For men, the ability to experience erections is preserved more frequently than the ability to experience ejaculation. Approximately one-half of women with spinal cord injury have been found to experience orgasm by self-report 19 , 20 and in the laboratory setting. Once orgasm is achieved, it is indistinguishable from non-injured counterparts. Women with sacral preservation can utilize manual and vibratory self-stimulation to augment their sexual response.
The need for sexual expression and intimacy often remain. Both men and women report that a sense of intimacy and their ability to please their sexual partner are important determinants of their own satisfaction. Involvement of the partner in the rehabilitation process is critical.
However, the person may receive much less information on the sexual implications of their injury and even less on related compensatory strategies. Studies have shown that there is a large void in addressing sexual rehabilitation despite continued acknowledged need for education and counseling.
Individuals with spinal cord injury evolve in their readiness to hear and process new information regarding their sexual functioning. Even though sexual education should be available in the acute rehabilitation period, the information should also be tailored to the individual's particular needs as they process the ramifications of their injury.
A longitudinal study assessing the need for sexual education showed that individuals with spinal cord injury were more realistic about their sexual functioning in the first 6 months after the spinal cord injury and were better prepared to assimilate education.
Many persons use pharmacological interventions and adaptive devices to achieve sexual satisfaction. Often, masturbation can be effective in helping individuals rediscover what is sexually pleasing and develop confidence. Application of vibrators to erogenous areas can facilitate achieving sexual arousal and orgasm. After spinal cord injury, different parts of the body, especially at the level of injury can become sexually pleasurable.
For example, stimulation to the nipples, earlobes, or inner thighs may be perceived as erogenous and even evoke genital awareness in the absence of genital sensation. Genital stimulation itself can elicit sexual arousal and even orgasm in some women with complete spinal cord injuries. This technique may be sexually satisfying for the partner and also help stimulate and maintain reflexive erections in the partially erect penis.
Perineal training exercises can improve penile rigidity and function in men who have some voluntary control of perineal muscles. This decrease is caused by interruption of sympathetic innervations to the genitalia, and can result in excessive shearing during penetration. Application of lubricant jelly to the genitalia can facilitate coitus, prevent tissue injury, and is well tolerated. If an individual does not have sufficient hand function, the partner can easily incorporate the application of a lubricant into foreplay.
Water-based lubricants are generally well tolerated and do not interfere with condoms or silicone-based sex toys. If individuals lack strong upper extremities to support their upper bodies, a side lying or inferior position can be assumed, which also frees up the upper extremities for touching and fondling.
Individuals who do not have hand function can guide their partner in trialing various positions as well as stimulation delivery methods.
For example, vibratory stimulation has been reported to be an effective method of enhancing sexual arousal in both men and women. Individuals with limited grasp may benefit from the addition of straps to vibrators, while others with minimal or no grasp can be prescribed custom wrist splints with adaptations to hold vibrators, dildos, or other appliances. In our opinion, an ideal candidate is someone who has good shoulder and elbow strength and range of motion but lacks intrinsic hand function.
In the absence of functional arm capability, vibrators can be attached to various body parts such as the thigh or tongue with the help of straps. Individuals may choose to use dildos that can be strapped on to their pelvis with the help of a harness or can be worn around the thigh with Velcro straps Velcro USA Inc.
Another frequently prescribed aid in achieving erections is the vacuum erection device, which causes penile engorgement by negative pressure. Even though the battery-operated devices require less hand dexterity than the manual option, some hand function is required.
Pharmacological agents such as oral phosphodiesterase inhibitors or intracorporal injections of vasoactive substances are frequently used and very successful. If self-administration is unrealistic, proper management can be performed by their partner or personal care attendant. If an individual has significant thigh adduction, determination must be made as to whether the adduction deformity is fixed or not. If the muscle is contracted in a shortened position, the limb cannot be stretched passively beyond a fixed point fixed deformity.
When there is sufficient pelvic access with passive range of motion, the adductor tone may be amenable to nonsurgical treatment. Sometimes gentle stretching of the affected muscles prior to positioning is sufficient and can easily be incorporated into foreplay. Positioning a pillow or wedge under the individual's pelvis and legs can minimize the stretch on spastic muscle and allow comfortable positioning. If an individual has severe adductor spasticity in the thighs, pillows should be placed between the knees to prevent rubbing and skin breakdown.
Often, however, pharmacological treatments need to be considered. This is a viable option for individuals who have sufficient truncal strength and balance to maintain a seated position without significant external support and in whom sitting does not trigger more spasms or spasticity.
A seated position can be more energy consuming and may not be an option in persons with severe cardiopulmonary compromise. Removable arm rests can facilitate positioning and movement of both partners. Sexual activities such as genital penetration can precipitate spasms that either cause or interfere with positioning.
Reduced libido, difficulty achieving erections and ejaculations have been reported and appear to be dose related with reversal of symptoms with dose reduction. Urinary and stool leakage can interfere with sexual activity and can present a major concern for individuals with spinal cord injury. Some individuals empty their bladder and bowel prior to sexual activity and decrease fluid intake several hours prior to intimacy.
Bladder relaxants can be prescribed to reduce bladder spasms that cause inconvenient urinary leakage. Alternatively, a condom can be slipped over the penis and catheter, but continued drainage must be ascertained.
Suprapubic catheters are preferable to indwelling catheters because they cause less urethral trauma, are associated with better self-image and are conducive to sexual activity requiring less preparation. Ejaculation is a well-known trigger for this condition, 60 but erections and sexual stimulation can also precipitate autonomic dysreflexia.
When autonomic dysreflexia develops, the initial management involves placing the patient in an upright position to take advantage of an orthostatic reduction in blood pressure and removing the trigger. In individuals who have blood pressure elevations beyond sexual activity, other sources of blood pressure elevation need to be investigated, such as bladder retention and pressure points.
Hormonal changes Spinal cord injury results in hormonal changes that can affect sexual behavior and function in both men and women. Women with spinal cord injury often experience transient amenorrhea after spinal cord injury lasting 6 months in the majority of cases.
Elevated prolactin has been reported in both sexes and should be suspected in women with galactorrhea, or prolonged amenorrhea. These symptoms can be managed with a short course of bromocriptine. In most women, other sexual hormones remain in normal ranges and do not correlate with sexual functioning.
A higher incidence of testosterone deficiency exists in men with spinal cord injury compared with matched control subjects.
Currently, there is insufficient information to make recommendations regarding routine hormone replacement in men with spinal cord injury. Positioning Positioning can be greatly affected by a spinal cord injury due to spasms, spasticity, contractures, and pain.
Limitation in hip extension, abduction, and external rotation can adversely affect genital stimulation and coital penetration. The weight of the partner can impede chest wall excursion causing respiratory distress and cause limb fractures in severely osteoporotic or osteopenic limbs. Persistent, unrelieved pressure caused by the combined weight of the couple against bony prominences can lead to skin damage and breakdown. Couples can adjust positioning such that both partners are either side lying spooning or face to face to maximize pressure distribution and minimize balance problems.
Proper positioning can be performed by the partner if hand function is limited, but skin integrity needs to be closely monitored. Slings that wrap around the neck and keep the thighs in a flexed and abducted position can be applied, but should not cause increased spasticity or pressure.
If an individual with spinal cord injury lacks pelvic movement, a side lying position can be conducive to thrusting movement and penetration. If an individual has good upper extremity and truncal strength a gliding seat that glides back and forth can also be considered.
Individuals who lack hand function can be evaluated for assistive devices. Individuals with limited grasp may benefit from the addition of straps to vibrators, whereas others with minimal or no grasp can be prescribed custom wrist splints with adaptations to hold vibrators, dildos, or other devices.
Individuals who have no hand function can pleasure their partner through creative means. For example, highlighting the areas with sensation such as the back of the ear and using that sensation for excitement and satisfaction. In men whose sacral spinal cord segments and nerve roots are preserved, vibratory stimulation to the penis can greatly augment reflexive penile erections.
This is particularly true for men with high complete lesions. Skin wounds and pressure sore Close monitoring of the skin remains very important, especially if one of the partners is completely insensate. The skin should be checked after intimacy for redness and induration. If the individual cannot inspect their skin with a mirror or video technology, a partner or care attendant should be instructed in visualization and palpation of the skin.
If an individual applies an aid such as a vacuum device or a dildo, the skin needs to be carefully inspected after use for redness or induration.
Use of satin sheets and pillows may decrease friction and risk for abrasions. If a person has a pre-existing ulcer, one must be careful to avoid positions that would further compromise the ulcer by generating pressure or friction. For example, persons with trochanteric ulcers should avoid side lying positions, with ischial ulcer avoid seated positions, and with sacral ulcers avoid supine positions. Superficial ulcers that may come in contact with the partner can temporarily be covered with a self-adhesive hydrocolloid dressing.
Emotional adjustment issues Depression, anxiety, and overall adjustment to spinal cord injury within the context of one's personalized life experience impacts on one's sense of sexuality with oneself and with others. Grieving and working toward re-establishing one's life and self-meaning take center stage during recovery efforts. The awareness and perception of sexuality may take a seat near the back of the room, but never really leaves the room.
Sexuality rejoins the recovery efforts to varying degrees based on opportunity, culture, and environmental climate, and individuality. The readiness for education, assessment, and intervention relies on the status of the medical condition as well as the individual's life situation e. Following the spinal cord injury event, there is a shift of focus from emergency crisis to living life.
Moving across the continuum of healthcare, the life tasks, demands, and opportunities for quality living becomes a spotlight on how well and how long one can function at optimal level.
Within the larger picture of healthcare outcome, it is critical how well health providers address issues relate to the comfort level, potential bias, and preference, resources available, and environmental support from the organization and community.
Cultural values, mores, and personal comfort are a shared dynamic within a relationship, applying the individual with injury and the professional helper. In instances of discomfort or concern, awareness, self-monitoring, communication, supervision, or consultation, and adherence to professional standards and process are critical to ensure quality care and safety for both parties.
The individual may have feelings of sexuality that are activated and find expression within a necessary environment related to the level of function and ability such as in a long-term care or residential setting.
Opportunities for email, visits, internet chat, social gatherings, and privacy occasions are critical resources for the individual to have access for even the basic aspects of human relationship.
However, such resources may be encumbered related to medical condition and functioning, settings resources, philosophy, and policy. For individuals living more independent in the community, readiness, access, and personal choice join forces as is the standard in life.