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Sexuality after SCI

Sexuality after SCI. William McKinley MD Associate Professor PM&R Director SCI Rehab Medicine Virginia Commonwealth University. Objectives. Describe & contrast male & female sexual response following SCI Identify options for management of sexual dysfunction following SCI

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Sexuality after SCI

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  1. Sexuality after SCI William McKinley MD Associate Professor PM&R Director SCI Rehab Medicine Virginia Commonwealth University

  2. Objectives • Describe & contrast male & female sexual response following SCI • Identify options for management of sexual dysfunction following SCI • Discuss the impact and approach to sexuality following SCI

  3. Demographics of SCI: “Who are we talking about?” • 8,000 - 10,000 traumatic SCI / year • (MVA, violence, falls) • men (4:1), ages 16-45 years • complete = incomplete • Non-traumatic SCI (33% of SCI admits) • (spinal stenosis, cancer, ischemia, infection) • male = female, older ages • incomplete > complete

  4. Sex vs Sexuality • Sexuality: an expression of maleness & femaleness through body, personality and behavior • involves: physical, emotional, social • affects sense of well-being, self image, self esteem, partner relationships & quality of life (QOL)

  5. Overview of Human Sexual Response (HSR) • Masters & Johnson: • 4 Phases of HSR • Excitement • Plateau • Orgasm • Resolution

  6. Normal Sexual Function in Females

  7. HSR in able-bodied Females • Excitement Phase • afferent stim of genitals (via pudendal N) • increase in blood flow • vasocongestion and tumescence of external genitalia (mons pubis, labia, clitoris, vagina) • vaginal lubrication • “Reflex (S2-4) • “Pschogenic” (T10-L2)

  8. HSR in a-b Females (cont) • Plateau Phase • vasodilation in vagina • uterine & cervical elevation • sexual flush (seen in 75%) • secretions from Batholin’s gland (analogous to “emission phase” in male ejaculation) • increase in breast size, nipple erection • increase in RR, pulse rate, BP

  9. HSR in a-b Females (cont) • Orgasm • Rhythmic contractions of uterus, outer 1/3 of vagina & anal sphincter • studies suggest orgasm is an S2-4 sacral reflex • Resolution Phase • gradual loss of vasocongestion & tumescence • (unlike males, during resolution, may return to orgasm phase…)

  10. SCI & Female sexual function

  11. Terminology • “Complete” SCI = no motor/sensory sparing • “Incomplete” = sparing of motor/sensory • Upper Motor Neuron (UMN) = descending sp cord tracts affected, caudal reflex arcs intact • Lower Motor Neuron (LMN) = non-functional reflex ability • (consider “spinal shock” period)

  12. SCI & HSR in Females • In “Complete UMN” SCI • maintenance of reflexic (S2-4), but not psychogenic (T10-L2) vaginal lubrication • PP at T11-12 predictive of Psych lubrication • Orgasms reported even with complete SCI T-9 & above • In “Complete LMN” SCI • No reflexic, but 25% psychogenic lubrication

  13. Females & Intercourse after SCI • 67% report IC post injury (87% prior) • Predictive info: • years post SCI - 50% yr 1, 75% > 10 yrs • LOI - 62% cerv, 70% thor, 82% L/S • Complete = Incomplete • Problems reported: • lubrication, decreased enjoyment… • positioning (40%), spasticity(26%), bl incont (17%), AD (11%)

  14. Female Sexual activity post SCI • Most individuals who were sexually active prior to SCI remain so. • Positive sexual adjustment is reported in majority (by 6 mo p-injury)

  15. Female sexual activity (cont) • Orgasm reported in 54% • took more time and more intensity • relocation of erogenous zones reported • 71% reported “pleasure” above LOI • Favorite sexuality activities • Pre- SCI : intercourse • Post-SCI: kissing, hugging, touching

  16. Impact of SCI on Female Fertility • No adverse impact on female fertility • Amenorrhea (seen initially in 60%) • returns by 6 mo (50%), by 12 mo (90%) • Once menses returns = Fertile! • No increase in spontaneous abortions noted

  17. Female Contraception p-SCI • Oral pills - contraindicated w/ h/o DVT • low dose progestin has lower risk • Implants (levonorgesterol) - appear safer • Cerv diaphram/caps/sponges - not rec’s due to dec. uterine sensation, inc risk PID • Barrier method (male contraception) - may be safest!

  18. Prenatal & Perinatal Pregnancy Issues • Prenatal: • constipation (decreased gastric motility) • UTI’s (? abx choice, change to sterile IC) • decreased mobility in 3rd trimester • vital capacity decreases (uterine elevation) • DVT risk (dec venous return & mobility) • Autonomic dysreflexia (T-6 & above) • Pressure ulcers • Spasticity

  19. Pregnancy Issues (cont) • Perinatal • SCI above T-10 do not feel onset of uterine cont (labor pains) • small increase in premature delivery & low birth weights • delivery before 37 weeks (30-40%) • vaginal delivery is preferred • episiotomy rx w/nonabsorb sutures (breakdown) • AD in 90% (HTN confused w/ pre-eclampsia) • Rx - epidural anesthesia

  20. Parenting Issues in Females • Most did NOT feel well informed • 70% satisfied with post-SCI sexual exp. • breast feeding not contra (dec milk w/sci >T6) • Felt family roles/relationships similar to before • more division of HH & child care tasks • children did not perceive mothers differently • partners did not perceive undue burden • Divorce rate higher, especially when married prior to SCI

  21. Normal Sexual Function in Males

  22. HSR in able-bodied Males • Excitement phase • Erection -vasocongestion & penile tumescence • vasodilation of penile arts w/i corpus cavernosum • (nitrous oxide / cGMP-mediated) • influx of blood flow • compression of venous outflow by non-distensible Tunica Albuginea (maintains erection)

  23. Neuro-innervation of erection • Psychogenic erection - SNS (T12-L2) via hypogastric N • Reflexogenic erection - PNS (S2-4) via Pelvic N • penile sensation - pudendal N.

  24. HSR in a-b Males (cont) • Plateau phase • testicular elevation & enlargement • secretions from bulbourethral (Cowpers) glands • sexual flush (seen in 25%) • increase in RR, pulse rate

  25. HSR in a-b males (cont) • Orgasm Phase = Ejaculation (2 phases) • 1. Emission - SNS innervation (T12-L2) • contraction of vas def, seminal vesicle & prostate sends emissions to posterior urethra • closure of bl. neck prevents retrograde ejaculation • 2. Ejaculation - PNS & Somatic innerv.(S2-4) • contraction of Bulbospongiosum & Ischiocavernosum pelvic floor m’s • opening of external urethral sphincter - anterograde projectile ejaculation

  26. HSR in a-b males (cont) • Resolution Phase • contraction of sinusoidal smooth muscle • entrapped blood flows out thru emissary veins • decreased rigidity, de-tumescence • males are refractory from “repeat” orgasm

  27. SCI and sexual function in Males

  28. Overview: SCI & male HSR • 1. Erectile dysfunction • UMN > LMN, incomplete > complete • 2. Ejaculatory dysfunction • LMN > UMN, incomplete > complete • anejaculation • retrograde ejaculation • 3. Poor semen quality

  29. Complete UMN SCI 90% reflex erections (lesions above T-10), poorly sustained no psychogenic erections (above T-10) 40% “successful” for intercourse 5-10% ejaculation Complete LMN SCI 25 % erections psychogenic 10-25% “successful” for intercourse 15-20% ejaculate (many retrograde due to dec opening of ext sph. & dec closure of bl neck) SCI & Male HSR: Overview (cont)

  30. Erectile Dysfunction (ED): Treatment options • 1. Penile implants / prosthesis • 2. Vacuum devices, constriction rings • 3. Intracavernous injections • 4. intraurethral / topical meds • 5. Oral medications (Viagra)

  31. Erectile Dysfunction: Treatment 1998 Viagra

  32. Erectile Dysfunction (ED): Treatment Options • Penile implant (within corp cavernosum) • types: rigid, semi-rigid, inflatable* • advantages: • spontaneity, duration, (external catheter) • disadvantages: • invasive surgical option • high complication rate (erosion, infection, mechanical failure, removal (10-30 %)

  33. ED treatment (cont) • venous constriction band- maintains rigidity • Vacuum pump - tube w/ constriction rings • negative pressure to inc bl flow • 90% successful • disadvantages: • dec spontaneity, discomfort, bruising, necrosis • flaccid proximal to ring (“pistoning”) • rec’d usage < 30 minutes at a time • relative contraindications - anticoag,

  34. ED treatment (cont) • Intracaverous Injections (90% success) • Papaverine 2-5 mg(sm m relaxant) & Phentolamine (alpha-adren antag) • Prostoglandin E-1 1-2ug (vasodil & sm m relax)(Alprostadil) • erection in 10 min, lasting 30 min-6 hours…(avg = 2 hours) • SE: scarring, infection, pain, priapism • Rec’d usage: 1-2 per week

  35. Priapism: management • Priapism (abnormally sustained erection): • Can be a potentially emergent situation requiring: • aspiration from corpus cav. • Alpha-agonist injection (ephedrine) • oral terbutaline 5mg

  36. ED treatment (cont) • Intraurethral meds • instillation of protoglandin (Alprostadil, MUSE) • erection in 5-10 min, lasting 30-60 min • less rigidity (may need constriction band), dec satisfaction • SE: hypotension (drop 20/10), pain, bleeding • Topical agents • NTG paste, minoxidil, prostoglandins • not approved by FDA

  37. Sildenafil (Viagra) • Sildenafil (Viagra) • originally studied as angina Rx • FDA approved (1998) as 1st oral ED med • Pathophysiology: • inhibits CGMP phosphodiesterase type 5 • (ie: increases cGMP) • (inc’d conc of PDE-5 in penis) • increases smooth m relaxation in corpus cav.

  38. Viagra: outcome studies • 75-80% success (vs 7% in placebo) • accepted as 1st line Rx for ED • Useful in both UMN & LMN • efficacy depends on sparing of either sacral (S2-4) or T-L (T10-L2) segments • absence of both seems to exclude success

  39. Viagra: (cont) • Dosage: 25-100 mg • given 20-60 min PTA, requires stimulation • Contraindications: Viagra + nitrates • (both inc c-GMP) • CVD is NOT a contraind. (NO signif inc in CV events) • SE’s: hypotension (10/7 drop), HA, dyspepsia, dizziness, blurred vision, rhinitis, diarrhea, rash (no AD or priapism)

  40. ED: Associated Factors to consider • Smoking • HTN, DM, CVD • Depression • Chronic ETOH • Medications: (anti-hypertensives, anti-depressants, anti-arrhythmics)

  41. Treatment Recommendations for ED • Review asso factors / meds • Satisfactory reflex erections • may enhance with constriction band • Viagra * • Injections or vacuum device (patient choice) • intraurethral meds

  42. Ejaculatory Dysfunction: treatment options • 1. Injected meds • 2. Penile vibratory stimulation • 3. Electro-ejaculation • 4. sperm aspiration

  43. Ejaculatory Dysfunction (cont) • Intrathecal neostigmine (cholinesterase inhibitor) & sub-Q physostigmine • SE: severe HA, N/V, AD • NOT approved! • NOT recommended!

  44. Penile Vibratory Stim. • activate ejaculatory reflex via dorsal penile N. (10-45 min) • 90% success w/newer settings (high amp 2.5cm, freq 100Hz), UMN > LMN • Predictors: hip flexion reflex & BC reflex • primarily anterograde ejaculate • SE: AD (10%), superficial trauma

  45. Electroejaculation • 85% success rate (UMN > LMN, but both possible) • electric probe placed in contact w prostate & Sem ves (@10 min) • anterograde & retrograde ejac • cath prior, instill sperm-friendly medium, cath post • SE’s: discomfort, AD (monitor BP), rectal injury, spasticity • generally tol’d (5% require sedation/anesth)

  46. AD: management • Autonomic Dysreflexia = “uncontrolled sympathetic hyperactivity” in SCI above T6 • potentially life-threatening • stimuli include: sexual activity, masturbation, semen retrieval tech’s, bladder… • Rx: education, prevention, pre-activity medications (nifedipine, nitropaste, clonidine)

  47. Sperm aspiration • Sperm aspiration from: • testes • vas deferens • epididymis

  48. Conclusion: Ejaculatory Dysfunction Rec’s • PVS / self administration • EEJ (if PVS failure) • IUI or IVF • Sperm aspiration

  49. SCI and Male Fertility • Significantly decreased fertility rate (1% with sexual intercourse alone…ie: w/o assistive options) secondary to: • Erectile dysfunction • Ejaculatory dysfunction • anejaculation • retrograde ejaculation • Poor sperm quality

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