Sexuality and Fertility - Impact on Men with SCI
by Suzy Kim, MD
Erectile Dysfunction (ED)
Men between the ages of 16 to 30 continue to represent the largest group of new traumatic SCIs worldwide. The psychologic and physiologic impact of SCI on a man’s sexuality can challenge his adjustment to a healthy, fulfilling life. A survey of 54 paraplegic men reported sexuality as the third most important concern after the ability to walk (first) and bladder and bowel function (second).
Types of Erectile Dysfunction
As previously discussed, psychogenic and reflexogenic erections are dependent on the preservation of certain spinal networks that mediate the vascular response needed to achieve an erection. After SCI, these nerve pathways may be partially or completely disrupted. For example, if you have a complete SCI above the T10 level, the ability to achieve a psychogenic erection is unlikely (less than 10%) as the injury disrupts the messages from the brain to the T11-L2 spinal nerves. However, with intact sacral nerves, S2-S4, you should be able to achieve a reflexogenic erection.
Clinical studies have reported the likelihood to achieve each type of erection. The table below summarizes this information.
| Severity and level of SCI |
Erection Type |
| Psychogenic Erection |
Reflexogenic Erection |
|
|
| Complete SCI above T12 |
Unlikely (10%) |
Likely (>90%) * |
| Incomplete SCI above T12 |
Possible (50%) |
Likely (>90%) |
|
| Complete SCI below T12 |
Possible (25%) |
Unlikely (12%) |
| Incomplete SCI below T12 |
Possible |
Possible |
*Quality of the erection is poor and usually not sustainable for intercourse without treatment
Since every SCI is different, the ability to achieve and sustain an erection will depend on the severity and level of SCI. Often, men can only sustain an erection while the penis is being stimulated and the quality of the erection is not sufficient for penetration without the use of medications and/or devices.
Treatment for Erectile Dysfunction
In the past ten years, available treatment options have emerged from a greater understanding and growing body of research for erectile dysfunction after SCI. In the “pre-Viagra” era, the mainstay of treatment included more invasive techniques and did not offer effective medications by mouth.
Medications
Viagra (sildenafil citrate) was approved by the FDA (Food and Drug Administration) in 1998 for the treatment of erectile dysfunction. It has been studied extensively to improve sexual arousal for both men and women with SCI. Pharmacologically, Viagra is a phosphodiesterase type 5 inhibitor which acts to enhance vasodilatation (blood vessel expansion) which leads to blood pooling in erectile tissue. It is most helpful in enhancing the erection in men who are able to generate reflexogenic erections, but will still require direct genital stimulation. If taken 20 to 60 minutes prior to the sexual activity, it is estimated to improve the quality of erections in 94% of men with SCI.[iii] It is generally well tolerated but may have serious side effects when taken with certain cardiac medications, including nitrate based medications or alpha blockers. The most common side effects include headaches, hypotension (low blood pressure), facial flushing, and blurred vision, which are similar to the symptoms of autonomic dysreflexia (AD). Therefore, men with SCI above T6 level who are susceptible to AD and/or have comorbid cardiac conditions should take these medications under the guidance of a physician.
