Sexual and Reproductive Health

Sexual Satisfaction

  1. Sexual satisfaction is reportedly lower in both men and women after SCI (Alexander et al. 1993; Fisher et al. 2002; Reitz et al. 2004; Kennedy et al. 2006; Sharma et al. 2006; Mendes et al. 2008).
  2. In an exploratory study of comparing African-American men and women with SCI, authors found that the women reported greater satisfaction with their sex lives than the men (Krause et al. 2004).
  3. A comparison study of women with and without SCI, found that married women with SCI are as sexually satisfied as their able-bodied counterparts (Black et al. 1998).
  4. In a study involving South Asian women with SCI, the women reported lack of sexual satisfaction more often than the men (Sharma et al. 2006). Conversely, in a survey study of Italian men and women with SCI, men reported significantly lesser satisfaction with sexual life post-injury than women (Sale et al. 2012).
  5. Moreno et al. (1995) included sexual parameters in their report of outcome of continent urinary diversion with a catheterizable umbilical stoma in women with tetraplegia (n=3). They found that sexual satisfaction improved in the 2 women who were sexually active and body image improved in all 3 women

Author Year; Country
Dates included in the
review
Total sample size
Level of evidence
Type of study
Score		 Methods
Databases		 Outcomes
Sunilkumar et al. 2015; India
Systematic Review
AMSTAR=
N=19		 Methods: Search key words and phrases:
SCI and sexuality, paraplegia and sexuality,
paraplegia and sexual functioning, Indian
males and SCI, Indian males and paraplegia
and sexual attitudes, and males and SCI and
sexual functioning. Inclusion criteria included:
English language, Indian male population
with sexuality issues, all age groups history
of a SCI with resultant paraplegia. The
search yielded 457 articles but only 19 were
specifically related to male views on
sexuality.
Databases: Cumulative Index to Nursing and
Allied Health Literature (CINAHL), Medline,
Applied Social Sciences Index and Abstracts
(ASSIA), and Google Scholar.
  1. 6 areas related to the topic of sexual functioning, SCI, and paraplegia were identified: sexual stigmatization, physiological barriers to sexual satisfaction, clinical aspects of sexual functioning, biomedical approaches to sexual dysfunction, partner satisfaction, and lack of accessibility to sexual education.
  2. SCI and sexual functioning affects a large segment of the male Indian population, yet most current research focuses on quantitative measurement with the emphasis on ejaculatory dysfunction, orgasm impairment, incontinence, and other physiological dysfunction.

Author Year; Country
Score
Research Design
Total Sample Size		 Methods Outcome
Cobo Cuenca et al. 2014; Spain
Case Control
Level 3
N=165 (85 SCI)		 Population: 165 men with sexual
dysfunction SD: Group A 85 with SCI
(mean age= 35.61±8.13 years) and Group
B 80 without SCI (mean age=46.31±10.69
years); duration of lesion 26.45±8.72
years; neurological level of injury 16
cervical, 46 thoracic, and 23 lumbar; 59
AIS A and 26 AIS B/C/D.
Treatment: None
Outcome Measures: The Sexual Health
Evaluation Scale, the Fugl-Meyer Life
Satisfaction Questionnaire scale (LISAT8),
the Hospital Anxiety and Depression
Scale, the Evaluation of the Sexual Health
Scale, and the Rosenberg’s Self-esteem
Scale.
  1. In the SCI group, 89.4% (76) showed erectile dysfunction and 75.2% (64) reported anejaculation.
  2. In the non-SCI group, 96.8% (75) showed erectile dysfunction and 58.7% (47) had disorders of sexual desire.
  3. All of the participants reported a high general QOL and a high satisfaction with their QOL but their satisfaction with their sexual lives was only at the acceptable level.
  4. Social QOL was significantly higher in the SCI group than the non-SCI group.
  5. The QOL, self-esteem, and anxiety and depression levels are significantly correlated.
  6. Sexuality and employment status are the areas where men with spinal cord injuries report less satisfaction.
Miranda et al. 2016; Brazil
Cross-sectional Study
Level 5
N=295		 Population: 295 men (mean age
40.7±14.5 years) with SCI for more than 1
year (median time since SCI= 3.6 years;
range= 1.6-7.0 years).
Treatment: None
Outcome Measures: Performance in
various domains of sexual function was
evaluated using the Male Sexual Quotient
(MSQ) questionnaire and Sexual Health
Inventory for Men (SHIM) questionnaires.
  1. The prevalence of sexual dysfunction was as follows: decreased sexual desire (28.8%), lack of confidence for partner seduction (38.3%), dissatisfaction with sexual foreplay (48.8%), frustration with partner’s sexual satisfaction (54.6%), inability to obtain an erection (71.0%), difficulty maintaining erection (67.8%), lack of full erections (64.4%), problems with ejaculatory control (89.4%), inability to achieve orgasm (74.5%), and overall sexual intercourse dissatisfaction (51.1%).
  2. Only 70 men (23.7%) had an MSQ score >60, which represents highly or partially satisfied individuals; only 71 individuals (24.1%) had good erectile function or mild dysfunction based on the SHIM questionnaire (SHIM >17).
  3. The Pearson correlation coefficient revealed a strong correlation between the MSQ and the SHIM (r=.826; 95% CI, .779 -.864).
Sunilkumar et al. 2015; India
Qualitative Study
Level 5
N=7		 Population: 7 men living with
SCI/paraplegia
Treatment: None
Outcome Measures: Semi-structured
and open-ended interviews regarding
participant perspective of living with SCI in
India.
  1. 7 themes emerged through qualitative methods: 1) recalling an active sexual life, 2) disconnection with sexual identity, 3) incongruence between a sense of physical and emotional capability, 4) isolation of spouse or sexual partner, 5) social readjustment of spouse, 6) perceived physical barriers to improved sexual functioning, and 7) coping and attempting ways of sexual integration.
  2. All patients were sexually active prior to injury and all desired a healthy and active sexual life. A huge gap existed between sexual desire and physical capability, and quality of life (physiological, social, existential, emotional) has been compromised for both patient and family, causing anxiety, distress, and sadness.
  3. There is a significant burden of added responsibility placed on the participants’ spouses in that she must find a way of coping and attempting ways of sexual reintegration.
Otero-Villaverde et al. 2015; Spain
Observational Study
Level 5
N=32		 Population: 32 women (mean age=29.8
years, range 13.9-59 years); most
common cause of SCI trauma (72%);
degree of disability 44% AIS A, 19% AIS
B, 9% AIS C, and 28% AIS D
Treatment: None.
Outcome Measures: Spinal Cord
Independence Measure (SCIM) version III.
  1. The only factors that we found to be related to sexual activity were not having a stable partner (P=0.017) and a lack of sensation in the genital area (P=0.039).
  2. When comparing the group of women who were sexually active with those who were not, variables such as age, neurological level, time since the SCI, ASIA or Spinal Cord Independence Measure score, urinary incontinence, chronic pain and spasticity were not related to sexual activity.
  3. The median score on the SCIM scale was 68.7. 80% of the women maintained a stable relationship at the time of the SCI, and 9 of these (37.5%) subsequently lost their partner.
Pakpour et al. 2016; Iran
Cross-sectional study
Level 5
N= 93		 Population: 93 men with SCI (mean
age=37.8 years, age range=19-63 years,
mean post-injury time=4.6 years).
Treatment: None
Outcome Measures: Levels of anxiety
and depressive mood were assessed
using the Hospital Anxiety and Depression
Scale. Religious coping strategies were
measured using the 14-Items Brief Coping
Questionnaire. Erectile function was
measured using the International Index of
Erectile Function (IIEF).
  1. SCI patients reported more positive religious coping than negative religious coping and higher levels of anxiety than depressive mood.
  2. Multivariate regression analyses indicated that age, education, the American Spinal Injury Association impairment scale, anxiety, positive religious coping, negative religious coping and the duration of injury were all independent factors influencing erectile function in SCI patients.
Akman et al. 2015; Turkey
Observational Study
Level 5
N=47		 Population: 47 men with spinal cord
injuries (age range = 20-62 years, mean
age = 35.2 years, mean time since
injury=6.3±4.0 years) who were out of the
spinal shock period and had their injury for
more than 6 months.
Treatment: None
Outcome Measures: Social status, sexual
activities, abilities, sexual education after
injury, and erectile function evaluated by
the International Index of Erectile
Function-5 (IIEF-5) questionnaire.
  1. 128 patients had lesions located above T10, 15 had lesions between T11 and L2, and 4 had lesions at the cauda equina.
  2. Mean IIEF-5 score of group was 5.3 + 4.1.
  3. 61.7% of patients reported sexual activity and 93.6% reported some degree of erection.
  4. 87.3% of men in this study had moderate to severe erectile dysfunction.

Issues perceived to affect sexual
satisfaction and/or sexual activity		 Positive or
Negative Impact		 Reported in
men/women or both		 Studies supporting
Age (<18 years or >30 years old) (-) Women Kreuter et al. 1994; Westgren et
al. 1997; Ferreiro-Velasco et al.
2005
Time since injury (+) Both, Men Black et al. 1998; Tepper et al.
2001; Anderson et al. 2007;
Lombardi et al. 2008; Pakpour et
al. 2016; Choi et al. 2015
Severity of injury (-) Both, Men Mona et al. 2000; Anderson et al.
2007; Kreuter et al. 2008; Sale et
al. 2012; Pakpour et al. 2016
Bladder management problems
(incontinence/UTI’s)		 (-) Both, Women White et al. 1993; Richards et al.
1997; Jackson & Wadley 1999;
Benevento & Sipski 2002; Blok &
Holstege 1999; Anderson et al.
2007; Kreuter et al. 2008; BieringSorensen et al. 2012; Sale et al.
2012; Moreno et al. 1995; Bozan
et al. 2015; Otero-Villaverde et al.
2015
Spasticity (-) Both, Women Jackson & Wadley 1999;
Anderson et al. 2007; BieringSorensen et al. 2012, OteroVillaverde et al. 201
Fecal incontinence (-) Both, Women Charlifue et al. 1992; White et al.
1993; Richards et al. 1997;
Kreuter et al. 2008; BieringSorensen et al. 2012; Bozan et al.
2015
Autonomic dysreflexia/Blood Pressure (-) Women Charlifue et al. 1992; Jackson &
Wadley 1999; Anderson et al.
2007
Pressure ulcers and pain (-) Both, Women Biering-Sorensen et al. 2012;
Otero-Villaverde et al. 2015
Making a female partner pregnant (+) Men Biering-Sorensen et al. 2012
Altered body image (-) Both, Women Bozan et al. 2015; Smith et al.
2015; Bailey et al. 2015;
Merghati-Khoei et al. 2017;
Richards et al. 1997; Elkland &
Lawrie 2004; Reitz et al. 2004;
Kreuter et al. 2008
Altered genital sensation (-) Women, Men Richards et al. 1997; Anderson et
al. 2007; Kreuter et al. 2008,
Miranda et al. 2016; OteroVillaverde et al. 2015; Akman et
al. 2015
Sexual desire (+) Both, Men Phelps et al. 2001; Reitz et al.
2004; Miranda et al. 2016
Lack of a partner (-) Women Jackson & Wadley, 1999; Kreuter
et al. 2008; Otero-Villaverde et al.
2015
Quality of intimate
relationship/relationship satisfaction		 (+) Both/Men Jackson & Wadley 1999; Phelps
et al. 2001; Reitz et al. 2004,
Lombardi et al. 2008; Smith et al.
2015
Repertoire of sexual behaviour (+) Men, Women Richards et al. 1997; Phelps et al.
2001
Partner as caregiver (-) Women Kreuter et al. 1996; Black et al.
1998; Pentland et al. 2002
Perceived partner satisfaction (+) Men, Women Phelps et al. 2001; Ekland & Lawie 2004;
Miranda et al. 2016
Partner’s understanding of sexual
needs		 (+) Kreuter et al. 1996
Level of social and vocational activity;
outgoing personality; acceptance of
the disability**		 (+) Kreuter 2000
Inadequate vaginal lubrication (-) Women Charlifue et al. 1992; Jackson &
Wadley 1999; Anderson et al.
2007
Ability to move (+) Both Reitz et al. 2004; Anderson et al.
20à7; Kreuter et al. 2008; Bozan
et al. 2015
Mental well-being (+) Both, Men Reitz et al. 2004; Kreuter et al.
2008, Smith et al. 2015, Pakpour
et al. 2016
Sexual education and counselling (+) Women, Men, Both White et al. 1993; Westgren et al.
1997; Hess et al. 2007; Valtonen
et al. 2006; New et al. 2016;
Akman et al. 2015
Peer support (+) Women, Both Richards et al. 1997; Fisher et al.
2002; Pentland et al. 2002;
Ekland & Lawrie 2004
Sexual arousal (-) Men Cardoso et al. 2008; Miranda et
al. 2016
Orgasm intensity (-) Men Cardoso et al. 2008; Miranda et
al. 2016

Discussion

Research shows that sexual function is important to people after SCI. A systematic review of 24 studies of health and life priorities for persons with SCI determined that motor function, bowel, bladder and sexual function emerged as the top four functional recovery priorities (Simpson et al. 2012). Two individual studies using community samples showed that the most common significant problem for people with SCI was sexual dysfunction (reported at 41% – New 2016; and 60.8% Park et al. 2016).

Despite the importance of sexual adjustment to overall quality of life, there have been few studies addressing this topic and few investigating the effectiveness of interventions on sexual satisfaction and adjustment to SCI. A number of studies have reported that the frequency of sexual activity and desire for sexual activity decreases after injury in both men and women (Julia & Othman 2011; Kreuter et al. 2011). The issues that are perceived to affect sexual satisfaction and/or sexual activity are multi-faceted. However, common barriers to sexual satisfaction from the effects of SCI include bladder and bowel problems, as well as other impairments resulting from the severity of injury (e.g., spasticity, lack of mobility) (Biering-Sorensen et al. 2012; Moreno et al. 1995; Anderson et al. 2007). Researchers suggest that improving sexual satisfaction, information and specific programs during rehabilitation can help women with SCI explore and investigate new erotic possibilities, thereby improving their self-esteem and social relationships (Otero-Villaverde et al. 2015).

Sexual dysfunction following SCI may take many forms, including: decreased sexual desire, lack of confidence, dissatisfaction with sexual foreplay or intercourse, frustration with partner’s sexual satisfaction, inability to obtain or maintain a full erection or to achieve orgasm, and problems with ejaculatory control.

Common barriers to sexual satisfaction include bladder and bowel problems, as well as other SCI-related impairments (e.g., spasticity, lack of mobility).

Continent urinary diversion in women with tetraplegia may result in improved self-image, quality of life, and greater sexual satisfaction.

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