Systematic Review

Consortium for Spinal Cord Medicine 2010; USA
Reviewed published and unpublished articles between Jan 1995 and Sept 2007
N=145
Level of evidence:
Methdological quality assessed using criteria from the Centre for Evidence-based Medicine in Oxford
Type of studies:
RCTs assessed using the Jadad Quality Score Assessment
AMSTAR = 5

1. Understanding the importance of sexuality and reproduction to the individual, and conveying the appropriate information in a timely manner
2. Obtain a sexual history and assessment
3. Provide information on sexual education and on maintaining sexual well-being
4. Discuss with the individual any relevant  physical and practical considerations (bladder/bowel, skin care, secondary medical complications, optimal position for sexual activity)
5. Discuss the effect of injury on sexual function, responsiveness and expression with the individual with SCI and their partner; and
6. Discuss dysfunction and fertility issues as needed.

1. In able-bodied persons, sexual activity resulted in modest increases in systolic blood pressure peaking at orgasm (males of 163mm Hg and females of 142mm Hg) and returning to baseline shortly afterward.
2. In persons with SCI, results varied from minimal changes to significant elevations in systolic blood pressure because of episodes of autonomic dysreflexia, especially in those with high thoracic and cervical lesions.
3. Peak systolic blood pressure in these individuals was measured to be as high as 325mm Hg. In the SCI population, more intense stimuli (including penile vibrostimulation and electroejaculation) tended to result in a greater increase in systolic blood pressure compared with self-stimulation.
4. Studies that used continuous versus intermittent monitoring were more likely to report greater changes in systolic blood pressure.
5. In able-bodied persons, sexual activity results in modest increases in blood pressure.
6. In those with SCI, intense stimulation and higher injury levels result in a higher likelihood of autonomic dysreflexia and elevated blood pressure.
7. Because of rapid changes in blood pressure, continuous monitoring is more advantageous than intermittent measurement, because the latter may miss peak values.

1. Twelve studies were selected.One article documented that 76% of subjects reached satisfactory sexual intercourse (SI) using intracavernosal injection of vasoactive medications (papaverine and prostaglandin E1). One study regarding perineal training showed a significant increase (P<0.05) in penile tumescence in 10 individuals with preserved sacral segment. Two studies reported contrasting results on erectile function (EF) using various dosages of oral fampridine (25-40 mg). Furthermore, 95.1% of patients on fampridine 25 mg experienced drawbacks. Disappointing findings were found with intraurethral alprostadil (125-1000 μg) and sublingual apomorphine 3 mg. Two studies concerning penile prosthesis reported valid SI more than 75% of the time with a mean follow-up of 11 years, although around 15% of individuals showed side effects. As for surgical treatments, 88% of males submitted to Brindley sacral anterior root stimulator after sacral dorsal rhizotomy achieved valid erection up to 8 years following the procedure. Three studies documented the impact of definitive sacral neuromodulation implant (Medtronic, Minneapolis, MN, USA) also on EF. After surgery, 20-37.5% of patients with ED recovered normal EF.
2. CONCLUSIONS:
3. Data are scant on the efficacy of ED 
treatments for SCL subjects who did not respond to PDE5Is. Further research should investigate the effects of any SCL treatments even when they are not strictly used for neurogenic sexual dysfunction.