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Management of Sexual Disorders in Spinal Cord Injured Patients
Vafa Rahimi-Movaghar1 and Alexander R Vaccaro2
1 Department of Neurosurgery, Research Deputy, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
2 Department of Orthopaedics and Neurosurgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, Pa 19107, USA
Received: 20 Jul. 2011; Received in revised form: 27 Oct. 2011 ; Accepted: 22 Feb. 2012
Spinal cord injured (SCI) patients have sexual disorders including erectile dysfunction (ED),
impotence, priapism, ejaculatory dysfunction and infertility. Treatments for erectile dysfunction include four
steps. Step 1 involves smoking cessation, weight loss, and increasing physical activity. Step 2 is
phosphodiesterase type 5 inhibitors (PDE5I) such as Sildenafil (Viagra), intracavernous injections of
Papaverine or prostaglandins, and vacuum constriction devices. Step 3 is a penile prosthesis, and Step 4 is
sacral neuromodulation (SNM). Priapism can be resolved spontaneously if there is no ischemia found on
blood gas measurement or by Phenylephrine. For anejaculatory dysfunction, massage, vibrator, electrical
stimulation and direct surgical biopsy can be used to obtain sperm which can then be used for intra-uterine or
in-vitro fertilization. Infertility treatment in male SCI patients involves a combination of the above treatments
for erectile and anejaculatory dysfunctions. The basic approach to and management of sexual dysfunction in
female SCI patients are similar as for men but do not require treatment for erectile or ejaculatory problems.
2012 Tehran University of Medical Sciences. All rights reserved.
Acta Medica Iranica
, 2012; 50(5): 295-299.
Spinal cord injury; Management; Sexual disorders; Erectile dysfunction
dysfunction" in PubMed from 1966 to 20th July 2011.
The reference lists of the identified articles were also
Spinal trauma complicated by spinal cord injury (SCI) is
a devastating event on a personal and family level, as
well as a great financial burden to society because of its
attendant morbidity, expense, and prolonged treatment
requirements (1, 2).
There is less known about SCI-related sexual
The prevalence of SCI has been evaluated in two
dysfunction in females than in males. However, these
papers reporting ranges from 110 to 1120 and 223 to
studies have shown that when vaginal stimulation is
755 per million people (3,4). In a population based
done in SCI females and a normal control group, orgasm
study, the point prevalence of SCI in Tehran was
will happen in 100% of normal controls but in less than
440/million (95% CI: 120-1140) (5). In Tehran, the
50% of T12-L1 SCI patients. In females with S2-S5
incidence was 98/million in males and 47/million in
lesions, only 17% achieved orgasm (8).
females (6). SCI complications were evaluated in 5995
In female SCI patients, fertility is possible. However,
complete motor SCI (ASIA A and B) patients supported
pregnancy needs careful observation for autonomic
by the Welfare Organization in Iran (7). The prevalence
dysreflexia. For delivery, Oxytocin induction is
of sexual dysfunction in males was 32.4% and in
contra-indicated but epidural anesthesia is recommended
females was 13.9%. Prevalence of infertility was 12.1%
to decrease the risk of autonomic dysreflexia.
and 7.0% in males and females, respectively.
Careful observation for bed sores, urinary tract
infections (UTI), leg edema, thrombophlebitis, transient
Materials and Methods
ischemic attack (TIA) and anemia is important.
Meanwhile, sequential breast examination is necessary.
A literature review was performed using the terms
In patients with cervical lesions, lactation typically
"spinal cord", "injury", "patient", "treatment",
continues for 3 months and then stops because of lack of
"management", "sex", "sexual", and "erectile
Department of Neurosurgery, Research Deputy, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
Tel: +98 216 6757010, 915 3422682, Fax: +98 216 6757009, E-mail: [email protected]
Management of sexual disorders in spinal cord injured patients
Most men with SCI are infertile. Erectile dysfunction
not successful, laboratory assessment is recommended to
(ED), ejaculatory dysfunction and semen abnormalities
include a fasting blood glucose level and lipid panel,
contribute to the problem. Although sperm count is
thyroid-stimulating hormone, and testosterone level
normal in SCI men, sperm motility is low. There is
abnormal sperm viability and morphology, too.
Genitourinary infection and endocrine abnormalities can
also be present (9-11).
First-line therapy for ED consists of lifestyle
changes, modifying drug therapy that may cause ED,
Erectile dysfunction (ED)
and pharmacotherapy with phosphodiesterase type 5
ED is defined by the National Institutes of Health
inhibitors (PDE5I). Obesity, inactive lifestyle, and
(NIH) as the inability to achieve or maintain an erection
smoking greatly increase the risk of ED. Grade A
sufficient for satisfactory sexual performance. ED is the
treatment recommendations, based on high-quality
most common sexual problem in men (10). The
patient-oriented studies, suggest that PDE5I are the most
incidence increases with age and affects up to one third
effective oral drugs for the treatment of ED in SCI
of men throughout their lives. It causes a considerable
patients (15,16). Retail sales of the three most popular
negative impact on close relationships, quality of life,
PDE5Is Sildenafil (Viagra), Tadalafil (Cialis), and
and confidence (12).
Vardenafil (Levitra) approached $1.48 billion in 2007
Compared with placebo, Sildenafil has been shown
ED may result from variety of psychological and/or
to improve erections (74% versus 21%) (18) and results
organic causes including vascular, neurogenic,
in more frequent intercourse attempts (57% versus 21%)
hormonal, anatomic and drug-induced conditions. A
normal sexual erectile response results from the
Approximately one third of men with ED do not
interaction between neurotransmitters and vascular
respond to therapy with PDE5 inhibitors. In addition,
smooth muscle initiated by parasympathetic and
these agents are not effective for improving libido (20).
sympathetic neuronal triggers that combine physical
The three PDE5I are considered to be somewhat
stimulation of the penis with sexual perception and
similar in effectiveness, but there are differences in
desire. Nitric oxide produced from endothelial cells after
dosing, onset of action, and duration of therapeutic
parasympathetic stimuli triggers a molecular cascade
that results in smooth muscle relaxation and arterial
The standard dose for Sildenafil is 50 to 100 mg
influx of blood into the corpus cavernosum. Then,
daily. Recommended time between onset of dosing and
compression of venous return occurs, and an erection
intercourse is one hour. Drug action starts in 14 to 60
minutes and drug duration extends for up to four hours.
Tadalafil and Vardenafil dose is 10 to 20 mg daily.
History taking and physical examination
Although the duration of action in Vardenafil and
In a patient with SCI, history and physical
Sildenafil are similar, the duration of action for Tadalfil
examination are adequate in making an accurate
is up to 36 hours.
diagnosis of ED in most cases. Sexual history should
There are no conclusive data to suggest that one
focus on erection adequacy, altered libido, quality and
PDE5I is better than others. An open-label trial
timing of orgasm, volume and form of ejaculate,
established that patients preferred Tadalafil and
presence of sexually-induced genital pain or penile
Vardenafil over Sildenafil (22). However, nearly all
curve and partner sexual function.
evidence supports equal efficacy between Sildenafil and
The physical examination should evaluate blood
pressure and heart rate; body habitus, for central obesity;
Headache is the most frequently reported side effect
and cardiovascular, neurologic, and genitourinary
of PDE5Is, occurring in roughly 10% of patients.
systems, including penile, testicular, and digital rectal
PDE5Is should not be taken simultaneously with nitrates
because this may lead to a synergistic effect, resulting in
a potentially severe, even lethal, decrease in blood
Laboratory workup is not initially necessary in SCI
The most frequent predictor of success for PDE5I is
patients. However, if the first line of treatment for ED is
upper motor neuron (UMN) lesion. Most patients
296 Acta Medica Iranica, Vol. 50, No. 5 (2012)
V. Rahimi-Movaghar and A. R Vaccaro
tolerate these medications well, and in a meta-analysis,
those taking anticoagulants. The worst complication of
only 1% of patients discontinued their PDE5I. However,
constriction devices in SCI patients with loss of penile
PDE5Is had no positive effect on ejaculation except in
sensation would be ischemic gangrene of penis.
Third line: Surgically implanted penile prostheses
When first and second line therapies have failed,
There is a limited indication for testosterone in SCI
surgical implantation of an inflatable penile prosthesis
patients. Testosterone supplementation in men with
can be considered in consultation with an urologist
hypogonadism improves ED and libido but requires
(31,32). There is a 16.7% complication rate associated
interval monitoring of hemoglobin, serum transaminase,
with penile prostheses, which include wound infections,
and prostate-specific antigen levels because of an
penile pain due to excessive prosthesis length, and
increased risk of prostate adenocarcinoma (25,26).
displeasure due to the partner's abnormal sensation (33).
Intracavernosal pressure and PDE5 activity are
androgen-dependent. The prevalence of hypogonadism
Fourth line: Sacral neuromodulation (SNM)
in men with ED is estimated to be 5 to 10 percent (27).
The fourth line of treatment can be SNM, which can
In men with hypogonadism, testosterone is superior
be performed in patients with complete SCI in detrusor
to placebo in improving erections and sexual function.
atonic phase 2-3 months after SCI (34). This minimally
Response rates are higher in primary versus secondary
invasive surgical operation can be performed under local
testicular failure. Testosterone is also associated with
anesthesia. It involves insertion of an electrode in each
improved satisfaction with erectile function and sexual
S3 root, using anal sphincter contraction following
stimulation to determine correct placement. Sievert et
performed the procedure in 10 patients and 6
Second line treatment
controls and showed the procedure prevented detrusor
Intracavernous and intraurethral injection of
overactivity and urinary incontinence, ensured normal
Papaverine, intraurethral prostaglandins (29), and
bladder capacity, reduced urinary tract infection rates,
vacuum constriction devices are alternative therapeutic
and improved bowel and erectile functionality without
options when PDE5Is fail. Much lower doses of
nerve damage (34).
intracavernous injection is prescribed in SCI patients
than those who have vasculopathies (29). Intra-
Cognitive behavioral therapy
cavernosal Papaverine is more effective, better tolerated,
Cognitive behavioral therapy aimed at improving
and preferred by men over the intraurethral form. There
relationships may help to improve ED (35). Education
is a danger for prolonged erection (priapism), which is a
about medical and psychosocial etiologies of ED in
medical emergency. Priapism is most frequently treated
combination with physician assurance may help patients
with aspiration of blood from the corpus cavernosum. If
return to normal male sexual function.
this treatment is inadequate, then intra-cavernosal
Screening for cardiovascular risk factors should be
injections of Phenylephrine should be performed with
considered in men with ED because symptoms of ED
hemodynamic monitoring. There is similar efficacy for
present on average three years earlier than symptoms of
intracavernosal Papaverine and oral PDE5I Sildenafil
coronary artery disease. Men with ED are at increased
risk of vascular diseases (36).
Vacuum constriction devices
Management of anejaculation
Some patients refuse vacuum constriction devices
Semen retrieval is necessary in the management of
treatment due to negative cultural perceptions, minor
anejaculatory patients hoping to conceive and can be
complications such as ecchymoses or petechiae, and
performed by penile vibratory stimulation,
lack of motivation. However, vacuum constriction is a
electroejaculation, prostate massage, and surgical sperm
reasonable, safe, and noninvasive alternative, and
retrieval, Intravaginal insemination, intrauterine
possibly a better initial treatment for the management of
insemination (pregnancy rate 28.6% per couple), and in
impotence secondary to SCI.
fertilization (pregnancy rate of 68.75% per couple)
Vacuum constriction is a noninvasive second-line
can all be used (37). Intracytoplasmic sperm injection
option and has minor side effects. It is contraindicated in
can be required if there is a low total motile sperm
men with sickle cell anemia or blood dyscrasias and in
Acta Medica Iranica, Vol. 50, No. 5 (2012) 297
Management of sexual disorders in spinal cord injured patients
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Acta Medica Iranica, Vol. 50, No. 5 (2012) 299
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