Transcript SCI and Male HSR - VCU Physical Medicine & Rehabilitation

Sexuality after SCI
William McKinley MD
Associate Professor PM&R
Director SCI Rehab Medicine
Virginia Commonwealth University
Objectives
 Describe & contrast male & female sexual
response following SCI
 Identify options for management of sexual
dysfunction following SCI
 Discuss the impact and approach to
sexuality following SCI
Demographics of SCI: “Who are
we talking about?”
 8,000 - 10,000 traumatic SCI / year
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(MVA, violence, falls)
men (4:1), ages 16-45 years
complete = incomplete
 Non-traumatic SCI (33% of SCI admits)
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(spinal stenosis, cancer, ischemia, infection)
male = female, older ages
incomplete > complete
Sex vs Sexuality
 Sexuality: an expression of maleness &
femaleness through body, personality and
behavior
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involves: physical, emotional, social
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affects sense of well-being, self image, self
esteem, partner relationships & quality of life
(QOL)
Overview of Human Sexual
Response (HSR)
 Masters & Johnson:
 4 Phases of HSR
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Excitement
Plateau
Orgasm
Resolution
Normal Sexual Function in
Females
HSR in able-bodied Females
 Excitement Phase
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afferent stim of genitals (via pudendal N)
• increase in blood flow
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vasocongestion and tumescence of external
genitalia (mons pubis, labia, clitoris, vagina)
vaginal lubrication
“Reflex (S2-4)
“Pschogenic” (T10-L2)
HSR in a-b Females (cont)
 Plateau Phase
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vasodilation in vagina
uterine & cervical elevation
sexual flush (seen in 75%)
secretions from Batholin’s gland (analogous to
“emission phase” in male ejaculation)
increase in breast size, nipple erection
increase in RR, pulse rate, BP
HSR in a-b Females (cont)
 Orgasm
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Rhythmic contractions of uterus, outer 1/3 of
vagina & anal sphincter
studies suggest orgasm is an S2-4 sacral reflex
 Resolution Phase
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gradual loss of vasocongestion & tumescence
(unlike males, during resolution, may return to
orgasm phase…)
SCI & Female sexual function
Terminology
 “Complete” SCI = no motor/sensory sparing
 “Incomplete” = sparing of motor/sensory
 Upper Motor Neuron (UMN) = descending
sp cord tracts affected, caudal reflex arcs
intact
 Lower Motor Neuron (LMN) = nonfunctional reflex ability
 (consider “spinal shock” period)
SCI & HSR in Females
 In “Complete UMN” SCI
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maintenance of reflexic (S2-4), but not
psychogenic (T10-L2) vaginal lubrication
• PP at T11-12 predictive of Psych lubrication
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Orgasms reported even with complete SCI T-9
& above
 In “Complete LMN” SCI
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No reflexic, but 25% psychogenic lubrication
Females & Intercourse after SCI
 67% report IC post injury (87% prior)
 Predictive info:
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years post SCI - 50% yr 1, 75% > 10 yrs
LOI - 62% cerv, 70% thor, 82% L/S
Complete = Incomplete
 Problems reported:
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lubrication, decreased enjoyment…
positioning (40%), spasticity(26%), bl incont
(17%), AD (11%)
Female Sexual activity post SCI
 Most individuals who were sexually active
prior to SCI remain so.
 Positive sexual adjustment is reported in
majority (by 6 mo p-injury)
Female sexual activity (cont)
 Orgasm reported in 54%
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took more time and more intensity
relocation of erogenous zones reported
71% reported “pleasure” above LOI
 Favorite sexuality activities
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Pre- SCI : intercourse
Post-SCI: kissing, hugging, touching
Impact of SCI on Female
Fertility
 No adverse impact on female fertility
 Amenorrhea (seen initially in 60%)
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returns by 6 mo (50%), by 12 mo (90%)
 Once menses returns = Fertile!
 No increase in spontaneous abortions noted
Female Contraception p-SCI
 Oral pills - contraindicated w/ h/o DVT
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low dose progestin has lower risk
 Implants (levonorgesterol) - appear safer
 Cerv diaphram/caps/sponges - not rec’s due
to dec. uterine sensation, inc risk PID
 Barrier method (male contraception) - may
be safest!
Prenatal & Perinatal Pregnancy
Issues
 Prenatal:
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constipation (decreased gastric motility)
UTI’s (? abx choice, change to sterile IC)
decreased mobility in 3rd trimester
vital capacity decreases (uterine elevation)
DVT risk (dec venous return & mobility)
Autonomic dysreflexia (T-6 & above)
Pressure ulcers
Spasticity
Pregnancy Issues (cont)
 Perinatal
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SCI above T-10 do not feel onset of uterine cont
(labor pains)
small increase in premature delivery & low
birth weights
• delivery before 37 weeks (30-40%)
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vaginal delivery is preferred
• episiotomy rx w/nonabsorb sutures (breakdown)
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AD in 90% (HTN confused w/ pre-eclampsia)
• Rx - epidural anesthesia
Parenting Issues in Females
 Most did NOT feel well informed
 70% satisfied with post-SCI sexual exp.
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breast feeding not contra (dec milk w/sci >T6)
Felt family roles/relationships similar to before
• more division of HH & child care tasks
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children did not perceive mothers differently
partners did not perceive undue burden
 Divorce rate higher, especially when
married prior to SCI
Normal Sexual Function in Males
HSR in able-bodied Males
 Excitement phase
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Erection -vasocongestion &
penile tumescence
• vasodilation of penile arts w/i
corpus cavernosum
– (nitrous oxide / cGMPmediated)
– influx of blood flow
• compression of venous outflow
by non-distensible Tunica
Albuginea (maintains erection)
Neuro-innervation of erection
 Psychogenic erection SNS (T12-L2) via
hypogastric N
 Reflexogenic erection PNS (S2-4) via Pelvic N
• penile sensation - pudendal
N.
HSR in a-b Males (cont)
 Plateau phase
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testicular elevation & enlargement
secretions from bulbourethral (Cowpers) glands
sexual flush (seen in 25%)
increase in RR, pulse rate
HSR in a-b males (cont)
 Orgasm Phase = Ejaculation (2 phases)
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1. Emission - SNS innervation (T12-L2)
• contraction of vas def, seminal vesicle & prostate
sends emissions to posterior urethra
• closure of bl. neck prevents retrograde ejaculation
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2. Ejaculation - PNS & Somatic innerv.(S2-4)
• contraction of Bulbospongiosum &
Ischiocavernosum pelvic floor m’s
• opening of external urethral sphincter - anterograde
projectile ejaculation
HSR in a-b males (cont)
 Resolution Phase
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contraction of sinusoidal smooth muscle
entrapped blood flows out thru emissary veins
decreased rigidity, de-tumescence
males are refractory from “repeat” orgasm
SCI and sexual function in Males
Overview: SCI & male HSR
 1. Erectile dysfunction
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UMN > LMN, incomplete > complete
 2. Ejaculatory dysfunction
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LMN > UMN, incomplete > complete
anejaculation
retrograde ejaculation
 3. Poor semen quality
SCI & Male HSR: Overview
(cont)
 Complete UMN SCI
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90% reflex erections
(lesions above T-10),
• poorly sustained
• no psychogenic
erections (above T-10)
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40% “successful” for
intercourse
5-10% ejaculation
 Complete LMN SCI
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25 % erections
• psychogenic
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10-25% “successful”
for intercourse
15-20% ejaculate
(many retrograde due
to dec opening of ext
sph. & dec closure of
bl neck)
Erectile Dysfunction (ED):
Treatment options
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1. Penile implants / prosthesis
2. Vacuum devices, constriction rings
3. Intracavernous injections
4. intraurethral / topical meds
5. Oral medications (Viagra)
Erectile Dysfunction: Treatment
1998
Viagra
Erectile Dysfunction (ED):
Treatment Options
 Penile implant (within corp cavernosum)
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types: rigid, semi-rigid, inflatable*
advantages:
• spontaneity, duration, (external catheter)
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disadvantages:
• invasive surgical option
• high complication rate (erosion, infection,
mechanical failure, removal (10-30 %)
ED treatment (cont)
 venous constriction band- maintains rigidity
 Vacuum pump - tube w/ constriction rings
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negative pressure to inc bl flow
90% successful
disadvantages:
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dec spontaneity, discomfort, bruising, necrosis
flaccid proximal to ring (“pistoning”)
rec’d usage < 30 minutes at a time
relative contraindications - anticoag,
ED treatment (cont)
 Intracaverous Injections (90% success)
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Papaverine 2-5 mg(sm m relaxant) &
Phentolamine (alpha-adren antag)
Prostoglandin E-1 1-2ug (vasodil & sm m
relax)(Alprostadil)
erection in 10 min, lasting 30 min-6
hours…(avg = 2 hours)
• SE: scarring, infection, pain, priapism
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Rec’d usage: 1-2 per week
Priapism: management
 Priapism (abnormally sustained erection):
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Can be a potentially emergent situation
requiring:
• aspiration from corpus cav.
• Alpha-agonist injection (ephedrine)
• oral terbutaline 5mg
ED treatment (cont)
 Intraurethral meds
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instillation of protoglandin (Alprostadil,
MUSE)
erection in 5-10 min, lasting 30-60 min
less rigidity (may need constriction band), dec
satisfaction
SE: hypotension (drop 20/10), pain, bleeding
 Topical agents
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NTG paste, minoxidil, prostoglandins
not approved by FDA
Sildenafil (Viagra)
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Sildenafil (Viagra)
• originally studied as angina Rx
• FDA approved (1998) as 1st oral ED med
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Pathophysiology:
• inhibits CGMP phosphodiesterase type 5
– (ie: increases cGMP)
– (inc’d conc of PDE-5 in penis)
• increases smooth m relaxation in corpus cav.
Viagra: outcome studies
 75-80% success (vs 7% in placebo)
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accepted as 1st line Rx for ED
 Useful in both UMN & LMN
 efficacy depends on sparing of either sacral
(S2-4) or T-L (T10-L2) segments
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absence of both seems to exclude success
Viagra: (cont)
 Dosage: 25-100 mg
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given 20-60 min PTA, requires stimulation
 Contraindications: Viagra + nitrates
• (both inc c-GMP)
– CVD is NOT a contraind. (NO signif inc in CV events)
 SE’s: hypotension (10/7 drop), HA,
dyspepsia, dizziness, blurred vision, rhinitis,
diarrhea, rash (no AD or priapism)
ED: Associated Factors to
consider
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Smoking
HTN, DM, CVD
Depression
Chronic ETOH
 Medications: (anti-hypertensives, antidepressants, anti-arrhythmics)
Treatment Recommendations for
ED
 Review asso factors / meds
 Satisfactory reflex erections
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may enhance with constriction band
 Viagra *
 Injections or vacuum device (patient choice)
 intraurethral meds
Ejaculatory Dysfunction:
treatment options
 1. Injected meds
 2. Penile vibratory stimulation
 3. Electro-ejaculation
 4. sperm aspiration
Ejaculatory Dysfunction (cont)
 Intrathecal neostigmine (cholinesterase
inhibitor) & sub-Q physostigmine
• SE: severe HA, N/V, AD
• NOT approved!
• NOT recommended!
Penile Vibratory Stim.
 activate ejaculatory reflex via dorsal penile
N. (10-45 min)
 90% success w/newer settings (high amp
2.5cm, freq 100Hz), UMN > LMN
 Predictors: hip flexion reflex & BC reflex
 primarily anterograde ejaculate
 SE: AD (10%), superficial trauma
Electroejaculation
 85% success rate (UMN > LMN, but both
possible)
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electric probe placed in contact w prostate &
Sem ves (@10 min)
anterograde & retrograde ejac
• cath prior, instill sperm-friendly medium, cath post
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SE’s: discomfort, AD (monitor BP), rectal injury,
spasticity
• generally tol’d (5% require sedation/anesth)
AD: management
 Autonomic Dysreflexia = “uncontrolled
sympathetic hyperactivity” in SCI above T6
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potentially life-threatening
stimuli include: sexual activity, masturbation,
semen retrieval tech’s, bladder…
Rx: education, prevention, pre-activity
medications (nifedipine, nitropaste, clonidine)
Sperm aspiration
 Sperm aspiration from:
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testes
vas deferens
epididymis
Conclusion: Ejaculatory
Dysfunction Rec’s
 PVS / self administration
 EEJ (if PVS failure)
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IUI or IVF
 Sperm aspiration
SCI and Male Fertility
 Significantly decreased fertility rate (1%
with sexual intercourse alone…ie: w/o
assistive options) secondary to:
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Erectile dysfunction
Ejaculatory dysfunction
• anejaculation
• retrograde ejaculation
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Poor sperm quality
Semen Quality after SCI
Semen Quality (cont)
 Poor sperm motility (in spite of nl #)
• 20% motile (vs 70% in a-b males)
• factors: recurrent UTI, epididymitis, scrotal
hyperthermia, meds, stasis of prostatic fluid,
retrograde ejaculation, chronic denervation, change
in hormones (test, FSH, LH)
• future research necessary!
 Should semen be frozen?
• Not recommended
• semen quality does not decline (freezing may
decrease motility by 50%)
• semen quality is better with PVS vs RPE
Insemination
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1. Home insemination
2. Intrauterine
3. In-vitro
4. Intracytoplasmic
5. Gamete fallopian transfer
Insemination
 Home insemination with PVS
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prophylactic nifedipine
non-spermacidal collection container
10 ml syringe for vaginal self-insem.
Multiple trial cycles
• timing, sx, body temp, “kits”
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25-60% successful
Assisted Reproduction
Technology (ART)
 Fertility success rate 90% w/ ART
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Intrauterine insemination (IUI) 10-15% success
• lad-collected sperm sep’d from semen fluid
• good for “motile” sperm
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In-vitro fertilization (IVF)
• 25% success,
• Usually asso w fertility drugs
– (inc # eggs)
• again, good for motile sperm
ART (cont)
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Intracytoplasmic Sperm inj. (ICSI) - inj of
single sperm directly into ovum (can be used if
poor motility)
• inc rate of multiple births, premature delivery,
miscarriage
• no inc in birth defects
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Gamete intra-fallopian transfer (GIFT)
• egg & sperm placed in fallopian tube
Parenting issues in Males w/SCI
 Children of males w/SCI well adjusted
 Sexual readjustment
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individual persons wishes
experience
pre-injury sexual habits
Related Practical Issues
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positioning
bladder / bowel
skin breakdown prevention
AD
spasticity
Sexual history & intervention
 “ENIGMA”
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E = engage in conversation
N = normalize sexuality
I = inform & educate
G = guide & suggest
M = maximize abilities
A = assess & reassess
Sexual Intervention (cont)
 “PLISSIT” model of sexual therapy
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a spectrum of interventional areas that can be
addressed in part by each member of the
interdisciplinary team
P = permission
LI = limited information
SS = specific suggestions
IT = intensive therapy
Summary: Female & Male
Sexual function after SCI
Summary: Female post-SCI
 Lubrication present or easily enhanced
 Enjoyment / orgasm are key issues
 Fertility essentially normal
Summary: male post-SCI
 “Succesful” Erection/intercourse in 33%
 Oral meds (Viagra) has enhanced efficiency
 Poor unassisted ejaculation / orgasm /
fertility
 With assistance, fatherhood very possible
Successful Sexuality after SCI
 Education!
 Preparation!
 Communication!
Q&A