Summary

There is level 1a evidence (from 9 RCTs, excluding 2 reporting outcomes of a previous trial: Derry et al. 1998; Giuliano et al. 1999; Hultling et al. 2000; Del Popolo et al. 2004; Giuliano et al. 2006; Tuzgen et al. 2006; Giuliano et al. 2007; Ergin et al. 2008; Khorrami et al. 2010) that supports the use of PDE5i as a safe and effective treatment for erectile dysfunction in men with SCI.

There is level 2 evidence (from 1 low quality RCT: Renganathan et al. 1997) that supports the use of ICI as treatment for erectile dysfunction in men with SCI. 

There is level 3 evidence (from 1 non-randomized controlled trial: Kim et al. 1995) that shows that the use of topical agents is not effective as treatment for erectile dysfunction in men with SCI. 

There is level 4 evidence (from a post-test study: Bodner et al. 1999) which suggests that the use of intraurethral preparations is not effective as treatment for erectile dysfunction in men with SCI.

There is level 4 evidence (Moemen et al. 2008; Denil et al. 1996; Chancellor et al. 1994; Heller et al. 1992; Zasler & Katz 1989) that supports the use of medically sanctioned vacuum constriction devices and penile rings as treatment for erectile dysfunction in men with SCI. 

There is level 4 evidence (Kim et al. 2008; Zermann et al. 2006; Gross et al. 1996) which suggests the use of penile prostheses as treatment for erectile dysfunction (ED) in men with SCI when other ED treatments have failed.

There is level 4 evidence (Denys et al. 1998; Jones et al. 2008) that implantation of intrathecal baclofen pump, while effective in managing spasticity, may cause difficulties with erection and sexual function.

There is level 4 evidence (from 1 pre-post study: Courtois et al. 2001) suggesting that perineal training may result in improvement in erectile function in men with SCI who have some voluntary pelvic floor muscle contraction. Oral PDE5i is the first line treatment for ED in men with SCI, with the more invasive but successful use of ICI being used most often in men who do not respond to the oral medications. Mechanical devices such as vacuum devices and rings may be effective but are not as favoured by consumers. Surgical prostheses should be reserved for refractory cases.

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.

There is level 4 evidence (Beretta et al. 1989; Sønksen et al. 1994; Le Chapelain et al. 1998; Brackett et al. 2007b, 2009; Kathiresan et al. 2012; Qiu et al. 2012; Sønksen et al. 2012) that semen retrieval may be assisted by vibrostimulation in men with lesions above T10. 

There is level 4 evidence (Soler et al. 2007a) that Midodrine may be an effective and safe adjunct to penile vibratory stimulation in men not responding to penile vibratory stimulation alone who are not at risk for significant autonomic dysreflexia. 

There is level 4 evidence (Brindley 1984; Halstead et al. 1987; Ohl et al. 1989; Lochner-Ernst et al. 1997; Le Chapelain et al. 1998; Kolettis et al. 2002) that semen retrieval may be assisted by electroejaculation in men who failed vibrostimulation.

There is level 4 evidence (Brindley et al. 1989) that surgical aspiration may be used to retrieve sperm if vibrostimulation and electroejaculation are not successful.

There is level 4 evidence (Arafa et al. 2007) that prostatic massage through the rectum to push the sperm out through the ejaculatory ductal system is one technique to retrieve semen in some men and is more successful with lesions above T10.

There is level 4 evidence (Lim et al. 1994) that the use of a balloon catheter to tamponade the bladder neck may be effective in obtaining antegrade samples in men who normally deliver retrograde samples.

There is level 4 evidence (Hibi et al. 2008) that retrograde vasal sperm aspiration can retrieve sperm of sufficient motility to afford pregnancy.

There is level 3 evidence (Kanto et al. 2008) that testicular sperm extraction followed by intracytoplasmic injection is an effective way to induce pregnancy, with fresh sperm giving better results than frozen-thawed sperm.

There is level 2 evidence (Brackett et al. 1997a; Ohl et al. 1997) that using a penile vibratory stimulus produces samples with better sperm motility than from electrostimulation.

There is level 2 evidence (from 1 weak RCT: Brackett et al. 2002) that sperm obtained by antegrade samples has better motility than retrograde samples and that interrupted current produces higher sperm motility than continuous current.

There is level 4 evidence (Rutkowski et al. 1995) that bladder management by clean intermittent catheterization (with low pressure filling and emptying) may improve semen quality over indwelling catheterization, reflex voiding or straining.

There is level 2 evidence that SCI sperm quality can be improved by placing sperm from SCI in able-bodied seminal plasma (Brackett et al. 1996), and that aspirated sperm from the vas deferens has better motility than that ejaculated (Brackett et al. 2000), demonstrating the etiology of poor semen quality may lie within the seminal plasma in men with SCI. These techniques have not been studied clinically with respect to pregnancy rates.

There is level 4 evidence (Cohen et al. 2004; Brackett et al. 2007a) that interference with receptors to all 3 cytokines in semen can improve sperm motility.

There is level 2 evidence (Ibrahim et al. 2009) that monoclonal antibodies and receptor interference agents do not change the degree of DNA fragmentation in sperm from subjects with SCI.

There is level 3 evidence (Kanto et al. 2008) that testicular sperm extraction followed by intracytoplasmic injection is an effective way to induce pregnancy, with fresh sperm giving better results than frozen-thawed sperm.

There is level 4 evidence (Hibi et al. 2008) that retrograde vasal sperm aspiration can retrieve sperm of sufficient motility to afford pregnancy.

There is level 4 evidence (Caremel et al. 2011) that botox injections to the overactive bladder may reduce semen volume, but increase semen quality.

There is level 3 (Kanto et al. 2008) and level 4 evidence (Buch and Zorn 1993; Hultling et al. 1994; Brackett et al. 1995; Dahlberg et al. 1995; Pryor et al. 1995; Nehra et al. 1996; Brinsden et al. 1997; Chung et al. 1997; Hultling et al. 1997; Sønksen et al. 1997; Taylor et al. 1999; Schatte et al. 2000; Heruti et al. 2001; Ohl et al. 2001; Shieh et al. 2003; Hibi 2008, McGuire et al. 2011; Kathiresan et al. 2011; Leduc 2012) that men with SCI have a good chance of becoming biological fathers with access to specialized care utilizing reproductive assisted technology.

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 4 evidence (Skowronsky & Hartman 2008) that women with SCI may give birth vaginally. With vaginal delivery or when Cesarean delivery or instrumental delivery is indicated, adequate anesthesia (spinal or epidural if possible) is needed to reduce the episodes of AD associated with birth.

There is level 4 and 5 evidence (from 2 case series and 2 observational studies) (Cross et al. 1992; Hughes et al. 1991; Cross et al. 1991; Skowronski & Hartman 2008) that epidural anesthesia is preferred and effective for most patients with AD during labour and delivery.

There is level 1b evidence from 1 RCT (Fronek et al. 2005, 2011) that educational workshops can improve clinician knowledge, comfort and attitudes towards sexual health counselling.

There is level 2 evidence (from 1 poor quality RCT: Sawyer et al. 1983) that microcounselling sessions can improve clinician’s ability to respond appropriately to sexual concerns of patients.

There is level 5 evidence (Hess et al. 2007) that a sexual health program may be positively received by patients with SCI. There is level 4 evidence (Schopp et al. 2002) which suggests that comprehensive gynecologic services may improve women’s health behaviours.