Spinal Cord Injury

A spinal cord injury (SCI) can have profound effects on a person’s quality of life including fertility and sexual function. Sexuality is an important part of a person’s identity as it relates to self-image and interpersonal relationships. The majority of people with SCI experience changes in sexual function and fertility due to changes in physical function, sensation, and/or response to stimulation.

Individuals can undergo a spectrum of emotional and psychological changes after SCI as they navigate through the rehabilitation process. As they begin to establish a new normal and explore their sexuality, they may experience sexual issues that were not present before the SCI. For example, men may be unable to get or maintain an erection (a condition known as erectile dysfunction) or may experience difficulty ejaculating after SCI, depending on the type and level of their injury. They may also present for an infertility evaluation either due to problems with ejaculation or decreased sperm counts. Men with SCI have a higher prevalence of hypogonadism (low testosterone) compared to non-SCI controls.

Women, on the other hand, may experience more difficulty achieving vaginal lubrication and increased latency to orgasm after SCI. SCI can also influence sex-relevant hormone levels, and elevated prolactin levels are more common after SCI in both sexes, but may have a particularly adverse effect on women. In women, excess prolactin can lead to amenorrhea (the absence of a menstrual period) in the acute “spinal shock” phase following injury. Altered hormone levels may also lead to anovulation (the absence of ovulation), making it challenging to conceive. Furthermore, mobility limitations and secondary health complications associated with SCI can pose challenges during pregnancy and childbirth. Women with SCI may require specialized prenatal care and assistance during labor and delivery to mitigate risks and ensure optimal care for both the mother and child.

For all people with SCI, a loss of sensation (in the genitals and elsewhere in the body) may impair cognitive arousal and sexual pleasure, even when the genital response (i.e., erections in men or vaginal lubrication in women) is still intact.

Both men and women can experience sexual function and fertility challenges after SCI. However, the mechanisms and effects may differ between the sexes.

Sexual Dysfunction in Women

For women, sexual function involves complex psychological and physiological factors. Psychogenic arousal is arousal that occurs in response to mental or sensory stimuli, while reflex arousal is arousal that occurs in response to physical stimulation of erotic areas, including the genitals.

Both psychogenic and reflex arousal can lead to genital engorgement and lubrication in women. Women with SCI may still experience psychogenic arousal, even though SCI might impact neurological functions and sensation. However, the extent and intensity of psychogenic arousal may vary depending on the individual’s specific injury and neurological condition.

The nerves responsible for reflex arousal are located in the sacral area of the spinal cord. Therefore, women with SCI may still retain the ability to experience reflex arousal, unless the sacral pathway is damaged.

Sexual response in women is guided by a combination of neural pathways and hormonal influences, both of which can be affected by SCI. Neural pathways are like highways in the body that carry signals from the brain to different body parts, such as the genitals, and back again. Hormones, on the other hand, are like messengers in the body that help regulate various functions, including sexual arousal and response. Estrogen and progesterone, two hormones which fluctuate throughout a woman’s menstrual cycle, can influence her sexual desire and sensitivity.

SCI can disrupt the neural pathways and hormonal influences that guide sexual response in women. Damage to the spinal cord can interfere with the transmission of signals between the brain and the genitals, affecting arousal and sexual sensations. Additionally, hormonal regulation may be altered due to SCI-related changes in the nervous system, potentially impacting sexual desire and responsiveness. Overall, SCI can lead to difficulties in achieving arousal, lubrication, and orgasm, affecting the sexual experience for women.

Sexual Dysfunction in Men

Similar to women’s sexual response, men have two types of erections, psychogenic and reflex. Psychogenic erections occur with auditory, mental, or visual stimulation. Upon stimulation, the brain sends a message to the nerves of the spinal cord at the T10-L2 level causing the penis to become erect. Men with an incomplete injury at a low level are more likely to have psychogenic erections than men with high-level, incomplete injuries. Men with complete SCI are less likely to experience psychogenic erections.

A reflex erection is an involuntary response that occurs with physical contact to the penis or other erotic areas. It does not require psychological stimulation like a psychogenic erection. The nerves that are necessary to have a reflex erection are located in the sacral area of the spinal cord at the level of S2-S4. Most men with SCI are still able to have a reflex erection with physical stimulation unless the S2-S4 pathway is damaged.

Spasticity

All people with SCI may experience spasticity, a condition characterized by increased muscle tone or stiffness, which can interfere with sexual function. Spasticity may increase with sexual stimulation and can possibly lead to autonomic dysreflexia, a potentially dangerous condition that is characterized by a sudden, excessive response of the autonomic nervous system to stimuli below the level of injury. This condition necessitates a temporary cessation of sexual activity and immediate medical attention. If you experience symptoms such as sudden high blood pressure, severe headache, sweating, flushing, or any other signs of autonomic dysreflexia, it is crucial to seek treatment right away to avoid serious complications such as seizures, stroke, or even death.

Fertility Issues in Women

Fertility issues in women with SCI encompass various aspects, including ovulation, fertilization, and gestation. However, compared to men, research on fertility-related implications of SCI in women is relatively scarce.

Spinal cord injuries can disrupt the neural pathways responsible for regulating ovulation and reproductive hormone production in women. Consequently, some women may experience irregular menstrual cycles or anovulation, potentially affecting fertility.

Additionally, mobility limitations and secondary health complications resulting from SCI can pose challenges during pregnancy and childbirth for women. Proper preconception counseling and comprehensive care are essential to address these concerns and optimize maternal and fetal outcomes in women with SCI.

Further research is needed to elucidate the specific effects of SCI on female fertility and develop tailored interventions to support reproductive health in this population.

Fertility Issues in Men

Over 90% of men with SCI report a problem with ejaculation. Ejaculation requires the spinal cord segment between T10-L2 to be intact. Problems with ejaculation can affect sexual satisfaction and fertility. Men may experience anejaculation (the inability to ejaculate), or retrograde ejaculation (when ejaculate moves backward into the bladder rather than out the penis). Sperm that mixes with urine in the bladder will leave the body during urination without causing any harm but can make it difficult to get a partner pregnant.

In addition to ejaculation, men with SCI can also have fertility issues related to sperm production and the quality of sperm. Sperm counts can drop dramatically during the initial period after SCI but may improve over time in some individuals.

Healthcare professionals can diagnose sexual dysfunction and fertility issues related to SCI in individuals through various methods. For all people with SCI, a thorough medical history is essential for a proper diagnosis. Information about one’s pre-injury sexual function and any changes or difficulties experienced since the injury can illuminate the potential neurological implications of the injury. Details about the level and extent of the SCI can also aid in this process.

Diagnosis of Sexual Dysfunction and Fertility Issues in Women

Healthcare providers may conduct a physical examination to assess genital sensation, muscle tone, and reflexes in women with SCI. This evaluation helps identify any physical factors contributing to sexual dysfunction. Since hormonal imbalances may also contribute to issues with sexual function and fertility in women with SCI, testing one’s hormone levels, such as estrogen and progesterone, can also provide insights in a woman’s reproductive and sexual health post-SCI.

In some cases, imaging studies such as pelvic ultrasound may be performed to evaluate pelvic organ function and anatomy. Additionally, functional assessments, including tests of vaginal lubrication and arousal responses, may be conducted to evaluate sexual function objectively in women with SCI.

For women experiencing fertility issues, healthcare providers may recommend fertility testing, including assessment of ovulation through methods such as basal body temperature monitoring or ovulation predictor kits.

Diagnosis of Sexual Dysfunction and Fertility Issues in Men

A healthcare provider can make a diagnosis of erectile dysfunction based on one’s medical history, particularly if there was normal erectile function before the SCI. When discussing this with the healthcare provider, it is helpful to have information regarding the level and extent of the SCI. Depending on the patient’s history and other medical conditions, the healthcare provider may also check their testosterone level or perform a penile Doppler ultrasound (ultrasound to measure blood flow within the penis).

If there are issues with fertility, a healthcare provider will ask to perform a semen analysis. If no or few sperm are present, an analysis of the urine sample after ejaculation (post-ejaculatory urinalysis) can reveal if retrograde ejaculation is present. Laboratory testing that may be helpful includes total testosterone and follicle-stimulating hormone to determine if there is a problem with sperm production within the testicles.

Treatment for SCI-related sexual dysfunction or fertility issues depends on the extent, location, and severity of the SCI. There are several options for treating different issues that may arise as the result of an SCI.

Treatment for SCI-Related Female Sexual Dysfunction

Treatment options for female sexual function issues related to SCI are multifaceted and aim to address specific symptoms and concerns.

• Sensory Stimulation Techniques. SCI can disrupt the normal transmission of sensory signals between the genitals and the brain, leading to reduced or altered sensation in the genital region. As a result, women with SCI may experience difficulties in becoming sexually aroused, achieving orgasm, or experiencing pleasure during sexual activity. Sensory stimulation techniques aim to re-establish or enhance genital sensation and arousal in women with SCI.

  • Sensory retraining: Engaging in sensory retraining exercises can help women with SCI re-establish connections between the brain and genital regions. This may involve focused attention on touch and sensation through techniques such as genital mapping or mindfulness-based exercises.

  • Vibratory stimulation: Vibratory devices designed for sexual stimulation can help enhance genital sensation and arousal in women with SCI. These devices can be used alone or with a partner to facilitate sexual enjoyment.

• Pelvic Floor Rehabilitation. SCI can contribute to weakened pelvic floor muscles, which can result in issues such as urinary incontinence, reduced sensation during sexual activity, and difficulty achieving orgasm. Pelvic floor rehabilitation is intended to address these problems by strengthening the pelvic floor muscles in women with SCI.

  • Pelvic floor exercises: Strengthening the pelvic floor muscles through exercises such as Kegels may improve vaginal tone, urinary control, and sexual function in women with SCI. Pelvic floor physical therapy provided by a trained professional can offer personalized guidance and support.

  • Biofeedback therapy: Biofeedback techniques can help women with SCI learn to control pelvic floor muscles more effectively, potentially improving sensation, lubrication, and orgasmic response.

• Hormone Therapy. Hormonal imbalances caused by SCI can lead to undesirable symptoms such as vaginal dryness and decreased libido. Hormone therapy can be used to restore hormonal balance and improve these symptoms.

  • Local estrogen therapy: For women experiencing vaginal dryness or atrophy post-SCI, local estrogen therapy in the form of creams, tablets, or rings may help restore vaginal lubrication and tissue health. These treatments are typically applied directly to the vaginal area and can provide relief from discomfort.

  • Hormonal replacement therapy: Systemic hormone replacement therapy may be considered for women with SCI experiencing hormonal imbalances affecting sexual function. However, the risks and benefits of hormone therapy should be carefully evaluated with a healthcare provider.

• Assistive Devices and Techniques. SCI can result in mobility impairments and sensory deficits that may hinder sexual activity. Assistive devices and techniques, such as vibrators, lubricants, positioning aids, and adjustable furniture, help overcome mobility limitations and facilitate comfortable and accessible sexual experiences for women with SCI.

  • Sexual aids: Various assistive devices and aids, such as vibrators, lubricants, dilators, and erotic accessories, can help enhance sexual pleasure and satisfaction for women with SCI. Exploring different options and techniques with a partner can promote intimacy and sexual fulfillment.

  • Adjustable furniture and positioning aids: Using adjustable beds, chairs, or cushions can facilitate comfortable and accessible sexual positions for women with SCI and their partners. Experimenting with different positions and supports can help find what works best for individual preferences and mobility levels.

Treatment for SCI-Related Erectile Dysfunction

There are several options available for erectile dysfunction, but men with SCI may have special concerns with their use. Please consult your healthcare provider to decide which treatment option is best for you.

• Oral Medication. There are currently four oral medications approved in the U.S. for the treatment of erectile dysfunction: sildenafil citrate (Viagra®), vardenafil hydrochloride (Levitra®), tadalafil (Cialis®), and avanafil (Stendra®). They may significantly improve the quality of erections for men with an injury between T6 and L5.

  • These medications work to increase blood flow to the penis. They are all similar in effectiveness, but have slightly different side effects.

  • Some medications work more quickly than others; they work within 20-120 minutes of taking the medication.

  • Possible side effects include flushing, nasal congestion, headache, visual changes, backache and stomach upset.

  • Side effects may be more severe in men with low blood pressure at baseline.

  • Drug interactions may also occur with certain blood pressure medications.

  • Men who have a prescription for nitroglycerin should not take these medications.

• Vacuum Erection Device (VED). The VED is a vacuum pump that causes blood to be drawn into the penis in order to create an erection. This is done by placing the penis into the vacuum cylinder and pumping air out of the cylinder. The erection is maintained by placing a constriction ring around the base of the penis. This ring also prevents urinary leakage that sometimes occurs with SCI.

  • A VED may be difficult to use for men with limited hand function due to their SCI.

  • Both battery-operated model and hand pump models are available.

  • The constriction ring should be removed immediately after intercourse and care should be taken to make sure that a VED does not cause skin breakdown, particularly in cases of limited sensation of the penis.

• Urethral Suppositories. Transurethral agents, also called intra-urethral agents, are medications inserted directly into the urethra (the tube that you urinate out of). The only FDA-approved urethral suppository is called MUSE® (Medicated Urethral System for Erection), which contains the drug Alprostadil.

  • MUSE works by dilating the blood vessels in the penis causing an erection.

  • Men should use a condom when having sexual intercourse with a pregnant female while using this medication because it can lead to uterine contractions.

  • The most common side effects include a burning sensation in the urethra and pain in the penis.

• Penile Injection Therapy. Injection therapy involves the injection of medication directly into the penis. The injected medication helps increase blood flow into the penis causing an erection.

  • Injection therapy typically uses a combination of two or three drugs prescribed by a healthcare provider, called “bi-mix” or “tri-mix” for short. The most common drugs are Papavarine, Phentolamine and Alprostadil. This formulation has to be made by a compounding pharmacy, which makes the formulation as prescribed by a healthcare provider, and therefore may not be available through a standard pharmacy.

  • The injections are not painful, as the type of needle used is very small.

  • Penile injection therapy will typically produce an erection within 10 min of injection.

  • The medication injected has to be refrigerated, which can make it difficult when traveling.

  • Most formulations of the medication expire within 30-45 days from the day the medication was made, after which the medication may not be effective.

  • For men with limited hand function, their partner can be taught how to administer the injection.

  • Rarely, patients may experience a prolonged erection that will not go away. In this case, you should seek medical attention immediately. To prevent this, you should determine a safe dose with the help of your healthcare provider.

• Penile Implant. A penile implant is an important treatment option for men with erectile dysfunction who don’t respond to medications or who are unsatisfied with non-surgical treatments (such as oral medications, vacuum devices, injection therapy etc.).

  • During surgery, the strength columns within the penis that normally fill with blood to create an erection are replaced with two cylinders that provide rigidity to produce an erection.

  • There are two different kinds of penile implants, a semi-rigid (partially erect at all times), or inflatable (saline-filled, inflate on demand) device. Discuss the risks and benefits of each with your healthcare provider to see which option is best for you.

  • A penile implant is a permanent surgical procedure that cannot be reversed so it is important to consider all the options, risks, and benefits prior to committing to surgery.

Treatment for SCI-Related Female Fertility Issues

Treatment options for female fertility issues related to SCI are essential for those seeking to conceive. Here are some approaches:

• Ovulation Induction. Ovulation induction is used to stimulate the release of eggs from the ovaries in women who have irregular or absent ovulation.

  • Fertility medications, such as clomiphene citrate or letrozole, may be prescribed to stimulate ovulation in women with irregular or absent menstrual cycles due to SCI-related hormonal imbalances. These medications can help regulate ovulation and improve fertility.

• Assisted Reproductive Technologies (ART). ART procedures can bypass SCI-related fertility issues such as hormonal imbalances and disrupted ovulation by directly manipulating eggs, sperm, or embryos to increase the chances of pregnancy.

  • Intrauterine insemination (IUI): IUI involves placing prepared sperm directly into the uterus during ovulation to facilitate fertilization. This technique may be suitable for women with SCI experiencing sperm-related fertility issues or cervical factors (changes in cervical mucus production and function) affecting sperm transport.

  • In vitro fertilization (IVF): IVF involves retrieving eggs from the ovaries, fertilizing them with sperm in a laboratory setting, and transferring the resulting embryos into the uterus. IVF can overcome certain fertility obstacles associated with SCI, such as impaired sperm transport or changes in cervical mucus.

• Donor Sperm or Egg. SCI can disrupt the communication between the brain and ovaries, interfere with the maturation and development of ovarian follicles, and alter blood flow and nerve signaling to the ovaries, leading to irregularities in ovulation.

  • In cases where sperm quality or egg production is compromised due to SCI, using donor sperm or eggs may be considered as an alternative fertility option. Donor gametes can be used in conjunction with ART procedures such as IUI or IVF to achieve pregnancy.

• Fertility Preservation. Fertility preservation for women may include egg or embryo freezing. These techniques allow women to preserve their fertility potential for future family planning.

  • Fertility preservation options may be considered for women with SCI who are undergoing medical treatments or procedures that could affect fertility.

Treatment for SCI-Related Male Fertility Issues

There are several options available for men with SCI to who would like to have children. All of the options will require the use of artificial reproductive techniques such as intrauterine insemination or in vitro fertilization.

The various options for men with SCI and infertility include:

• Penile Vibratory Stimulation. Penile vibratory stimulation is an inexpensive way to achieve ejaculation at home and is effective in some men with SCI. In vibratory stimulation, a vibrator is applied to the tip of the penis and surrounding area causing vibrations to travel along the sensory nerves to the spinal cord to induce a reflex ejaculation.

  • It is most likely to be successful in men with SCI above T10.

  • A variety of vibrators and massagers are available. Men with SCI should look for a vibrator device specifically designed with an output power that will induce ejaculation while minimizing skin problems.

  • For men who lack sensation in the genital area, caution must be used to avoid bruising, bleeding or ulceration.

• Electroejaculation. Rectal probe electroejaculation is a more invasive method than penile vibratory stimulation. It is usually performed under general anesthesia and involves placing an electrical probe in the rectum to produce controlled electrical stimulation to induce ejaculation.

  • It is a relatively safe, effective way to obtain a sperm sample.

• Testicular Sperm Extraction (TESE). For men who penile vibratory stimulation and electroejaculation are not successful, sperm can be obtained directly from the testicle using TESE.

  • TESE is a 30-minute procedure that can be performed in the office using numbing medication. A small cut is made in the skin of the scrotum and a piece of tissue is removed from the testicle.

  • The tissue is inspected under the microscope to confirm that sperm are present.

  • The sperm are then stored or cryopreserved for future use with in vitro fertilization.

  • TESE may not be successful in cases where there is a problem with sperm production in the testicle.

• Donor Sperm or Adoption. For men who do not have enough sperm to be used for intrauterine insemination or in vitro fertilization, donor sperm (from a sperm bank) may be used instead. Lastly, for those who do not want to use donor sperm, adoption is an option.