Sexuality and Fertility - Impact on Men with SCI

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 percent) 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. 

*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 percent 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. 

Cialis (tadalafil) and Levitra (vardenafil) are also approved by the FDA and currently undergoing studies for individuals with SCI.

Penile Vacuum Devices
Penile vacuum devices (PVDs) are cylindrical pumps placed over the penis to create a negative pressure to increase the blood flow into the penis. It is commonly used with a tension ring at the base of the penis to help maintain the erection. It has been shown to be safe, affordable, and most helpful for men who are unable to obtain any erection, but also useful to augment a “soft” erection. 

The device is recommended for limited use (no longer than 30 minutes) to prevent irreversible skin breakdown and caution should be taken for those men who lack genital sensation. It can also be used while taking medications such as Viagra. Independent use may be difficult for those with high level SCI since using the manual pump requires sufficient hand dexterity. 

However, this provides an opportunity to involve the partner in the use of the pump. Battery operated pumps are available and may be covered by some insurance policies with a physician’s prescription. Men who have used the pump report that a recumbent position (may require transfer out of wheelchair) provides a better seal for the vacuum.

Penile Injections
Direct injection of medications into the penile tissue has been an effective means of treatment for men with and without SCI. Caverject (alprostadil) is a prostaglandin derivative found to be helpful in creating favorable vasocongestion for an erection. Its use should be under the guidance of a urologist who will work with the individual to carefully titrate the dose of the medication to prevent a complication called priapism. 

Priapism is a sustained erection caused by an inability to drain blood out of the penis. This is a medical emergency. If the erection is persistent for longer than 4 hours, immediate medical drainage is required to prevent permanent damage to the vascular system. Other risks include bruising, infection, or penile fibrosis (scarring). By limiting the frequency of use to once weekly, there is a reduced risk of scarring. So, for men who desire more frequent erections, other treatment options must be explored.

Penile Implants
Penile implants were the first type of treatment for erectile dysfunction in both able-bodied men and men with SCI. These are devices surgically implanted into the shaft of the penis and can be inflated by a pump or simply bent into position (malleable rod). (diagram 7). However, due to its complications, including penile erosion, infection, and mechanical failure and the development of safer treatment options, its current use in SCI has become increasingly limited. Its use should be considered as a “last resort” when all other treatment options are unsuccessful or there is known vascular damage in the penis.

Ejaculatory Dysfunction
Fact or fiction? A man with SCI can father a biologic child. The answer is: fact. But in the 1960s, the concept of a paralyzed man having children may have been considered “fiction” without the medical advances available today. So, let’s return to 2007, where in fact, the potential for a man with SCI to become a biologic father is dependent on his ability to ejaculate and his semen quality rather than quantity.  

Similar to achieving an erection, ejaculation is a complex neurologically coordinated event. In general, regardless of the level of SCI, men with incomplete SCI are more likely able to have erections and ejaculate. However, studies show that most men with SCI do not reach the orgasm phase or ejaculate during sexual intercourse so medical interventions to retrieve the sperm may still be necessary. As described previously, normal ejaculation occurs with closing of the bladder neck and anterograde ejaculation (forward) of seminal fluid out of the penis. Normal neural pathways that coordinate this process are disrupted due to SCI. Consequently, retrograde ejaculation (backwards) may occur while the bladder neck remains open, allowing semen to enter the bladder.

Treatment for Ejaculatory Dysfunction
Due to the challenges regarding fertility associated with SCI, a specialized team consisting of a physiatrist, reproductive specialist, urologist, and psychologist is recommended for the emotional roller coaster ride facing those planning a family. In fact, many specialized SCI centers, such as facilities designated as a Model Spinal Cord Injury System of care, have established sexual dysfunction clinics with a multidisciplinary team. To maximize the function of some reflex pathways that may remain partially intact after SCI, many strategies have focused on assisted ejaculation procedures allowing for retrieval of sperm with high quality.

Penile Vibratory Stimulation
Since the 1980s, penile vibratory stimulation (PVS) has been commonly used to assist ejaculation in the SCI community. PVS is applied to the tip of the penis to activate the ejaculatory reflex mediated by the “sexual function centers” at T11-L2 and S2-S4 of the spinal cord. Hence, it does not work well in men with low level paraplegia (lower motor neuron) resulting from injury to these spinal segments. 

In clinical studies, men were capable of successful anterograde ejaculations if the “triple flexion response" (hip flexion, knee flexion, and ankle dorsiflexion) and bulbocavernous reflex (S2-S4) were present.[iv] Other studies correlated a high percentage of anterograde ejaculations if erections or abdominal and leg spasms occurred during PVS.[v] Additionally, the degree of stimulation has been shown to predict success.

Two types of vibrators are used: high amplitude vibrators (available only with a prescription) and low amplitude vibrators (available without a prescription). Research has shown that high amplitude vibrators stimulate ejaculations at a much higher rate (55-95 percent) when compared to low amplitude vibrators (30-40 percent).8 PVS is generally well tolerated, minimally invasive, produces high quality sperm, and can be done in the home setting for many men. Men with SCI above T6 should consult their physician due to the risk of inducing autonomic dysreflexia.

Rectal Electroejaculation
Rectal electroejaculation (EEJ) is a procedure often used for sperm retrieval when PVS has failed in men with SCI. Unlike PVS, EEJ has shown to be successful with all levels of SCI. However, it is more invasive. It is performed in a doctor’s office by placing an electrical probe in the rectum to stimulate the seminal vesicles. 

In contrast to PVS, EEJ tends to produce a greater amount of retrograde ejaculations which correlate with poorer sperm quality when compared to anterograde ejaculations. Urinary catheterization post-procedure may be done to collect retrograde ejaculate which may be considered for use in fertilization if the sperm quality is acceptable. EEJ is very effective with recent studies reporting ejaculation in 80-100 percent of men with SCI.7 Because the procedure can be quite uncomfortable, it commonly induces autonomic dysreflexia in men with SCI above T6. Blood pressure monitoring is recommended and pre-procedure pain medications may be required in men with some preserved sacral sensation.

Surgical Sperm Retrieval
Sperm retrieval from the testicles or vas deferens may be indicated if assisted ejaculation has failed to yield sufficient viable sperm with PVS and EEJ.

Male Fertility
Using either PVS or EEJ, the majority of men with SCI can produce an ejaculate. However, thorough semen analysis has found poorer sperm motility from retrograde ejaculate, compared to anterograde ejaculate. So the problem is sperm quality, rather than quantity. A review of recent studies suggests possible factors for poor semen quality include recurrent urinary tract infections, scrotal hyperthermia (abnormal elevated temperature) due to prolonged sitting in a wheelchair, long term use of certain medications, indwelling catheters, and sperm contact with urine during retrograde ejaculations.[vi] Despite these challenges, advances in assisted reproductive technologies have made pregnancies possible.

Home insemination - A combination of PVS and self-vaginal insemination has proven to be quite effective, with a pregnancy rate comparable to non-SCI couples (25-30 percent).[vii] Although multiple ovulation cycles are usually necessary, full-term pregnancies with healthy live births are increasingly reported in the medical literature. Precautions for treating autonomic dysreflexia should be reviewed with your doctor if you have an SCI above T6 level.

Assisted Reproductive Techniques
Successful pregnancy rates after sperm retrieval from PVS or EEJ using advances in assisted reproductive techniques are also comparable to the able-bodied population at 25 percent. Because length of time after SCI has not proven to influence sperm quality, these medical advances continue to offer hope for fatherhood. Intrauterine insemination, the simplest technique, involves direct injection of sperm into the uterus. Although invasive and expensive, intracytoplasmic sperm injection (ICSI) combined with in-vitro fertilization (IVF) provides the greatest chance for a couple to become parents.

Using microscopic guidance, ICSI involves direct injection of only a few motile sperm into an egg. Then, after the eggs are fertilized outside the womb, they are implanted into the uterus (IVF). Similar to fertility-challenged able-bodied couples, there is an increased possibility for multiple births with IVF. Further studies show that birth defects are no more likely to occur in live births fathered by men with SCI who use assisted reproductive techniques than their non-SCI counterparts.