Sexual issues are very important in the patients of spinal cord injury as it discides the quality of life.

1. 1/8/2017
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2.  “Gain of function” was most important to their
quality of life, with spinal cord injury (SCI)
 Sexuality should have a major priority
 SCI alters sexual sense
 By improving sexual function quality of life will
be improved
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3.  In 1966, By Masters and Johnson (M&J)
 Rising and declining sexual arousal
a. Excitement
b. Plateau (high arousal before orgasm)
c. Orgasm
d. Resolution
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4.  Associated with the senses, memory, and fantasy
• Increases in heart rate, blood pressure,
respiratory rate
• Late myotonia
 Men: Engorgement of the corpus cavernosa of
the penis, testicular elevation, scrotal skin
flattening
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5.  Women: Clitoral enlargement, vaginal
lubrication, constriction of the lower third of the
vagina with dilation of the upper two-thirds,
uterine elevation out of the deep pelvis, nipple
erection, areolar enlargement
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6.  Increase in HR, RR and muscle tone
 Sex flush may develop, sense of well-being
 Men: Increase in diameter and size of penis 50%-
100% over baseline, testicular elevation
 Women: Breast engorgement by up to 50% and
clitoral shaft and glans retraction
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7.  Maximum HR, respiratory rate, blood pressure
 Involuntary rhythmic contractions of the pelvic
floor muscles
 Men: Only one orgasm per cycle
 Women: Can have multiple orgasms per cycle or
can go straight from plateau to resolution
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8.  Generalized perspiration
 Gradual reversal of the above changes in heart
rate, blood pressure, and respiratory rate
 Lasts 5-15 minutes
 The penis does not return to its normal size for
30-60 minutes after orgasm
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9. Two neurological pathways
 Reflexogenic
 Psychogenic
 Common pathway involving a sacral
parasympathetic route
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10.  It is triggered by direct stimulation of the genital
organs
 Afferent via pudendal nerve to the S2–4
 Efferent returns through the sacral
parasympathetic center, via fibers to the pelvic
nerve and cavernosal nerves at the genitalia
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11.  Supraspinal origin (auditory, imaginative, visual,
etc.)
 Medial preoptic nucleus (MPOA)
 Paraventricular nucleus of the hypothalamus
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13.  Arousal is predominately parasympathetic
 Ejaculation is primarily a sympathetic phenomenon
 Ejaculation occurs in two phases
1.Seminal emission (sympathetic T10–L2)
2.Pulsatile expulsion
(parasympathetic S2–4)
 The sympathetic hypogastric nerve (L1, L2) activity
closes the bladder neck to prevent retrograde
ejaculation
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14.  Complete SCI above the level of the psychogenic
pathway eliminates the natural supratentorial
control
 Enhancing the reflexogenic mechanism initiated
by touch
 SCI involving the lumbosacral region results in
loss of reflexogenic but not psychogenic capacity
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16.  Anxiety and fear
 Decreased libido
 Limited ROM
 Loss of mobility-paralysis, spasticity, contracture
 Poor body image
 Incontinence
 Impotence-ED
 Catheter
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17.  Stimulation to cause reflexive lubrication
 If needed, artificial water-based lubricants (such
as moods and durex) can be used
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18.  The patient should be encouraged to explore his
body by rubbing the penis, the thighs, or the anus
 Alternative forms of sex that do not require an
erect penis, such as using a vibrator or trying oral
or digital sex
 Injections of hormones that stimulate erections
can be used
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19.  The use of a vibrator or massager against the
penis helps to ejaculate, it is a less invasive
technique
 Surgical implants can be used
 The possibility of infection and skin breakdown
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20.  Women who sustain a SCI may experience a
disruption in their menstrual cycle
 This may last upto 6 months after an injury
 The ability for a woman to have children is
usually not affected
 Men with SCI also experience difficulty with
fertility due to inability to ejaculate during
intercourse
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21.  The person might not be aware of an abrasion or
infection, if there is sensory impairment in and
around the genital area
 Any genital irritation or infection allows easy
entrance for STDs
 Extra caution should be taken by the person with
SCI due to high risk for HIV and STDs
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22.  Hygiene issues may occur for several reasons
lack of education, poor hand function, and
poor sensation
 Sex is possible for both men and women, but
some precautions should be taken
 The bladder should be fully voided before
sexual activity
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23.  Urine flow should be restricted for as short
time as possible and no more than 30 minutes
 No fluids for at least 2 hours before sex
 Positions that avoid placing pressure on the
bladder should be used
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25.  A sanitary napkin or pad requires less fine motor
skill and is less dependent on intact sensation
than a tampon
 To educate the pros and cons of using either a
sanitary pad or a tampon during menstruation
 Impairment of bowel or bladder function may
have an occasional episode of incontinence
during sexual activities
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26. Orgasmic ability has been shown to be preserved
 In 38% to 50% of men with complete UMN SCI
 78% to 84% of men with incomplete UMN
injury
 0% of men with complete LMN injury
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27.  Most studies of men have focused on the ability
to ejaculate instead of the ability to have an
orgasm
 Some men are also occasionally able to achieve
orgasm without anterograde ejaculation, possibly
indicating either anejaculation or retrograde
ejaculation into the bladder
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28.  Fertility impaired
 Because of a decreased ability to ejaculate
 Semen quality has also been found to be poor
1.Decreased sperm motility
2.Decreased mitochondrial activity
3.Increased sperm DNA fragmentation
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29.  Reasons for altered semen quality due to
1.Seminal fluid stasis
2.Testicular hyperthermia
3.Recurrent genitourinary tract infections
4.Hormonal dysfunction
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30.  ALLOW
A– Ask the patient
L– Legitimize the patient’s problem
L– Limitations in the evaluation
O– Open up the discussion
W–Work together
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31.  P–Permission
 LI–Limited information
 SS–Specific suggestions
 IT–Intensive therapy
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32.  B–Bring up the topic of sexuality
 E–Explain that sexuality is important
 T–Tell the patient
 T–Time of discussion
 E–Educate the patient about the side effects
 R–Record that you had a conversation
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33.  Complete blood cell count, fasting blood glucose,
and fasting lipid profile
 TFT , serum free testosterone, prolactin
 Sex hormones such as estrogen, FSH, LH, or
total testosterone but less utility in a majority of
cases
 Vaginal wet mount testing or screens for
gonorrhea, chlamydia, or human
immunodeficiency virus can be done if infection
suspected
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34.  For men with ED, specialized diagnostic
procedures are used to determine the specific
etiology of disease
 Electro-diagnostic testing- by dorsal nerve
stimulation
 Penile color duplex ultrasound is the most
practical
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35.  Penile pharmacoarteriography, PHCAS or
PHCAG
 In women, pelvic ultrasound can be indicated if
uterine or adnexal pathologic disorders are
suspected
 The objective measures of genital blood flow-
vaginal photoplethysmography
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36.  Erectile dysfunction
 PDE-5 inhibitors: sildenafil, vardenafil, tadalafil
 Sildenafil is FDA aproved
 Tadalafil is approved for on-demand or daily
 Significantly improve 60%- 70% of patients
 80% success rates in men with SCI
 Contraindicated in pts on nitrates for chest pain
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37.  Intra-cavernosal injection therapy with PGE1
 Intra-urethral alprostadil (medicated urethral
system for erection [MUSE]) therapy
 The most commonly injected medications are
alprostadil, papaverine, and phentolamine in
various combinations
 Vacuum constriction devices
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38.  Patients who cannot take PDE-5 inhibitors
 Do not want to try intra-cavernosal injection
therapy
 Its efficacy is only 30%
 Rarely associated with hypotension and syncope
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39.  Negative pressure draws blood into the corpora
cavernosa
 A constriction band applied at the base
 Efficacy rates are as high as 90%
 It is preferred who want to avoid medications
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40.  Include surgical options such as penile prostheses
 Penile prostheses come in two types:
1.Semirigid
2.Inflatable
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41.  Semi-rigid(malleable)- prostheses have malleable
silicone elastomer rods with central metal cables
that can be bent or straightened to produce an
erection
 Inflatable -Inflatable prostheses cylinders that are
implanted into the corpora cavernosa, reservoir
with fluid, and a pump that is placed in the
scrotum
 Erection is achieved by compressing the scrotal
pump to transfer fluid
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43.  The main treatment for PE is CBT and
psychologic counseling
Various approaches are
 Start-pause and frenulum squeeze techniques
 Experimentation with positioning, rhythm, speed,
breathing, and depth of penile penetration
 Success rates of up to 70 %
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44.  Often very time-consuming, expensive, and
perceived as intrusive and mechanistic, affecting
intimacy and spontaneity during a sexual
encounter
 No medications are FDA approved for the
treatment of PE, SSRIs (paroxetine, followed by
fluoxetine) are the most commonly
 TCA clomipramine has also been used
successfully, but anticholinergic side effects limit
its tolerance
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45.  Assisted ejaculation methods for fertility
treatment in men with SCI
1.Penile vibratory stimulation (PVS)
2.Rectal probe electro-ejaculation (EEJ)
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46.  PVS is most commonly used technique
 It produces superior sperm quality
 More comfortable and preferable to patients, and
can be used in a home setting
 PVS produces ejaculation in 60% to 80% of
cases
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47.  EEJ is usually only when PVS has been
unsuccessful
 EEJ is 80% to 100% successful to produces
ejaculation
 Chemically like midodrine to improve
ejaculation success rates in combination with
PVS
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48.  A recent study showed that vardenafil can
improve the ejaculation rate in men with SCI
 Monitor BP and look for signs of AD as it is
common in spinal cord–injured men undergoing
assisted ejaculation
 Cognitive-behavioral modification and
psychotherapy are indicated in men with
psychogenic (situational or relational) orgasmic
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49.  It is important to remember that libido is very
different from that of men
 The first step is to educate her what is normal
for women
 The major pharmacologic treatment for
HSDD in women is testosterone therapy
 A transdermal patch of testosterone is the
most commonly used
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50.  It is more with psychosocial factors than with
organic causes
 Sexual behavioral techniques and couple’s
counseling is beneficial
 Helping to reduce anxiety and exaggerated
sexual expectations
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51.  The medication has been well tolerated
 PDE-5 inhibitors remain a viable treatment
option, in acquired genital arousal disorder of an
organic nature (SCI)
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52.  To focus on decreasing anxiety and promoting
changes in attitudes sexual thoughts, sensation
 These behavioral treatments have been shown to
be effective in 60% of women
 As with decreased arousal, mechanical devices
can help with attainment of orgasm
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53.  Disability doesn’t automatically diminish the
importance of sexuality to the overall quality of a
patient’s life
 A thorough understanding of the diagnosis and
treatment of sexual dysfunction is needed
 Discussions about sexuality with patients will
enable the practitioner to have a significant
impact on their quality of life
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54. Thank you
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