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Sexual and Reproductive Health

Sexual Response in Women With SCI

While it is true that women with SCI have clinically significant impairment in arousal and orgasm, women with complete SCI have been self-reporting orgasm that seemed physiologically impossible (Richards et al. 1997). Multiple laboratory-based studies have documented the presence of sexual arousal and orgasm in women with SCI (Whipple & Komisaruk 2002Komisaruk et al. 2004, Sipski et al. 1995200020042005). Following SCI, women may attain genital sexual arousal through a psychogenic and/or a reflex pathway. Preservation of T11 – L2 sensory dermatomes is associated with psychogenically mediated genital vasocongestion and lubrication (Sipski et al. 1997Sipski 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. 1997Sipski 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).

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 (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).

Similar cardiovascular responses were found in women with SCI compared to able-bodied controls at time of orgasm (Sipski et al. 1995Sipski 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 sexuality seems to be related to sexual responsiveness (Sipski et al. 1995).

A number of treatments to improve sexual responsiveness in women with SCI have been explored over the past decade. Two therapies were based on the assumption 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. 20002004). 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. 2000). 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 subjects 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. Sipski et al. (2005)studied the effect of vibratory stimulation on sexual arousal in women with SCI. Vibratory clitoral stimulation resulted in increased genital responsiveness as compared with manual clitoral stimulation, although the differences were not statistically significant. One randomized controlled trial tested the effect of sildenafil 50mg versus placebo on sexual responsiveness (Sipski et al. 2000). Sildenafil administration improved both subjective and physiologic measures of sexual arousal. The effect was most evident under optimal stimulation conditions (manual combined with visual).

Further studies are required to investigate augmenting sexual arousal responses in women with SCI by combining psychological, physical/physiological and pharmacological approaches.

Author Year;
Country
Score
Research
Design
Total Sample
Size
Methods Outcome
Alexander et al.
2018
RCT
Level 1
PEDro =
N = 23
(11 w/SCI)
Population: 23 women (18 MS, 5 SCI) completed the study including 13 of 16 and 10 of 15 randomized to the 2 conditions.
Treatment: A 12-week trial of the use of a clitoral vacuum suction device (CVSD) versus vibratory stimulation (V) to treat orgasmic dysfunction in women with multiple sclerosis (MS) or spinal cord injury (SCI).
Outcome Measures: Female Sexual Function Inventory (FSFI) and Female Sexual Distress Scale (FSDS) including subscales.
  1. There were statistically significant increases in total FSFI score (p=.011), desire (p=.009), arousal (p=.009), lubrication (p=.008), orgasm (p=.012), and satisfaction (p=.049), and a significant decrease in distress as measured by FSDS (p=.020) in subjects using the CVSD.
  2. In participants who used V, there was a statistically significant increase in the orgasm subscale of the FSFI (p=.028).
  3. Participants using the CVSD maintained improvements 4 weeks after treatment, but participants using V did not have significant differences between baseline and follow-up on any measures.
  4. CVSD is safe and efficacious to treat female neurogenic sexual dysfunction related to MS and SCI. V is also safe and efficacious for female neurogenic orgasmic dysfunction; however, results were limited to the active treatment period.

Alexander et al. 2011; Sweden PEDro=9
RCT Level 1
N = 129

Population: 129 females (mean age=37 years, range=19-62 years); 86 (67%) with female sexual arousal disorder (FSAD) resulting from paraplegia/tetraplegia for >12months. Patients from clinical practice sites in North America, Europe, Australia, and South Africa. Mean sensory score was 133 and the mean motor score was 59.
Treatment: Double-blind,placebo-controlled, flexible-dose design; after 4 week, treatment free, run-in period (baseline) patients randomized to receive either oral sildenafil 50mg as needed or a matching placebo for 12 weeks. Dose adjustments were allowed once, either increasing to 100 mg or decreasing to 25 mg.
Outcome measures: event log for sexual activity, study dosing, and sexual satisfaction; Sexual Function Questionnaire (SFQ); Sexual Quality of Life Questionnaire-Female (SQoL- F); global efficacy question (GEQ); Sexual Distress Question.

 
  1. There is no statistically significant difference in satisfactory sexual activities between baseline and end of treatment (EOT).
  2. No statistically significant difference between sildenafil and placebo in questionnaire data, Total score on the SQoL-F increased for both groups, but the difference was not statistically significant.
  3. GEQ and SDQ results favoured sildenafil but were not statistically significant. 55% of the sildenafil group compared with 38% of the placebo group report improvement in GEQ.

Effect Sizes: Forest plot of standardized mean differences (SMD ± 95%C.I.) as calculated from pre- and post-intervention data

Sipski et al. 2005; USA
PEDro=4
RCT
Level 1
N SCI=46
N controls=11
Population: Women with SCI (n=46) and 11 non-disabled/control women; Age: Mean (SCI) 35.1 yrs, SD=7.9, (control) 34.3 yrs, SD=8.2; Injury level: C5-S3; Lesion level:
upper motor neuron (UMN) (n=32), lower motor neuron (LMN) (n=14); Time since injury: mean 127 months, range 15-494.
Treatment: Vibratory stimulation vs manual stimulation.
Outcome Measures: Vaginal pulse amplitude (VPA), levels of arousal.
  1. Increased arousal from both manual and vibratory stimulation in both groups. No difference in arousal level between vibratory and manual clitoral stimulation in women with SCI.
  2. In participants with SCI, VPA increased (nonsignificant) more from vibratory clitoral stimulation compared to manual stimulation.
  3. No impact on VPA or arousal levels by completeness of injury or by UMN vs LMN injury.
Sipski et al. 1995;
USA
Matched
Controlled Trial
Level 2
N=34
Population: Women with SCI (n=25) and 9 non-disabled/control women; Age: Mean (SCI)
32 yrs, SD=7.9, (control) 34 yrs, SD=8.2; Injury level: Cervical = 20, Thoracic = 5. Time
since injury: mean 98 months, range 10-242.
Treatment: Participants attempted to perform stimulation to orgasm in a controlled laboratory-based setting.
Outcome Measures: Dependent Variables included: vaginal pulse amplitude, heart rate, respiration rate, blood pressure, subjective arousal and subscores on the Derogatis Sexual Functioning Inventory (DSFI).
  1. All able-bodied participants achieved orgasm whereas 52% of SCI participants achieved orgasm.
  2. Degree and type of SCI did not significantly relate to participants’ ability to achieve orgasm, and there were no significant differences (p > .05) between subject groups on any of the dependent measures.
  3. Participants with no lower extremity function took significantly longer than able-bodied participants to achieve orgasm.
  4. Results of DSFI revealed that able-bodied participants acknowledged greater sexual satisfaction than the participants with SCI.
  5. No consistent characteristics were identified that would allow prediction of which women with SCI would be able to experience orgasm.
Celik et al. 2014;
Turkey
Cross-Sectional
Level 5
N=26
Population: 26 women (mean age 32.96±8.23 years, range=22-50 years), mean time post injury=168±88.73 months’; level of injury: 24 paraplegia, 2 tetraplegia.
Treatment: None
Outcome Measures: Demographic questionnaires regarding marital status before and after SCI, sexual experience, pregnancy, miscarriages and abortions, and family members of the patients. Female Sexual Function Index (FSFI) and Beck Depression Inventory (BDI) were also administered.
  1. 8 participants had regular sexual intercourse while one married woman did not have any sexual relationship after SCI.
  2. 24 people received no information about pregnancy or sexual health after SCI. 2 people only received information when actively requested. All women were willing to receive information about sexuality after SCI. These patients expected the doctors to start the conversation about sexuality rather than asking about it.
  3. FSFI revealed 5 of the 8 sexually active patients had sexual dysfunction.
  4. BDI scores depicted that 3 out of the 8 sexually active patients had depression, whereas 14 out of 18 sexually inactive patients had depression.
Hajiaghababaei
et al. 2014; Iran
Cross-sectional
study
Level 5
N=105
Population: 105 women (mean age 41.0 years); AIS A-E, lesion level 8.6% cervical, 42.9% thoracic, 21.9% lumbar-sacral; etiology of SCI 80% car accident, 11.4% impact of object on body, 8.6% fall.
Treatment: None
Outcome Measures: Sociodemographic information, Female Sexual Function Index, Hospital Anxiety and Depression Scale, and Female Sexual Distress Scale-Revised questionnaire.
  1. Women with SCI reported significantly higher levels of sexual dysfunction compared with normal controls.
  2. 88% of SCI patients reported at least 1 type of sexual dysfunction, whereas only 37% of healthy controls reported sexual dysfunction.
  3. Lack of vaginal lubrication was reported more frequent in SCI patients compared with controls.
  4. Women with SCI reported a significantly higher level of sexual distress compared with healthy women.
  5. Sexual dysfunction was observed to be significantly higher in older patients, those with less education, patients with complete lesions, those with sexual distress and patients who were anxious and depressed.
Merghati-Khoei et
al. 2017; Iran
Case-control
study
Level 3
N=62 (31 SCI)
Population: 62 women; 31 women with SCI (mean age 35.42±6.51) and 31 case controls (mean age 33.77±4.02 years); mean time since injury 36.32±19.21 months; 13 AIS A, 10 AIS B, 5 AIS C, 3 AIS D; most common cause was traffic injuries (74.2%), falls (19.3%), surgery side effect (6.5%).
Treatment: None
Outcome Measures: Socio-demographic and reproductive traits questionnaire, Sexual Quality of life-Female (SQOL-F), Female Sexual Function Index (FSFI) and Spinal Cord Independence Measure (SCIM).
  1. The SCI group performed worse in scores of quality of life, SQOL-F, and FSFI domains (except satisfaction).
  2. In the case group, there was a significant positive correlation between SCIM score and the mean score of and SQOL-F, suggesting that higher levels of independence correlate with better sexual function and quality of sexual life in women with SCI.
  3. Although our participants showed low sexual dysfunction, they tended to report moderate to poor quality of sexual life.
  4. Results from regression models indicated that spinal cord injury, participant’s education, occupation and duration of SCU were variables most affecting the quality of sexual life e.g., proportional regression showed that women with SCI had 4.2 times the odds of being in the poor or moderate quality of sexual life category, compared with the good quality.
Moreno-Lozano
et al. 2016; Mexico
Cross-Sectional
Level 5
N = 295
Population: 83 women with SCI (mean age 42.8±15.87 years); mean time since SCI 65.16±117.65 months; 40 AIS A, 10 AIS B, 12 AIS C, 19 AIS D, and 2 AIS E; level of injury: 16 cervical, 26 high thoracic level, 34 low
thoracic, and 7 lumbar.
Treatment: None.
Outcome Measures: AIS, Female Sexual Function Index (FSFI, Modified Ashworth Scale for spasticity, Spinal Cord Independence Measure III Score. Other variables such as neurologic level, time since injury, age, relationship status, socioeconomic status, spasticity, use of antispasticity drugs, education level, antidepressant medication, offspring, work activities and neuropathic pain were also considered.
  1. There is a high percentage of sexual dysfunction among women with SCI in this study (81.9%).
  2. The study showed a negative correlation between age and the FSFI questionnaire (- 0.384).
  3. Results showed that the younger the person is, the better sexual function they have, and offspring decreased sexual function and work activities increased it.
Fritz et al. 2015; USA
Observational
Level 5
N=20
Population: 20 women (mean age=46 years, age range=27-77 years); average time since SCI=19.5 years; 11 had paraplegia and 9 had tetraplegia; 60% obtained SCI via car accidents and 20% were obtained from gunshot wounds.
Treatment: None
Outcome Measures: In-depth qualitative interview re: sexual and reproductive health experiences of 20 women with SCI. Questions about overall health and physical functioning, accessibility of doctor offices, interactions with health care providers, gynecological healthseeking behaviors, sexuality and sexual behavior, and complementary and alternative medicine use.
  1. Regardless of participants’ personal definitions of sexual intimacy, 15 (75%) reported wanting to be more sexually active than they currently were.
  2. The lack of bowel and bladder control was especially problematic for women who were developing new intimate relationships.
  3. Participants believed that women with SCI “age faster” than able-bodied women and that they experienced age-related barriers to sex at an earlier age than their able-bodied peers.
  4. Lack of support and education about sexual activity also contributed to the challenges faced by participants in our study. Only 1 woman received any education regarding sexual activity.
  5. The life stage of participants and their level of adjustment to their injury affected how ready and interested they were in education about sexual intimacy and the types of concerns they reported about their sexual lives.
  6. Ultimately, SCI can greatly alter a person’s sexual identity and sexual self-esteem. Identity and self-esteem issues can further complicate a person’s efforts to date potential partners or develop new intimate relationships.

Discussion

A survey of 105 women with SCI in Iran found that women with SCI reported significantly higher levels of sexual dysfunction compared with normal controls. Of all the participants in this study, 88% of SCI patients reported at least 1 type of sexual dysfunction, whereas only 37% of healthy controls reported sexual dysfunction. Lack of vaginal lubrication was reported more frequent in SCI patients compared with controls. Women with SCI reported a significantly higher level of sexual distress compared with healthy women (Hajiaghababaei et al. 2014). A US interview study with 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).

Vibratory and manual clitoral simulation in women with SCI improved sexual arousal (Sipski et al. 2005). Small studies (Sipski et al. 2000) have evaluated the use of sildenafil (Viagra) 50 mg 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. 2011) 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.

Conclusion

There is level 1b (Alexander et al. 2011) evidence 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 able-bodied controls.

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