly with other populations of women. Morrison et al. (2018) conducted manually assisted locomotor training for both men and women (n=20) that found significant improvements in bowel, bladder, and sexual function. The functional outcome score increased from 11 (enrollment) to 23 (after 120 sessions). Although PDE5i like sildenafil have been highly effective as a treatment for erectile dysfunction in men with SCIs, this was less the case for women. Greater increases in activity, arousal and satisfaction were seen in women with SCI when compared to the placebo in one RCT (Alexander et al. 2011b).
Similar cardiovascular responses were found in women with SCI compared to non-SCI controls at time of orgasm (Sipski et al. 1995a; Sipski et al. 1996). Another study found only significant increase in blood pressure, but not in heart rate, in women with complete SCI above T10 level in response to self-stimulation, however, not all women stimulated to orgasm (Whipple et al. 1996). Greater knowledge about sexual health seems to be related to sexual responsiveness (Sipski et al. 1995a).
Several treatments to improve sexual responsiveness in women with SCI have been explored over the past decade. Two therapies assumed that psychogenic genital vasocongestion is under control of the sympathetic nervous system and that sympathetic activation may lead to enhanced sexual arousal (Sipski et al. 2000, 2004). Positive feedback was shown to increase psychogenic arousal in women with SCI, and furthermore, increased genital arousal in those women who had preservation of sensory function in the T11-L2 dermatomes (Sipski et al. 2000a). In another study, anxiety-eliciting videos were used to elicit sympathetic activation (Sipski et al. 2004). Anxiety pre-exposure resulted in a small increase in genital responsiveness to erotic stimulation in participants with impaired, but not absent, ability to achieve psychogenic genital vasocongestion (those with T11-L2 sensory score < 23). While these two studies help to understand the role of the sympathetic nervous system in mediating sexual arousal in women with SCI, clinical application of these two approaches has yet to be determined. Vibratory clitoral stimulation resulted in increased genital responsiveness as compared with manual clitoral stimulation, although the differences were not statistically significant (Sipski et al. 2005). Sildenafil administration improved subjective measures of sexual arousal with borderline objective measures and the effects were optimal with both manual and visual stimulation (Sipski et al. 2000b).
Further studies are required to investigate augmenting sexual arousal responses in women with SCI by combining psychological, physical/physiological and pharmacological approaches. There is also promising new research that suggests that electrical stimulation can improve sexual response for women after SCI.
Conclusion
There is level 1 evidence (Alexander et al. 2011) that sildenafil does not result in clinically meaningful benefits in women who have sexual arousal disorder as a result of SCI.
There is level 2 evidence (from 1 weak RCT: Sipski et al. 2005) that supports the use of manual and vibratory clitoral stimulation to increase genital responsiveness in women with SCI.
There is level 5 evidence (Moreno-Lozano et al. 2016; Hajiaghababaei et al. 2014; Fritz et al. 2015) that women with SCI reported significantly higher levels of sexual dysfunction and sexual distress compared with non-SCI controls.
