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REVIEW ARTICLE
Management of Sexual Disorders in Spinal Cord Injured Patients
Vafa Rahimi-Movaghar1 and Alexander R Vaccaro2
1 Department of Neurosurgery, Research Deputy, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran 2 Department of Orthopaedics and Neurosurgery, Thomas Jefferson University and the Rothman Institute, Philadelphia, Pa 19107, USA Received: 20 Jul. 2011; Received in revised form: 27 Oct. 2011 ; Accepted: 22 Feb. 2012 
Abstract- Spinal cord injured (SCI) patients have sexual disorders including erectile dysfunction (ED),
impotence, priapism, ejaculatory dysfunction and infertility. Treatments for erectile dysfunction include four steps. Step 1 involves smoking cessation, weight loss, and increasing physical activity. Step 2 is phosphodiesterase type 5 inhibitors (PDE5I) such as Sildenafil (Viagra), intracavernous injections of Papaverine or prostaglandins, and vacuum constriction devices. Step 3 is a penile prosthesis, and Step 4 is sacral neuromodulation (SNM). Priapism can be resolved spontaneously if there is no ischemia found on blood gas measurement or by Phenylephrine. For anejaculatory dysfunction, massage, vibrator, electrical stimulation and direct surgical biopsy can be used to obtain sperm which can then be used for intra-uterine or in-vitro fertilization. Infertility treatment in male SCI patients involves a combination of the above treatments for erectile and anejaculatory dysfunctions. The basic approach to and management of sexual dysfunction in female SCI patients are similar as for men but do not require treatment for erectile or ejaculatory problems. 2012 Tehran University of Medical Sciences. All rights reserved. Acta Medica Iranica, 2012; 50(5): 295-299. Keywords: Spinal cord injury; Management; Sexual disorders; Erectile dysfunction

Introduction
dysfunction” in PubMed from 1966 to 20th July 2011. The reference lists of the identified articles were also Spinal trauma complicated by spinal cord injury (SCI) is a devastating event on a personal and family level, as well as a great financial burden to society because of its attendant morbidity, expense, and prolonged treatment There is less known about SCI-related sexual The prevalence of SCI has been evaluated in two dysfunction in females than in males. However, these papers reporting ranges from 110 to 1120 and 223 to studies have shown that when vaginal stimulation is 755 per million people (3,4). In a population based done in SCI females and a normal control group, orgasm study, the point prevalence of SCI in Tehran was will happen in 100% of normal controls but in less than 440/million (95% CI: 120-1140) (5). In Tehran, the 50% of T12-L1 SCI patients. In females with S2-S5 incidence was 98/million in males and 47/million in females (6). SCI complications were evaluated in 5995 In female SCI patients, fertility is possible. However, complete motor SCI (ASIA A and B) patients supported pregnancy needs careful observation for autonomic by the Welfare Organization in Iran (7). The prevalence dysreflexia. For delivery, Oxytocin induction is of sexual dysfunction in males was 32.4% and in contra-indicated but epidural anesthesia is recommended females was 13.9%. Prevalence of infertility was 12.1% to decrease the risk of autonomic dysreflexia. and 7.0% in males and females, respectively. Careful observation for bed sores, urinary tract infections (UTI), leg edema, thrombophlebitis, transient Materials and Methods
ischemic attack (TIA) and anemia is important. Meanwhile, sequential breast examination is necessary. A literature review was performed using the terms In patients with cervical lesions, lactation typically “spinal cord”, “injury”, “patient”, “treatment”, continues for 3 months and then stops because of lack of “management”, “sex”, “sexual”, and “erectile
Corresponding Author: Vafa Rahimi-Movaghar
Department of Neurosurgery, Research Deputy, Sina Trauma and Surgery Research Center, Tehran University of Medical Sciences, Tehran, Iran
Tel: +98 216 6757010, 915 3422682, Fax: +98 216 6757009, E-mail: [email protected] 
Management of sexual disorders in spinal cord injured patients 
Most men with SCI are infertile. Erectile dysfunction not successful, laboratory assessment is recommended to (ED), ejaculatory dysfunction and semen abnormalities include a fasting blood glucose level and lipid panel, contribute to the problem. Although sperm count is thyroid-stimulating hormone, and testosterone level normal in SCI men, sperm motility is low. There is abnormal sperm viability and morphology, too. Genitourinary infection and endocrine abnormalities can Conservative management
First-line therapy for ED consists of lifestyle changes, modifying drug therapy that may cause ED, Erectile dysfunction (ED)
and pharmacotherapy with phosphodiesterase type 5 ED is defined by the National Institutes of Health inhibitors (PDE5I). Obesity, inactive lifestyle, and (NIH) as the inability to achieve or maintain an erection smoking greatly increase the risk of ED. Grade A sufficient for satisfactory sexual performance. ED is the treatment recommendations, based on high-quality most common sexual problem in men (10). The patient-oriented studies, suggest that PDE5I are the most incidence increases with age and affects up to one third effective oral drugs for the treatment of ED in SCI of men throughout their lives. It causes a considerable patients (15,16). Retail sales of the three most popular negative impact on close relationships, quality of life, PDE5Is Sildenafil (Viagra), Tadalafil (Cialis), and Vardenafil (Levitra) approached $1.48 billion in 2007 ED pathophysiology
Compared with placebo, Sildenafil has been shown ED may result from variety of psychological and/or to improve erections (74% versus 21%) (18) and results organic causes including vascular, neurogenic, in more frequent intercourse attempts (57% versus 21%) hormonal, anatomic and drug-induced conditions. A normal sexual erectile response results from the Approximately one third of men with ED do not interaction between neurotransmitters and vascular respond to therapy with PDE5 inhibitors. In addition, smooth muscle initiated by parasympathetic and these agents are not effective for improving libido (20). sympathetic neuronal triggers that combine physical The three PDE5I are considered to be somewhat stimulation of the penis with sexual perception and similar in effectiveness, but there are differences in desire. Nitric oxide produced from endothelial cells after dosing, onset of action, and duration of therapeutic parasympathetic stimuli triggers a molecular cascade that results in smooth muscle relaxation and arterial The standard dose for Sildenafil is 50 to 100 mg influx of blood into the corpus cavernosum. Then, daily. Recommended time between onset of dosing and compression of venous return occurs, and an erection intercourse is one hour. Drug action starts in 14 to 60 minutes and drug duration extends for up to four hours. Tadalafil and Vardenafil dose is 10 to 20 mg daily. History taking and physical examination
Although the duration of action in Vardenafil and In a patient with SCI, history and physical Sildenafil are similar, the duration of action for Tadalfil examination are adequate in making an accurate diagnosis of ED in most cases. Sexual history should There are no conclusive data to suggest that one focus on erection adequacy, altered libido, quality and PDE5I is better than others. An open-label trial timing of orgasm, volume and form of ejaculate, established that patients preferred Tadalafil and presence of sexually-induced genital pain or penile Vardenafil over Sildenafil (22). However, nearly all evidence supports equal efficacy between Sildenafil and The physical examination should evaluate blood pressure and heart rate; body habitus, for central obesity; Headache is the most frequently reported side effect and cardiovascular, neurologic, and genitourinary of PDE5Is, occurring in roughly 10% of patients. systems, including penile, testicular, and digital rectal PDE5Is should not be taken simultaneously with nitrates because this may lead to a synergistic effect, resulting in a potentially severe, even lethal, decrease in blood Laboratory tests
Laboratory workup is not initially necessary in SCI The most frequent predictor of success for PDE5I is patients. However, if the first line of treatment for ED is upper motor neuron (UMN) lesion. Most patients 296 Acta Medica Iranica, Vol. 50, No. 5 (2012)
V. Rahimi-Movaghar and A. R Vaccaro 
tolerate these medications well, and in a meta-analysis, those taking anticoagulants. The worst complication of only 1% of patients discontinued their PDE5I. However, constriction devices in SCI patients with loss of penile PDE5Is had no positive effect on ejaculation except in sensation would be ischemic gangrene of penis. Third line: Surgically implanted penile prostheses
Testosterone
When first and second line therapies have failed, There is a limited indication for testosterone in SCI surgical implantation of an inflatable penile prosthesis patients. Testosterone supplementation in men with can be considered in consultation with an urologist hypogonadism improves ED and libido but requires (31,32). There is a 16.7% complication rate associated interval monitoring of hemoglobin, serum transaminase, with penile prostheses, which include wound infections, and prostate-specific antigen levels because of an penile pain due to excessive prosthesis length, and increased risk of prostate adenocarcinoma (25,26). displeasure due to the partner's abnormal sensation (33). Intracavernosal pressure and PDE5 activity are androgen-dependent. The prevalence of hypogonadism Fourth line: Sacral neuromodulation (SNM)
in men with ED is estimated to be 5 to 10 percent (27). The fourth line of treatment can be SNM, which can In men with hypogonadism, testosterone is superior be performed in patients with complete SCI in detrusor to placebo in improving erections and sexual function. atonic phase 2-3 months after SCI (34). This minimally Response rates are higher in primary versus secondary invasive surgical operation can be performed under local testicular failure. Testosterone is also associated with anesthesia. It involves insertion of an electrode in each improved satisfaction with erectile function and sexual S3 root, using anal sphincter contraction following stimulation to determine correct placement. Sievert et al., performed the procedure in 10 patients and 6 Second line treatment
controls and showed the procedure prevented detrusor Intracavernous and intraurethral injection of overactivity and urinary incontinence, ensured normal Papaverine, intraurethral prostaglandins (29), and bladder capacity, reduced urinary tract infection rates, vacuum constriction devices are alternative therapeutic and improved bowel and erectile functionality without options when PDE5Is fail. Much lower doses of intracavernous injection is prescribed in SCI patients than those who have vasculopathies (29). Intra- Cognitive behavioral therapy
cavernosal Papaverine is more effective, better tolerated, Cognitive behavioral therapy aimed at improving and preferred by men over the intraurethral form. There relationships may help to improve ED (35). Education is a danger for prolonged erection (priapism), which is a about medical and psychosocial etiologies of ED in medical emergency. Priapism is most frequently treated combination with physician assurance may help patients with aspiration of blood from the corpus cavernosum. If this treatment is inadequate, then intra-cavernosal Screening for cardiovascular risk factors should be injections of Phenylephrine should be performed with considered in men with ED because symptoms of ED hemodynamic monitoring. There is similar efficacy for present on average three years earlier than symptoms of intracavernosal Papaverine and oral PDE5I Sildenafil coronary artery disease. Men with ED are at increased Vacuum constriction devices
Management of anejaculation
Some patients refuse vacuum constriction devices Semen retrieval is necessary in the management of treatment due to negative cultural perceptions, minor anejaculatory patients hoping to conceive and can be complications such as ecchymoses or petechiae, and performed by penile vibratory stimulation, lack of motivation. However, vacuum constriction is a electroejaculation, prostate massage, and surgical sperm reasonable, safe, and noninvasive alternative, and retrieval, Intravaginal insemination, intrauterine possibly a better initial treatment for the management of insemination (pregnancy rate 28.6% per couple), and in vitro fertilization (pregnancy rate of 68.75% per couple) Vacuum constriction is a noninvasive second-line can all be used (37). Intracytoplasmic sperm injection option and has minor side effects. It is contraindicated in can be required if there is a low total motile sperm men with sickle cell anemia or blood dyscrasias and in Acta Medica Iranica, Vol. 50, No. 5 (2012) 297 
Management of sexual disorders in spinal cord injured patients 
Priapism might be seen in SCI males. Corporal blood 11. Brackett NL, Ibrahim E, Iremashvili V, Aballa TC, Lynne gas measurement is recommended to confirm non- CM. Treatment for ejaculatory dysfunction in men with ischemic priapism. Intracorporeal phenylephrine is used spinal cord injury: an 18-year single center experience. J for priapism treatment. Spontaneous resolution might 12. Bacon CG, Mittleman MA, Kawachi I, Giovannucci E, Detrusor-external sphincter dyssynergia (DSD) is Glasser DB, Rimm EB. Sexual function in men older than seen in SCI patients. DSD is a debilitating problem and 50 years of age: results from the health professionals even life expectancy can be affected. This can be follow-up study. Ann Intern Med 2003;139(3):161-8. managed with urethral stents and botulinum toxin 13. McVary KT, Kaufman J, Young JM, Tseng LJ. Sildenafil injection. First line treatment is the use of antimuscarinic citrate improves erectile function: a randomised double- medication and catheterization. External sphincterotomy blind trial with open-label extension. Int J Clin Pract is the surgical option in refractory cases. However, it can 14. Montague DK. Penile prosthesis implantation for end- stage erectile dysfunction after radical prostatectomy. Rev References
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