The document discusses the impact of spinal cord injury (SCI) on sexuality and sexual function, emphasizing the importance of addressing sexual health to improve the quality of life. It covers physiological responses, challenges faced by both men and women, and various therapeutic options available for sexual dysfunction, including medications and assisted ejaculation techniques. The document highlights the need for healthcare providers to engage in open discussions about sexual health with patients to enhance their overall well-being.

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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