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1. Sexual rehabilitation
Dr. Mukesh kumar Yadav
2nd year resident
Pm&r Department

2. INTRODUCTION
 Sexuality is an integral part of human being and is a vehicle to demonstrate attraction, intimacy, and
commitment. Because of this, sexuality persists beyond reproductive years and/or good health.
 Persons with disabilities often feel that since significant changes to their sexuality are not life
threatening, sexual concerns do not merit attention by health care professionals.
 Sexuality is highly important and medically legitimate and greatly affects quality of life.
 “GAIN OF FUNCTION” is most important in quality of life, men and women with spinal cord injury
stated that sexuality was a major priority even above the return of sensation, ability to walk, and
normal bladder and bowel function.
 SCI altered their sexual sense of self, and that improving their sexual function would improve their
quality of life .

3. Models of Sexual Function
 In 1966, Masters and Johnson (M&J) proposed a physiological model of sexual response by
details of genital, breast, skin, muscle, and cardiovascular functions.
 Since the M&J model, many more models have been proposed embracing the biopsychosocial
approach to sexuality, especially for women.
 The M&J model describes a four-phase “sexual mountain” of rising and declining sexual arousal:
1) Excitement,
2) Plateau (high arousal before orgasm),
3) Orgasm, and
4) Resolution (the reversal and/or dissipation of phase 1)

4.  In Excitement And Plateau phase;
 Pelvic vasocongestion and neuromuscular tension results in tumescence and/or erection of the
erectile tissues in both men and women and,
 Additionally in women, vaginal lubrication and accommodation (lengthening and uterine
lifting).
 Cardiovascular and respiration parameters increase, and sweating appears.
 In “preorgasmic” phase, men have maximal erection and rigidity and approach ejaculatory
inevitability, and
 In women, outer third of vagina forms a thickening called the “orgasmic platform.”

5.  In Orgasm phase;
 A pleasant experience in the genital area, brain, or total body and accompanied by
involuntary rhythmic contractions of the pelvic floor muscles as well as smooth muscle
contractions of internal accessory sexual organ and structures.
 Has maximal HR, BP, and respiratory rate in neurologically intact persons.
 Ejaculation, is usually concomitant with orgasm in men but can be separated in
neurological conditions.
 The resolution phase;
 Gradual reversal of the tumescence, pelvic vasocongestion, neuromuscular tension, and
cardiovascular parameters .
 Men, but not women, have a physiological refractory period , and women have the
capacity to have extended, repeated (multiple), or compounded orgasms

6. Definitions of Sexual Dysfunctions
 Sexual dysfunctions are multifactorial, involving physiological, psychological, social, and emotional
components.
 Sexual desire or libido is especially complex and under central neurophysiologic control. Kaplan defines
it as “the experience of specific sensations that motivate the individual to initiate or become responsive
to sexual stimulation.”
 If a person with disability experiences a change in drive, it is most often a reduction, known as
hypoactive sexual desire disorder.
 In rarer cases, sexual drive may be increased due to brain stimulation from injury (i.e., hypersexuality of
the Kluver-Bucy syndrome) or medications (neurotransmitter dopamine in Parkinson’s disease).
 Three other disorders of sexual dysfunction are clinically identified using the M&J model:
1. Arousal disorders
2. Ejaculatory dysfunction, and
3. Orgasmic disorders

7. SEXUAL NEUROPHYSIOLOGY
 Both somatic and autonomic nerves provide important sexual afferent and efferent communication
between the brain and periphery.
 Autonomic nerves are activated by ,stretch or lack of oxygen and Somatic system by, tactile inputs.
 Both somatic and autonomic nerves appear critical to recognize stimuli as “sexual” .
 The cerebral evaluation of skin and visceral stimulation; of visual, gustatory, and auditory inputs; and of
fantasy and emotion forms either a ;
 Sexually excitatory or
 Inhibitory signal.
 This generated neuronal “trigger,” coordinated in limbic system, hypothalamus, and other midbrain
structures, carried distally through brainstem and spinal cord tracts and can be modulated by mood,
hormones, emotions, and physical factors .

8.  Once the descending signal has passed down the spinal cord, the pelvic sexual organs receive their
information from the spinal cord via three nerve pathways:
1) Sacral parasympathetic S2-S4 (pelvic nerves and pelvic plexus),
2) Thoracolumbar sympathetic T10-L2 (hypogastric nerves and lumbar sympathetic
chain), and
3) Somatic (bilateral pudendal nerves)
 Sexual arousal leads to genital erectile tissue engorgement and pelvic vasocongestion, via vasodilatation of
arteries and smooth muscle relaxation.
 In women, lubrication depends on both intact innervation and normal estrogen levels.
 In men, internal accessory organ function and erection are depends on adequate testosterone levels.

9. There are two neurological pathways for genital arousal:
Reflexogenic pathway
 Triggered by direct stimulation of genital organs.
 Has an afferent component conveyed by the
pudendal nerve to the S2–4 segments of the spinal
cord and ,
 Responding efferent component returns through the
sacral parasympathetic center, contributing fibers
to the pelvic nerve and onto the cavernosal nerves at
the genitalia.
Psychogenic pathway
 Supraspinal origin (auditory, imaginative, visual,
etc.)
 Involving the medial preoptic nucleus (MPOA),
paraventricular nucleus of the hypothalamus, and
reticular activating systems.
 Raticular activating system involved in nocturnal
arousal during REM sleep.

10. Psychogenic and reflexogenic pathways;
 Can act independently
 usually act synergistically to determine the genital response ,via a final common pathway
involving a sacral parasympathetic route .
 The long efferent tracts from the central nervous system between cortex, cord, and autonomic
nervous system must be intact to elicit the thoracolumbar sympathetic center and the sacral
parasympathetic center .
 Both men and women undergo measurable genital arousal during rapid eye movement (REM)
sleep.
 In men, the presence of REM sleep erections is a sign that daytime erection problems are more
likely psychogenic in nature.

11. Ejaculation occurs in two phases: -
1) Seminal emission (sympathetic T10–L2) and
2) Propulsatile ejaculation or expulsion (parasympathetic S2–4 and somatic)
 The sympathetic hypogastric nerve (L1, L2) activity closes the bladder neck to prevent retrograde
ejaculation.
 Estrogen does not seem to influence the orgasmic potential in women, low androgen levels make
orgasm more difficult to reach in both men and women.
 “Orgasm” after disability may include orgasmic attainment without genital stimulation (i.e.
“Eargasms” after SCI, orgasm arising from breast stimulation alone, etc).

12. Disability–related Disruptions To Sexual Function
Disability can affect sexual function through four basic mechanisms:
1. Direct effects of vascular, neurological (including pain), hormonal, anatomical, or other damage to
any area functionally connected to the sex response.
2. Indirect effects of the medical/psychological condition, such as changes to perception or judgment,
sensory or motor alterations, bladder and bowel incontinence, spasticity, tremor, fatigue, anxiety,
chronic pain, etc.
3. Iatrogenic effects of treatment (e.g., radiation, surgery, medication, and chemotherapy)
4. Contextual factors, that is, the biopsychosocial complexity and the situational components.

13. Medications that interfere sexual functioning
The central neurotransmitters involved in the descending signal through the thalamospinal tracts are:
1) Excitatory neurotransmitters -DA and noradrenaline (ex. as sympatholytic antihypertensives ,DA
blockers negatively affect sexual function and DA agonists can elevate)
2) Inhibitory neurotransmitter- serotonin (ex. SSRI causes reduced libido, ejaculatory and orgasmic
delay)
 Tricyclic antidepressants have most negative impact on sexual function, so use in reducing doses,
short drug holidays, or switching to a “sex-friendly antidepressant” such as buproprion,
nefazodone, trazodone, or mirtazapine.
 PDE5i’s can often ameliorate the altered genital arousal side effects of such drugs.
 PDE5i’s work less in low testosterone level.

14. Cardiovascular Factors and Risks
 An average peak HR of 110 to 130 bpm and peak systolic BP of 150 to 170 mm Hg was observed
during the sexual activities of couples with longstanding relationships .
 Energy requirements during sexual activity do not exceed 4 to 5 METs (metabolic equivalents) and it
was established that walking on a treadmill at 3 miles/hour at a 5% grade or climbing two flights of
stairs at a rate of 20 steps in 10 seconds would require equivalent amounts of energy as sexual
intercourse .
 Two-flight test, which is equivalent to 6 METs, has been widely used to determine the risk of ischemia
and/or safe return to sexual activity after cardiac events.
 However, without any cardiac pathology, disordered autonomic control of the heart and/or blood vessels
can result in significant alteration of cardiovascular responses during sexual activities, especially
prominent in individuals with SCI , where abnormal autonomic control could result in the onset of
autonomic dysreflexia (AD) during sexual activities and/or continuation of AD after activities.

15. Fertility Concerns
 With any disability, the question of fertility needs to be approached from four directions :
1) Sexual functioning problems interfering with the ability to enter into the act of intercourse
and for men, to ejaculate
2) Hormonal alterations secondary to the condition (i.e., Head injury) or treatment (i.e., MS
medications, brain irradiation)
3) Altered oocyte or sperm quality secondary to the condition or treatment; and
4) Inheritable genetic trait

16. SEXUALITY IN SPECIFIC DISABILITIES

17. Spinal Cord Injury
 Complete SCI above the lumbosacral spinal cord center (usually above T10), reflexogenic arousal
should be preserved whereas psychogenic arousal will not.
 Complete lesions interrupting the sacral reflexogenic pathways will result on the reliance of
psychogenic arousal to promote genital erection in men and women.
 The degree of preservation of sensation in the T11-L2 dermatomes is helpful in predicting those
persons with SCI who are capable of psychogenic arousal , whereas the presence of BCR is indicative
of an intact sacral reflex, boding well for the reflexogenic arousal capacity.
 Ejaculatory disorders (primarily anejaculation) are highly prevalent (over 90%) and thus fertility is a
major issue for men with SCI .

18.  SCI involving the lumbosacral
region :-
 Results in loss of reflexogenic but not
psychogenic capacity.
 pathway from the brain to the thoracolumbar
center is still intact.
 The sympathetic nervous system can
maintain genital arousal capacity after injury
to parasympathetic pathways , and has a role
in the development of psychogenic arousal
 Complete spinal cord injury (SCI)
above the level of the psychogenic
pathway :-
 Eliminates the connection to psychogenic
pathway and natural supratentorial
inhibitory control,
 Enhancing the reflexogenic mechanism
initiated by touch.

19.  In incomplete conus medullaris or cauda equina lesions in men ; Natural ejaculation is most
likely occur and least likely in complete supraconal lesions .
 VS-assisted ejaculation is more reliable in complete supraconal lesions.
 Orgasm is attainable in 40% to 45% of men and approximately 50% of women after SCI .
 Lack of genital sensation, and especially lower motor neuron injury affecting the sacral
segments, make it significantly less likely to reach a genitally triggered orgasm .
 Sexual satisfaction after injury is lower in both men and women after SCI.

20. Multiple Sclerosis
 >70% of people with MS experience sexual dysfunction even in the absence of severe disability.
 Libido problems can be acute or chronic, and are linked to depression, presence of cerebral plaques, and
the inability to experience orgasm.
 Male with MS had, 60% ED, 50% ejaculatory or orgasmic dysfunction or both, and 40% reduced desire.
 Women with MS report unsatisfactory sexual lives secondary to fatigue (68%), reduced genital sensation
(48%), reduced vaginal lubrication and difficulty with arousal (35%), difficulty reaching orgasm and
anorgasmia (72%), and sexual pain disorders.
 Spasticity, fatigue, changes to genital sensation , muscle weakness, fear of fatigue and continence during
sex can affect the ability or willingness in sexual acts, especially intercourse.
 Cognitive changes and psychological impact of the disorder can result in anxiety, depression, poor self-
image, and lack of interest in sex in both patient and partner..

21. Limb Amputation
 If amputation is not traumatic but secondary to diabetes or cancer treatments, there will be added sexual
complications from the underlying disorder.
 Medically indicated loss of a limb can have serious psychosexual impact, for surgical procedure itself, and
perioperative and prosthetic pain, deformity, phantom limb pain, and inability to perform sexual acts
 Positioning options for sexual intercourse may need to be provided, and preservation of the knee joint is
helpful for balance.
 Positioning with pillows or wedges, or use or side-by-side intercourse may be necessary for upper limb or
transfemoral amputations

22. Parkinson’s Disease
 Women with PD at least 75% of report difficulties with arousal and orgasm and 50% experience low
sexual desire.
 Men with PD 70% experience erectile difficulties, 40% have premature ejaculation, and 40% have
delayed orgasm.
 Bladder and bowel dysfunction that could interfere with sexual activity.
Neuromuscular Disorders
 In this sexual dysfunction is usually due to non-genital causes, like physical limitations, privacy, and
caregiver issues.
 These disorders vary from a moderate loss of stamina and strength, to life-threatening motor disability
including loss of pulmonary capacity, the effect on sexual functioning can vary greatly.
 Age of onset and rate of progression are critical determinants of a patient’s sexual problems.

23. Traumatic Brain Injury
 TBI can have variable effects on sexual function depending on the severity of the injury, the location
of the lesion, and endocrinological disturbances and seizures secondary to the brain insult.
 Decreased desire and arousal disorders are common, whereas hypersexuality and/or sexual deviancy
post-brain injury is rare.
 Men and women with brain injury reported lower energy and low interest in initiating sex and
difficulties with erection, vaginal dryness causing pain during sexual activities, and orgasm.
 ED is common, and can be organic in nature even if bladder or bowel problems are not evident.
 TBI not only affect the cognitive status and personality but can also affect physical issues such as
sensory loss to erogenous areas, paralysis, and/or spasticity.

24. Stroke
 Men and women who suffer strokes frequently report a decrease in libido, decrease in lubrication and
decline in erectile capability and decrease the frequency of sexual activity .
 This may be due to inhibition or disinterest on the part of the person who had the stroke, but may also
be due to reluctance of the partner when unattractive behaviors such as drooling or incontinence are
present.
Coronary Artery Disease
 75% of middle aged male patients either decreased or stopped sexual activity.
 80% of male patients with congestive heart failure reported either marked problems with or an inability
to engage in sex.

25. Pulmonary Disease
 Patients with emphysema and chronic bronchitis, or COPD, often have concomitant issues with
diabetes mellitus, endocrine abnormalities, cardiac disease, and autonomic nerve dysfunction that can
affect sexual functioning,
 So it is difficult to differentiate those sexual concerns stemming from pulmonary problems alone and
those of the comorbidities and their medications used to treat them.
 In COPD, dyspnea leads to diminished activity tolerance, and full exhalation is not possible, the
respiratory rate of 40 to 60 breaths per minute required for sexual activity can be a problem. Partner
weight on the chest can also worsen the dyspnea.
 Testosterone levels reduced with chronic hypoxia, contributes to poor genital arousal capacity.

26. Diabetes
 Diabetes affects the core physiology of sexual function in both sexes.
 Small and large vessel disease, peripheral neuropathy, smooth muscle dysfunction in genitalia, and
psychological problems are responsible for libido, arousal, and orgasmic difficulties and dyspareunia.
 Neurovascular pathology can affect genital sensation, thus impairing orgasm.
Chronic Renal Failure
 Comorbid etiologies of CRF responsible for ED, menstrual abnormalities, decreased libido and fertility.
 Physiologic changes from uremia and the disturbances in the hypothalamic- pituitary-gonadal axis can
occur before and/or after the initiation of hemodialysis or continuous peritoneal dialysis.
 Hyperprolactinemia in both men and women results in decreased libido, decreased frequency of sexual
intercourse rates, orgasmic difficulties, and abbreviated longevity of sexual activity between couples.

27. Arthritis and Connective Tissue Diseases
 Individuals with OA and RA have many assaults on their sexuality, centered around pain, joint stiffness
and/or deformity, weakness, and depression.
 Poor hand function, loss of range of motion to the hips, adduction difficulties, knee pain, and back spasm
can affect the mechanics for sexual acts (including pelvic thrusting), and positioning.
 Approximately one third of patients with ankylosing spondylitis have some degree of sexual dysfunction.
 Systemic lupus erythematosus (SLE) have greater impairment with sexual dysfunction the greater the
severity of disease
 In women with systemic sclerosis, vaginal involvement, skin tightness, and muscle weakness affect sexual
function, and decreased orgasmic function is prominent.
 Women with fibromyalgia have similar overall sexual function, but have more problems with sexual
desire, satisfaction, pain, and insensitivity of their genitals around the times of sexual activity .

28.  SEXUAL REHABILITATION FRAMEWORK
 One does not have to be a sexual medicine expert to take a sexual history.
 Below is a user-friendly framework adapted from Szasz for clinicians to use, since it allows for an
intuitive process to assess and manage patients;
1) Sexual interest (biological urge combined with the motivation and/or wish to be sexual)
2) Sexual response (mental and genital arousal, ejaculation in men, ability to attain orgasm and
orgasmic quality)
3) Changes to genital sensation or other erogenous zones (loss of erotic zone sensitivity or
hypersensitivities in specific areas, etc.)
4) Changes to motor function (hand function, balance, ability to transfer to a bed, hold a partner, etc.)

29. 5) Bladder and bowel issues (management strategies, concerns with continence during social and
sexual activities, and social implications)
6) Factors associated with the condition (medication effects, alteration in hormone status, pain,
fatigue, AD, anemia, etc.)
7) Practical use of contraception, concerns about fertility, pregnancy, delivery
8) Parenting issues specific to the disability or illness
9) Relationship and partnership issues (the sexual context within which the person lives)
10)Sexual self-esteem and self-view issues (physical presentation, disfigurement, masculinity/
femininity, changes in gender role, etc.)

30.  The physical examination and any accompanying bloodwork should appropriately address the issues.
 Serum-free or bioavailable testosterone levels should be checked in persons with head injury,
especially if they have noticed a change in sexual desire.
 It is important to assess genital sensation (light touch and pinprick), rectal tone, voluntary anal
contraction, and the presence or absence of a BCR. The BCR signifies an intact sacral reflex and the
probability of reflexogenic arousal and ejaculation capacity.
 Detection of pinprick sensation around the glans penis or clitoris with the combined ability to
voluntarily contract the anal opening is helpful in assessing the capacity for genitally triggered orgasm
in persons with neurologic changes (with the exception of complete SCI).

31. CURRENT THERAPIES FOR SEXUAL DYSFUNCTIONS
 Sexual rehabilitation is multidisciplinary.
 Physician assessment must include inquiring about sexual concerns (as patients often do not bring up the
topic), rehabilitation therapists, nurses, social workers and others may be asked questions regarding
sexuality from patients who feel particularly comfortable with that particular clinician.
 If the inquiry may seem misplaced or inappropriate in some cases, a simple reflective “It seems you have
some concerns about your sexual functioning, is that the case?” can put professionalism back into the
situation without deflecting the legitimacy of the patient’s concern.
 Nonjudgmentally acknowledging the patient as a sexual human being, providing basic support, discussing
options, or arranging a referral, can go a long way to alleviate patient anxiety.
 Obtaining assistance related to physical limitations for self and partner pleasuring may require the
persistence of occupational or physical therapists, sexual health counselors, and even surgeons.

32.  MEDICAL OPTIONS FOR SEXUAL DIFFICULTIES
1.Sexual Drive Problems
 Changes to sexual drive involve complex biopsychosocial issues.
 Medically it is imperative not to miss any biologically reversible factors, such as hypogonadism,
hypothyroidism, untreated depression, and inadequate pain management.
 If possible, medications affecting drive should be altered or eliminated. It is also critical to address
issues that affect sexual willingness and/or motivation, such as those noted in the previous suggestions.
 Ongoing hypoactive desire problems need specialist assessment and management.
 Hypersexuality is more difficult to manage, especially if cognitive behavioral therapy is not possible; in
some cases, use of SSRIs, antiandrogens, or DA antagonists can be tried.

33. 2.Erection Enhancement
 Oral medications that indirectly relax the penile smooth muscle and enhance an erection attained from
psychogenic sexual stimulation are the first-line therapy.
 The PDE5i’s, including sildenafil, vardenafil, and tadalafil, work very well when there is a source of
nitric oxide (NO) from either intact peripheral nerves (stimulated by intact arousal pathways) or
healthy endothelial lining.
 PDE5i’s, do not work as well when there is poor neuronal or endothelial NO sources, such as in
diabetes, atherosclerosis, hypertension, peripheral nerve injury, or autonomic neuropathy.
 In these cases, adjusting the medication to higher on demand dosing, or even using a lower dose of
PDE5i on a daily basis, with or without additional PDE5i on demand, may prove beneficial.

35.  In other cases, where the PDE5i are more reliably effective, that is, ED secondary to SCI ,
psychogenic ED, and ED secondary to antidepressant use , lower dose on demand dosing is likely
adequate since the endothelial and nerve generation of NO is presumed to be better.
 Slight BP lowering effect of the PDE5i, a lower starting dose of on demand PDE5i should be used in
men at risk for hypotension.
 Lower doses should also be started in men with significant renal or hepatic impairment, or who may
be taking drugs that increase the serum levels of PDE5i, such as antiretrovirals.
 PDE5i should be used with caution in patients with cardiac failure, within 6 months of acute
myocardial infarction or stroke, and in patients with unstable angina pectoris.
 Coadministration of PDE5i with organic nitrates is contraindicated due to compounded lowering of
BP. Relative contraindications include uncontrolled hypertension and impaired cardiac reserve, or
symptomatic hypotension (such as in tetraplegia).

36.  There is relatively little interaction with other drugs, and the PDE5i’s have proven safe with no
increased incidence of cardiovascular events or stroke.
 PDE5i have potentially beneficial effects on other body systems primarily through their smooth
muscle relaxant effect.
 Some improvements have been seen with lower urinary tract symptoms and benign prostatic
hyperplasia, and PDE5i may also be beneficial as well in vasoconstrictive disorders, may be
protective against neurodegeneration and memory impairment, and are approved for use in pulmonary
hypertension.
 Injectable medication which directly relaxes the penile smooth muscle to create an erection is
administered through intracavernosal injections (ICI) or penile injections. Prostaglandin E1 (PGE1),
also called alprostadil, can be injected into the side of the penis.

37. Inject the medication into a specific
area of penis. This is so for don’t
inject into a nerve or blood vessel.
In image penis is divided in 3 parts.
Injection is given in the middle
third of penis at the 10 o’clock (left
side) or the 2 o’clock (right side)
position (showing in figure ).

38.  PGE1 is most commonly used for ICI due to its higher safety profile, but other combinations
typically of PGE1, papaverine and phentolamine, and occasionally atropine, can be compounded.
 ICI is the most effective treatment for ED, but proper technique and dosing must be taught.
 Men with neurological impairment require lower doses as they are at risk for prolonged erections
or even priapism.
 Higher doses may be necessary in those with primarily vascular ED, such as diabetics and
hypertensive patients. Good eyesight and adequate steady hand function is required for ICI, unless
a needle injector is used or the partner agrees to administer ICI.
 Topical alprostadil is currently being investigated .
 An intraurethral preparation of PGE1 (MUSE) is available , but is less effective than ICI,
especially in SCI patients .

39. Treatment of men with
erectile dysfunction
with transurethral
alprostadil. Medicated
Urethral System for
Erection (MUSE)

40.  After all reversible erection enhancement methods noted above have been exhausted, surgical
implantation of a penile prosthesis can be considered, but since the cavernosal tissue is destroyed
during placement of the implants, oral medications and ICI will no longer be effective.
 This permanency, plus the risks of surgery and infection, makes the placement of penile implants
worthy of proper assessment.
 Partner acceptance and cost also influence the choice of which ED therapy to use.
 Practical issues such as visual acuity, hand function, bladder management, whether the ED option can
be performed independently or requires the assistance of a partner or caregiver, must be taken into
consideration.
 Mechanical methods such as vacuum devices and penile rings are an effective nonmedicinal option

41. By placing the cylinder over
penis, create a vacuum with a
manual or an electronic pump
which removes the air from the
cylinder. This process draws blood
into the penis so that it gets
swollen and then erect.
After removing the pump need to
place the rubber or silicon ring
around the base of the penis, to
keep an erection. Never leave the
ring on for more than 30 minutes.

42. 3.Male Ejaculatory and Orgasmic Difficulties
 Ejaculatory problems after injury or chronic illness (like diabetes) are most often a result of
neurological changes as opposed to psychological causes.
 High dose pseudoephedrine can encourage seminal emission if sympathetic nerves have been
compromised or if retrograde ejaculation is present.
 Those men who acquire secondary rapid or spontaneous ejaculation after spinal cord impairment may
not be helped by the traditional use of SSRI medications used to treat premature ejaculation but slight
improvement has been noted with phenoxybenzamine, terazosin, or prazosin.
 Testosterone replacement in hypogonadal males and selection of sex-friendly antidepressant options
in depressed men can be tried to assist delayed orgasm.

43.  The use of vibratory stimulation (VS), especially when the vibrating attachment is cup shaped to
enclose the glans penis, can assist with orgasmic attainment, even in neurologically intact men.
 For fertility purposes, VS used in men with SCI involves the use of specialized powerful vibrators
made with adjustable frequencies and amplitudes such that the uninjured sacral ejaculatory reflex can
be triggered by placing the vibrator, or sometimes two in a sandwiching technique, on the glans
penis. VS can often trigger AD, so it must initially be done in a clinic, setting with experienced
clinicians.
 If VS fails to elicit ejaculation, then electroejeculator (EE) can be tried. EE consists of placement of
an electrical probe through the anal opening to approximate the location of the periprostatic nerves.
Once current is applied, seminal emission is evoked.

46.  If there is genital sensory sparing, an incomplete injury or a low SCI, anesthesia may be required.
 Depending on the cost-benefit ratio of the patient’s health care benefits and the level of injury, it may
be more efficient to do operative extraction, such as percutaneous epididymal sperm aspiration or
testicular sperm aspiration, micro surgical testicular sperm extraction.
 However, VS and EE often provide enough sperm to allow the option of lower technologies such as
intravaginal or intrauterine insemination,
 whereas utilization of operative techniques and the removal of only a few spermatozoa commits the
partner of the man to more elaborate and expensive IVF/ intracytoplasmic sperm injection (ICSI).
 Decisions on fertility technologies are also based on sperm quality, female factors such as age and
tubal patency, and cost.
 In general, the higher the technology, the higher the chance of pregnancy per attempt.

47. 4.Female Arousal and Orgasmic Difficulties
 In contrast to treatments for men with arousal difficulties, there are no approved medications for these
sexual difficulties in women.
 However, clitoral cavernosal tissue responds as male cavernosal tissue does to PDE5i (especially in
premenopausal women), but in healthy women without sexual dysfunction, it results only in
enhancing vaginal engorgement during erotic stimuli but not in subjective sexual arousal.
 Some women, however, may benefit from a trial of lower dose PDE5i.
 Minor increases in vaginal lubrication were noted in randomized trials of sildenafil in women with
SCI and MS.
 Since direct clitoral stimulation has traditionally been the most effective method of attaining orgasm
in women, VS on or near the clitoris may trigger the orgasmic reflex in women with genital sensory
alterations.

48.  Some women with SCI have found vibration intravaginally or on the cervix to be more effective than
clitoral stimulation, but in any case, more prolonged stimulation is usually required compared to
preinjury.
 The EROS-Clitoral Therapy Device (CTD), a vacuum device inducing clitoral vascular engorgement, is
the only cleared-to-market device available by prescription to treat female sexual dysfunction, and it may
prove to be of benefit in increasing orgasmic responses in women with altered pelvic neurophysiology
(such as SCI) or with arterial insufficiency.
 Theoretically, initiating the CAR reflex and vasocongestion may also improve sensory awareness in
women with some pelvic floor sensory preservation.
 In addition, by strengthening the pelvic floor, VS and/or CTD may prove helpful with urinary
incontinence in women with disabilities, further enhancing their sexual selfesteem, but further trials need
to be done.

50. THANKS