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Although the frequency of sexual acts typically declines after injury (either for physical or mental and emotional reasons pertaining to depression and a sense of loss), the frequency increases after time.<ref name="Hesse12"/> People with SCI may change their sexual practices, moving to greater emphasis on touching above the level of injury (where sensation is spared), and other aspects of intimacy such as kissing and caressing.<ref name="Perrouin-Verbe13"/> Couples with an injured member engage in manual and oral stimulation and hugging and kissing the same amount as uninjured couples.<ref name="Hesse12"/>
Although the frequency of sexual acts typically declines after injury (either for physical or mental and emotional reasons pertaining to depression and a sense of loss), the frequency increases after time.<ref name="Hesse12"/> People with SCI may change their sexual practices, moving to greater emphasis on touching above the level of injury (where sensation is spared), and other aspects of intimacy such as kissing and caressing.<ref name="Perrouin-Verbe13"/> Couples with an injured member engage in manual and oral stimulation and hugging and kissing the same amount as uninjured couples.<ref name="Hesse12"/>


Considerations exist for [[sexuality and disability]], for example muscle weakness and movement limitations may restrict options for positioning.{{sfn|Alpert|Wisnia|2009|p=123}} Spasticity and pain can also create barriers to sexual activity.{{sfn|The Mayo Clinic|2011|p=155}} These changes may require couples to use new positions, such as seated in a wheelchair.{{sfn|Alpert|Wisnia|2009|p=138}} Loss of sensation in the skin after SCI puts people at risk for wounds such as [[pressure sores]] and injuries that could become worse before being noticed; friction from sexual activity can damage the skin, so it is necessary after sex to inspect areas that could have been hurt.<ref name="Consortium10"/> Another risk for people with injuries at T6 or higher is [[autonomic dysreflexia]], a medical emergency involving dangerously high blood pressure.{{sfn|Alpert|Wisnia|2009|p=144}} Sexual activity could also cause bladder or bowel leakage due to [[urinary incontinence|urinary]] or [[fecal incontinence]].<ref name="Consortium10"/> Anxiety about incontinence and the time necessary to manage bowel and bladder function prior to sexual activity can stop a person from being willing to pursue sex.{{sfn|Elliott|2009|p=521}}
Considerations exist for [[sexuality and disability]], for example muscle weakness and movement limitations may restrict options for positioning.{{sfn|Alpert|Wisnia|2009|p=123}} Spasticity and pain can also create barriers to sexual activity.{{sfn|The Mayo Clinic|2011|p=155}} These changes may require couples to use new positions, such as seated in a wheelchair.{{sfn|Alpert|Wisnia|2009|p=138}} Loss of sensation in the skin after SCI puts people at risk for wounds such as [[pressure sores]] and injuries that could become worse before being noticed; friction from sexual activity can damage the skin, so it is necessary after sex to inspect areas that could have been hurt.<ref name="Consortium10"/> Another risk for people with injuries at [[Thoracic vertebra 6|T6]] or higher is [[autonomic dysreflexia]], a medical emergency involving dangerously high blood pressure.{{sfn|Alpert|Wisnia|2009|p=144}} Sexual activity could also cause bladder or bowel leakage due to [[urinary incontinence|urinary]] or [[fecal incontinence]].<ref name="Consortium10"/> People with [[urinary catheters]] must take special care with them.{{sfn|Parsons|Fitzpatrick|2013|p=}} Anxiety about incontinence and the time necessary to manage bowel and bladder function prior to sexual activity can stop a person from being willing to pursue sex.{{sfn|Elliott|2009|p=521}}


==Interventions==
==Interventions==
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* {{cite book|author=The Mayo Clinic|title=Mayo Clinic's Guide to Living with a Spinal Cord Injury (Large Print 16pt)|url=http://books.google.com/books?id=LHz1REXsYKwC&pg=PA135|date=May 2011|publisher=ReadHowYouWant.com|isbn=978-1-4587-5865-1|ref=harv}}
* {{cite book|author=The Mayo Clinic|title=Mayo Clinic's Guide to Living with a Spinal Cord Injury (Large Print 16pt)|url=http://books.google.com/books?id=LHz1REXsYKwC&pg=PA135|date=May 2011|publisher=ReadHowYouWant.com|isbn=978-1-4587-5865-1|ref=harv}}

* {{cite book|last1=Parsons|ref=harv|first1=Keith F. |first2=John M.|last2 Fitzpatrick|title=Practical Urology in Spinal Cord Injury|url=http://books.google.com/books?id=mqGvBQAAQBAJ&pg=PT134|date=29 June 2013|publisher=Springer Science & Business Media|isbn=978-1-4471-1860-2}}


* {{cite book|last1=Verhaagen|ref=harv|first1=Joost |first2=John W.|last2= McDonald III|title=Spinal Cord Injury: Handbook of Clinical Neurology Series|url=http://books.google.com/books?id=8TL9IIs0OZMC&pg=PA224|date=31 December 2012|publisher=Newnes|isbn=978-0-444-53507-8}}
* {{cite book|last1=Verhaagen|ref=harv|first1=Joost |first2=John W.|last2= McDonald III|title=Spinal Cord Injury: Handbook of Clinical Neurology Series|url=http://books.google.com/books?id=8TL9IIs0OZMC&pg=PA224|date=31 December 2012|publisher=Newnes|isbn=978-0-444-53507-8}}

Revision as of 03:08, 18 October 2015

Changes occur in a person's sexuality after a spinal cord injury (SCI), but many people with a spinal cord injury are able to have satisfying sex lives. SCI impairs the brain's ability to send and receive messages to parts of the body served by the spinal cord below the level of injury to it; this results in lost or reduced sensation and muscle motion, which can impair sexual function. Impairments can include loss of ability have an orgasm, to get an erection, to ejaculate, or for the vagina to become sufficiently lubricated. However, some people with SCI can have satisfying sex lives, including sexual arousal and orgasm, although these may take longer to achieve.[1] Treatments such as drugs, devices, and surgery exist to help men achieve erection and ejaculation. People with SCI employ a variety of changes and adaptations to help carry on their sex lives healthily, including changes in the types of sexual acts they engage in and the areas of the body they focus on. Education and counseling can be helpful but is often missing as part of SCI rehabilitation.

Sexuality and quality of life

Sexuality includes not just sexual behaviors but also sex drive, relationships, self-image,[2] and gender expression.[3] Although a myth has existed for years that people with SCI are asexual, research has been changing that perception by showing sexuality to be a high priority for injured people.[4] Studies have found recovery of sexual function to be a high priority for people with SCI, as an important aspect of quality of life.[5][6] Most paraplegics rated sexual function as their top priority, and most quadruplegics rated it second after hand and arm function.[4] Loss of sexual function can harm a person's self-esteem and reduce quality of life.[7] Yet patients' needs for care dealing with sexuality are often unmet.[8] A disabling injury can cause a person to question one's sexual identity, particularly if the disability precludes fulfilment of societally taught gender roles.[9]

Sexual satisfaction depends on a host of factors: more important than the physical function of the genitals, it depends on intimacy, quality of relationships, and satisfaction of partners, among other things.[10] People are often as concerned about failing to keep their partner satisfied as they are about meeting their own sexual needs.[10]

People with SCI do not get divorced more often than the rest of the population, but marriages that took place prior to the injury fail more often than those that took place after (33% vs. 21%).[11] People married after the injury report happier marriages and better sexual adjustment than those married before, possibly indicating difficulty adjusting to the new circumstances on the part of the spouse in preinjury marriages.[12] For those who made a choice to become involved with someone after an injury, the disability was an accepted part of the relationship from the outset.[13]

Complete vs. incomplete injury

The area of the body affected depends on the location of the injury along the spinal cord.

The completeness of the injury is an important aspect in determining how much function returns as the patient recovers.[10] An incomplete spinal cord injury is one in which the brain can still send and receive some messages beyond the damaged area of the cord. Thus people with incomplete injury might retain some sexual sensation or function. In men, having an incomplete injury improves chances of being able to achieve orgasm over those with complete injuries.[14] However, even people with complete SCI, who have no sensation or function retained below the level of injury on the spinal cord, can achieve orgasm.[10]

Level of injury

A dermatome is an area of the skin served by a specific portion of the spinal cord.

How much sexual function is retained or regained after injury is affected by the location of damage to the spinal cord:[15] the lower the level of injury, the more sensation and function is preserved above it. The location of injury to the spinal cord maps to the body: the area of skin innervated by a specific level of the spinal cord is called a dermatome. All dermatomes below the level of injury to the spinal cord may be affected with loss of sensation.

Psycogenic and reflexogenic responses

The body's physical arousal response (erection in men and vaginal lubrication and the clitoris filling with blood in women) occurs due to two separate pathways: psychogenic and reflex.[16] Arousal due to fantasies, visual input, or other mental stimulation is a psychogenic sexual experience, and that resulting from physical contact to the genital area is reflexogenic.[17] In psychogenic arousal, messages travel from the brain via the spinal cord to the nerves in the genital area.[18] The psychogenic pathway is served by the spinal cord at levels T11–L2.[16] Thus people whose injury occurred above the level of the T11 vertebra do not usually experience psychogenic erection or vaginal lubrication, while those with an injury below T12 can (but even without these reflexive responses, people often report that they feel aroused just as uninjured people do).[10] A person's ability to feel the sensation of a pinprick and a light touch in the dermatomes for T11–L2 predicts how well preserved the ability to have psychogenic arousal is preserved.[16]

The reflex pathway is served by the sacral segments of the spinal cord at S2–S4.[16][17] Although a man's ability to get a psychogenic erection when mentally aroused may be impaired after SCI,[7] a "reflex erection" may result in the absence of arousal when the penis is touched or brushed, e.g. by clothing; these commonly last less than five minutes.[1] The increase in reflex or "spontaneous" erections from physical contact such as by a catheter can be attributed to loss of inhibitory input that would quell the response in an uninjured man.[16] A complete injury below the S1 level impairs reflex erections.[19] People who have some preservation of sensation in the dermatomes at the S4 and S5 level and display a bulbocavernosus reflex (contraction of the pelvic floor in response to touching the clitoris or glans penis) are usually able to experience reflex erections or lubrication.[1] People with complete injuries affecting S4 and S5 for whom this reflex and the anal wink reflex are absent generally cannot have physiological orgasms.[1] Reflexive sexual responses (erection and vaginal lubrication) are lost immediately after injury but may return during rehabilitation.[10]

Men

Men with incomplete injuries below the level of T10 are the most likely to be able to get psychogenic erections.[19] By two years post-injury, 80% of men recover at least partial erectile function.[10] Although men may lose sensation in their genitals and the ability to have erections and orgasms, these factors are not as important to their sexual satisfaction as are a partners' satisfaction and intimacy of relationships.[20]

Ejaculation

Nerves that control ejaculation connect to the spinal cord at level T10–S4.[15] As many as 95% of men with SCI have problems with ejaculation (anejaculation), but half of men with SCI still experience orgasm, although it may feel different than it did before the injury.[10] Ejaculation can occur independent of erection as well, but the chance of ejaculation seems linked to the quality of the erection.[14] Even men with complete injuries may be able to ejaculate, because other nerves involved in ejaculation can do it without input from the spinal cord.[5] The higher the level of injury, the more physical stimulation a man needs to ejaculate.[14]

Premature or spontaneous ejaculation can be a problem for men with injuries at levels T12–L1.[14]

Male fertility is reduced after SCI; sperm are less mobile and do not survive as well, and higher numbers of white blood cells are found in the semen.[15] Without medical intervention, the male fertility rate after SCI is 5–14%, but the rate increases with treatments.[21]

Women

After a SCI, 80% of women return to being sexually active.[22] In one study 69% of women reported being sexually satisfied.[23] Often women who do experience reduced sexual satisfaction also continue to be sexually active after the injury.[24] Half of women with spinal cord injury are able to reach orgasm, usually when their genitals are stimulated,[23] and they describe the sensation the same way non-injured women do.[10] Women with injuries in the sacral region are less likely to achieve orgasm than those with injuries at higher levels, which suggests that the sacral reflex may be required for orgasm.[15]

Pregnancy

Women with spinal injuries can get pregnant and give birth; female fertility is not reduced by SCI.[25] Menstruation commonly stops immediately post-injury but then returns within six months.[26] Pregnancy is associated with greater than normal risks in women with SCI.[20] Special considerations exist such as the need to maintain proper positioning in a wheelchair.[1] A risk during labor and delivery for which patients with SCI are monitored is autonomic dysreflexia,[1] in which the blood pressure in the brain increases to dangerous levels high enough to cause potentially deadly stroke.[27]

Factors in reduced function

Loss of sexual function that results directly from impaired neural transmission is called primary sexual disfunction; secondary dysfunction results from factors that follow from that impairment, such as loss of bladder and bowel control or impaired movement.[28] SCI can also cause neuropathic pain which can make it difficult to engage in sex acts.[29] Spasticity, tightening of muscles due to increased muscle tone, is another SCI complication that can make sex difficult.[30] Hormonal changes can take place after SCI that alter sexual function, including reduced levels of testosterone in men, amenorrhea, loss of menstruation in women, and heightened levels of prolactin in both sexes.[10]

Tertiary sexual dysfunction results from psychological and social factors.[28] A person's libido, desire, or experience of arousal may change after SCI; a decrease could be due to psychological or situational factors such as depression, anxiety, changes in relationships, and hopelessness about finding relationships.[1] People frequently experience feelings of grief and despair initially after the injury.[31] Other psychological factors that can affect sexuality include loss of self-confidence and feeling less attractive.[24] SCI can lead to serious insecurities about one's ability to start or maintain romantic relationships.[32] People frequently feel that they are undesirable or worthless after they suffer SCI and may even suggest to their partners that they find someone better.[33]

Both sexes experience reduced sexual desire after SCI,[15] and most people have problems with the body's physical sexual arousal response.[4] Almost half of men and almost three quarters of women have trouble becoming psychologically aroused.[4]

Changes in sexual practices

Adjusting to post-injury changes in the body's sensation can be difficult enough to cause some to give up on the idea of satisfying sex at first.[34] But changes in sensation above and at the level of injury occur; people may find erogenous zones like the nipples or ears have become more sensitive, enough to be sexually satisfying.[10] These erogenous areas can even lead to orgasm when stimulated.[1][28] These changes may result from "remapping" of sensory areas in the brain due to neuroplasticity, particularly when sensation in the genitals is completely lost.[14] Commonly there is an area on the body between the areas of full sensation and those where sensation is lost called a "transition zone" that has changed sensation and is often sexually pleasurable when stimulated.[1] Also known as a "border zone", this area can feel the way the penis or clitoris did before injury, and can even give orgasmic sensation.[35] Due to such changes in sensation, people are encouraged to explore their bodies after SCI to discover what areas are pleasurable.[36] Masturbation can be a useful way to learn about the body's new responses.[37]

Although the frequency of sexual acts typically declines after injury (either for physical or mental and emotional reasons pertaining to depression and a sense of loss), the frequency increases after time.[10] People with SCI may change their sexual practices, moving to greater emphasis on touching above the level of injury (where sensation is spared), and other aspects of intimacy such as kissing and caressing.[23] Couples with an injured member engage in manual and oral stimulation and hugging and kissing the same amount as uninjured couples.[10]

Considerations exist for sexuality and disability, for example muscle weakness and movement limitations may restrict options for positioning.[2] Spasticity and pain can also create barriers to sexual activity.[36] These changes may require couples to use new positions, such as seated in a wheelchair.[35] Loss of sensation in the skin after SCI puts people at risk for wounds such as pressure sores and injuries that could become worse before being noticed; friction from sexual activity can damage the skin, so it is necessary after sex to inspect areas that could have been hurt.[1] Another risk for people with injuries at T6 or higher is autonomic dysreflexia, a medical emergency involving dangerously high blood pressure.[38] Sexual activity could also cause bladder or bowel leakage due to urinary or fecal incontinence.[1] People with urinary catheters must take special care with them.[39] Anxiety about incontinence and the time necessary to manage bowel and bladder function prior to sexual activity can stop a person from being willing to pursue sex.[40]

Interventions

A person's experience in managing sexuality after the injury relies not only on physical factors like severity and level of the injury, but also on aspects of life circumstances and personality such as pre-existing attitudes about sex.[10] Counseling about sex and sexuality by medical professionals, psychologists, social workers, and nurses is a part of most rehabilitation programs.[20] Education is also part of the followup treatment for people with SCI, including information about pregnancy.[23] While sexual education shortly after injury is known to be helpful and desired, it is frequently missing in rehabilitation settings.[10] Longer-term education and counseling on sex after discharge from a hospital setting are especially important.[41] Clinicians must be circumspect in bringing up the topic since people may be uncomfortable with it, or not ready for the information.[1] Health care providers must show respect and acceptance for each individual's sexual orientation and gender identity while communicating, listening, and emotionally supporting in order to provide effective care and counseling.[1] The partner of an injured person frequently needs support and counseling to help adjust to a new relationship dynamic and self-image (such as being in the role of caretaker) and to deal with stresses that arise in the sexual relationship.[42] Children and adolescents need ongoing, age-appropriate sex education that addresses questions of SCI as it relates to sexuality and sexual function.[26]

Tests exist to measure how much sensation a person has retained in their genitals after an injury, which can be used to tailor treatment to a given patient.[23] Medications also exist to increase ability to feel sexual pleasure.[23] Sex toys such as vibrators are also available that some people find helpful, e.g. to enhance sensation in areas of reduced sensitivity, and these can be modified to accommodate disabilities.[1]

Although erection is not necessary for satisfying sexual encounters, many men see erections as important, and treating erectile dysfunction, improves their relationships and quality of life.[40] A variety of treatments exist, including oral medication such as sildenafil and vardenafil; injections such as papaverine and phentolamine; topical treatments such as prostaglandin and nitroglycerine; devices such as penis pumps and rings; and surgical penile implants.[43] Medications such as papaverine, phentolamine and prostaglandin that alter the blood flow in the penis and trigger erection are injected into a vein in the penis.[44] Implants, which can be of flexible rods or inflatable tubes, carry the risk of eroding penile tissue (breaking through the skin).[45] Electrical stimulation of efferent nerves at the S2 level can be used to trigger an erection that lasts as long as the stimulation does.[46] Men who experience erectile problems as the result of a testosterone deficiency can receive testosterone therapy.[1]

Therapies exist to help men ejaculate (e.g. to collect sperm for insemination) such as medications, vibration, and even electrical stimulation.[5] The rate of anejaculation varies with the level of the spinal cord injury, with for example complete lesions strictly above Onuf's nucleus (S2–S4) being responsive to penile vibratory stimulation in 98%, but not in cases of complete lesion of the S2–S4 segments.[47] For anejaculation in spinal cord injury, the first-line method for sperm retrieval include is penile vibratory stimulation (PVS).[47] In case of failure with PVS, spermatozoa are sometimes collected by electroejaculation, or surgically by per cutaneous epididymal sperm aspiration (PESA) or testicular sperm extraction (TESE).[47]

References

  1. ^ a b c d e f g h i j k l m n o Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 20737805, please use {{cite journal}} with |pmid=20737805 instead.
  2. ^ a b Alpert & Wisnia 2009, p. 123.
  3. ^ The Mayo Clinic 2011, p. 135.
  4. ^ a b c d Elliott 2009, p. 514.
  5. ^ a b c Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1093/humupd/dmt029, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1093/humupd/dmt029 instead.
  6. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1089/neu.2011.2226, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1089/neu.2011.2226 instead.
  7. ^ a b Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 26003247, please use {{cite journal}} with |pmid=26003247 instead.
  8. ^ Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 23152456, please use {{cite journal}} with |pmid=23152456 instead.
  9. ^ Hammell 2013, pp. 288–9.
  10. ^ a b c d e f g h i j k l m n o Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 22925747, please use {{cite journal}} with |pmid=22925747 instead.
  11. ^ Leyson 2013, p. 352.
  12. ^ Leyson 2013, pp. 352–3.
  13. ^ Leyson 2013, p. 354.
  14. ^ a b c d e Elliott 2009, p. 518.
  15. ^ a b c d e Committee on Spinal Cord Injury; Board on Neuroscience and Behavioral Health; Institute of Medicine (27 July 2005). Spinal Cord Injury: Progress, Promise, and Priorities. National Academies Press. pp. 56–8. ISBN 978-0-309-16520-4.
  16. ^ a b c d e Elliott 2009, p. 516.
  17. ^ a b The Mayo Clinic 2011, p. 143–4.
  18. ^ The Mayo Clinic 2011, p. 143.
  19. ^ a b The Mayo Clinic 2011, p. 144.
  20. ^ a b c Harvey 2008, p. 20.
  21. ^ Verhaagen & McDonald III 2012, p. 190.
  22. ^ Verhaagen & McDonald III 2012, p. 304.
  23. ^ a b c d e f Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 23830253, please use {{cite journal}} with |pmid=23830253 instead.
  24. ^ a b Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1038/sc.2010.51, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1038/sc.2010.51 instead.
  25. ^ The Mayo Clinic 2011, p. 153.
  26. ^ a b Verhaagen & McDonald III 2012, p. 140.
  27. ^ Harvey 2008, p. 18.
  28. ^ a b c Attention: This template ({{cite pmid}}) is deprecated. To cite the publication identified by PMID 25599613, please use {{cite journal}} with |pmid=25599613 instead.
  29. ^ Verhaagen & McDonald III 2012, p. 303.
  30. ^ The Mayo Clinic 2011, p. 159.
  31. ^ Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1093/brain/awh699 , please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with |doi=10.1093/brain/awh699 instead.
  32. ^ Hammell 2013, p. 292.
  33. ^ Leyson 2013, p. 344.
  34. ^ Alpert & Wisnia 2009, p. 124.
  35. ^ a b Alpert & Wisnia 2009, p. 138.
  36. ^ a b The Mayo Clinic 2011, p. 155.
  37. ^ Alpert & Wisnia 2009, p. 137.
  38. ^ Alpert & Wisnia 2009, p. 144.
  39. ^ Parsons & Fitzpatrick 2013.
  40. ^ a b Elliott 2009, p. 521.
  41. ^ Harvey 2008, p. 21.
  42. ^ Leyson 2013, p. 356.
  43. ^ Elliott 2009, p. 522.
  44. ^ The Mayo Clinic 2011, p. 145.
  45. ^ Alpert & Wisnia 2009, p. 131.
  46. ^ Verhaagen & McDonald III 2012, p. 250.
  47. ^ a b c Chehensse, C.; Bahrami, S.; Denys, P.; Clément, P.; Bernabé, J.; Giuliano, F. (2013). "The spinal control of ejaculation revisited: A systematic review and meta-analysis of anejaculation in spinal cord injured patients". Human Reproduction Update. 19 (5): 507–26. doi:10.1093/humupd/dmt029. PMID 23820516.

Bibliography

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