Prevalence and Etiology of Hypogonadism in Young Men With Chronic Spinal Cord Injury: A Cross-Sectional Analysis From Two University-Based Rehabilitation Centers

A moderate spinal contusion injury in rats alters bone turnover both below and above the level of injury with sex-based differences apparent in long-term recovery

Spinal cord injury (SCI) leads to significant sublesional bone loss and high fracture rates. While loss of mechanical loading plays a significant role in SCI-induced bone loss, animal studies have demonstrated mechanical loading alone does not fully account for loss of bone following SCI. Indeed, we have shown that bone loss occurs below the level of an incomplete moderate contusion SCI, despite the resumption of weight-bearing and stepping. As systemic factors could also impact bone after SCI, bone alterations may also be present in bone sites above the level of injury. To examine this, we assessed bone microarchitecture and bone turnover in the supralesional humerus in male and female rats at two different ages following a moderate contusion injury in both sub-chronic (30 days) and chronic (180 days) time points after injury. At the 30-day timepoint, we found that both young and adult male SCI rats had decrements in trabecular bone volume at the supralesional proximal humerus (PH), while female SCI rats were not different from age-matched shams. At the 180-day timepoint, there were no statistical differences between SCI and sham groups, irrespective of age or sex, at the supralesional proximal humerus. At the 30-day timepoint, all SCI rats had lower BFR and higher osteoclast-covered trabecular surfaces in the proximal humerus compared to age-matched sham groups generally matching the pattern of SCI-induced changes in bone turnover seen in the sublesional proximal tibia. However, at the 180-day timepoint, only male SCI rats had lower BFR at the supralesional proximal humerus while female SCI rats had higher or no different BFR than their age-matched counterparts. Overall, this preclinical study demonstrates that a moderate contusion SCI leads to alterations in bone turnover above the level of injury within 30-days of injury; however male SCI rats maintained lower BFR in the supralesional humerus into long-term recovery. These data further highlight that bone loss after SCI is not driven solely by disuse. Additionally, these data allude to potential systemic factors exerting influence on bone following SCI and highlight the need to consider treatments for SCI-induced bone loss that impact both sublesional and systemic factors.

Lived Experiences of Sexuality and Sexual Functioning in Males with SCI: A Mixed-Methods Study

Background

Sexual dysfunction is highly prevalent in males with spinal cord injury (SCI) and has been recognized to be a key recovery priority.

Objectives

This cross-sectional, mixed-methods study aimed to investigate the major themes linked to sexual functioning in males with chronic (>1 year) SCI.

Methods

Twenty male participants with SCI, aged 25 to 59 years, completed validated questionnaires exploring sexual function/satisfaction and health-related quality of life and a semi-structured interview with an experienced sexual medicine physician. Sex hormone concentrations and metabolic biomarkers, along with body composition and habitual physical activity levels, were assessed. Interview recordings were transcribed and thematic analysis performed using combined COM-B (Capability, Opportunity, Motivation, and Behavior) and biopsychosocial models to identify and organize major contributors and barriers to sexual functioning.

Results

Metabolic and hormonal biomarkers largely fell within normal physiological ranges despite reduced sexual functioning reported in our cohort (19/20 participants reported some degree of erectile dysfunction). Qualitative analysis of interview transcripts revealed 24 themes. Adaptability was important for improving sexual satisfaction. Attraction and attentiveness to sex and partners remained stable over time, while the desire for intimacy increased post injury. Sexual social norms, and comparisons to the able-bodied population, provided challenges for sexual activity and partnership. Environmental concerns regarding access to sexual health resources and accessible physical spaces during intimacy were relevant. Mood disorders and general life stressors negatively impacted sexual desire, while physical activity encouraged sexual activity.

Conclusion

By considering a holistic view of sexuality in males with SCI, we identified key contributors and barriers to sexual functioning for the cohort studied.

Sex hormone supplementation improves breathing and restores respiratory neuroplasticity following C2 hemisection in rats

In addition to loss of sensory and motor function below the level of the lesion, traumatic spinal cord injury (SCI) may reduce circulating steroid hormones that are necessary for maintaining normal physiological function for extended time periods. For men, who comprise nearly 80% of new SCI cases each year, testosterone is the most abundant circulating sex steroid. SCI often results in significantly reduced testosterone production and may result in chronic low testosterone levels. Testosterone plays a role in respiratory function and the expression of respiratory neuroplasticity. When testosterone levels are low, young adult male rats are unable to express phrenic long-term facilitation (pLTF), an inducible form of respiratory neuroplasticity invoked by acute, intermittent hypoxia (AIH). However, testosterone replacement can restore this respiratory neuroplasticity. Complicating the interpretation of this finding is that testosterone may exert its influence in three possible ways: 1) directly through androgen receptor (AR) activation, 2) through conversion to dihydrotestosterone (DHT) by way of the enzyme 5α-reductase, or 3) through conversion to 17β-estradiol (E2) by way of the enzyme aromatase. DHT signals via AR activation similar to testosterone, but with higher affinity, while E2 activates local estrogen receptors. Evidence to date supports the idea that exogenous testosterone supplementation exerts its influence through estrogen receptor signaling under conditions of low circulating testosterone. Here we explored both recovery of breathing function (measured with whole body barometric plethysmography) and the expression of AIH-induced pLTF in male rats following C2-hemisection SCI. One week post injury, rats were supplemented with either E2 or DHT for 7 days. We hypothesized that E2 would enhance ventilation and reveal pLTF following AIH in SCI rats. To our surprise, though E2 did beneficially impact overall breathing recovery following C2-hemisection, both E2 supplementation and DHT restored the expression of AIH-induced pLTF 2 weeks post-SCI.

Bone microarchitectural alterations associated with spinal cord injury: Relation to sex hormones, metabolic factors, and loading

CONTEXT

People living with spinal cord injury (SCI) are at high risk for bone fractures. Neural, hormonal and metabolic contributors to bone microarchitectural alterations are incompletely understood.

OBJECTIVE

To determine the relationship of physical, metabolic and endocrine characteristics with bone microarchitecture, characterized using high-resolution peripheral quantitative computed tomography (HRpQCT) in SCI.

DESIGN

Cross-sectional analyses of bone properties in people with SCI.

PARTICIPANTS

Twenty adults with SCI and paraplegia (12) or motor incomplete quadriplegia (8).

OUTCOME MEASURES

Distal tibia and radius HRpQCT parameters, including density, microstructure and strength by microfinite element anaysis (μFEA); sex hormones; metabolic and inflammatory markers.

RESULTS

The mean age of the participants with SCI was 41.5 ± 10.3 years, BMI 25.7 ± 6.2 kg/m2, time since injury 10.4 ± 9.0 years. Participants with SCI had significantly lower median total (Z score - 3.3), trabecular (-2.93), and cortical vBMD (-1.87), and Failure Load by μFEA (-2.48) at the tibia than controls. However, radius vBMD, aBMD and microarchitecture were similar in participants with SCI and un-injured controls. Unexpectedly, C-Reactive Protein (CRP) was positively associated with tibial trabecular vBMD (β = 0.77, p = 0.02), thickness (β = 0.52, p = 0.04) and number (β = 0.92, p = 0.02). At the radius, estradiol level was positively associated with total vBMD (β = 0.59, p = 0.01), trabecular thickness (β = 0.43, p = 0.04), cortical thickness (β = 0.63, p = 0.01) and cortical porosity (β = 0.74 p = 0.04).

CONCLUSIONS

Radius vBMD and microarchitecture is preserved but tibial total, cortical and trabecular vBMD, and estimated bone strength are markedly lower and bone microarchitectural parameters substantially degraded in people with SCI. The alterations in bone microarchitecture in people with SCI are likely multifactorial, however marked degradation of bone microarchitecture in tibia but not radius suggests that unloading is an important contributor of site-specific alterations of bone microarchitecture after SCI. Fracture prevention in SCI should focus on strategies to safely increase bone loading.

CLINICALTRIALS

gov registration #: (NCT03576001).

Aging with spinal cord injury: A narrative review of consequences and challenges

Given the increase in life expectancy, aging with a pre-existing spinal cord injury (SCI) is becoming more common. This condition is challenging as compromised health status and functional independence can worsen. We aimed to provide an updated overview of the consequences of aging with SCI, highlighting the main challenges facing this population in a narrative review of the current literature we retrieved from the PubMed database from 2000 to 2022 on any aspect related to aging in persons with SCI. Here we address adverse circumstances that increase disability and hinder an active lifestyle, such as progressive physical deterioration, secondary health conditions, limitations in personal activity, changes in family and social support structures, aging of caregivers, and depletion of economic resources. Favorable changes are also observed, including psychosocial adjustments that improve quality of life. Additionally, various interventions are discussed to promote well-being, health, and social participation. Due to the relevance of this issue, people with SCI and all those who take care of them must have up-to-date information to carry out the necessary measures to promote healthy aging in a more inclusive social environment.

A Systematic Review of Testosterone Therapy in Men With Spinal Cord Injury or Traumatic Brain Injury

Spinal cord injuries (SCI) and traumatic brain injuries (TBI) increase the risk of testosterone deficiency and result in adverse changes in body composition and poor functional outcomes. The current systematic review aims to provide insights into the use of testosterone therapy for treating men with SCI and TBI. The PubMed and EMBASE databases were systematically reviewed using appropriate terms, and resulting manuscripts were screened using defined Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The patient population included male patients with SCI or TBI. Further inclusion criteria were: a) human participants 18 years of age or older; b) manuscript published in English; c) study included an intervention with exogenous testosterone; and d) articles published in peer-reviewed journals with full text available. Two reviewers independently extracted data regarding injury type, intervention, and outcomes. Following screening for inclusion/exclusion criteria, a total of 12 primary research studies conducted over the last 30 years were included. Men with SCI were investigated in 11 articles. The combination of testosterone patches and resistance training with functional electrical stimulation (FES) for 16 weeks in men with SCI and an average baseline testosterone level above the cutoff for testosterone deficiency increased muscle mass, strength, bone quality, and basal metabolic rate while testosterone patches without exercise for 16 weeks produced no significant changes in these parameters. Testosterone patches for 12 months in men with SCI and testosterone deficiency also increased lean tissue mass (LTM) and resting energy expenditure (REE). In one study, men with TBI and testosterone deficiency receiving testosterone gel for eight weeks showed a non-statistically significant greater absolute change in functional independence measure (FIM) and grip strength compared to a placebo group. Testosterone therapy with exercise may help improve muscle mass, bone health, strength, energy expenditure, and cardiac health in men with SCI without major side effects. It is difficult to draw conclusions regarding the effects of testosterone therapy in men with TBI based on the limited available evidence. Further investigation is warranted to explore the relationship between testosterone therapy and recovery after SCI and TBI.

Early Changes in Androgen Levels in Individuals with Spinal Cord Injury: A Longitudinal SwiSCI Study

We aimed to explore longitudinal changes in androgen levels in individuals with spinal cord injury (SCI) within initial inpatient rehabilitation stay and identify clinical/injury characteristics associated with hormone levels. Linear regression analysis was applied to explore the association between personal/injury characteristics and androgen hormones (total testosterone, free testosterone, sex hormone-binding globulin (SHBG), dehydroepiandrosterone (DHEA), and dehydroepiandrosterone sulfate (DHEA-S)) at admission to rehabilitation. Longitudinal changes in androgen levels were studied using linear mixed models. Analyses were stratified by sex and by injury type. We included 70 men and 16 women with SCI. We observed a non-linear association between age, time since injury, and androgens at baseline. At admission to initial rehabilitation, mature serum SHBG (full-length, protein form which lacks the N-terminal signaling peptide) was higher, while DHEA and DHEA-S were lower among opioid users vs. non-users. Serum levels of total testosterone and DHEA-S increased over rehabilitation period [β 3.96 (95%CI 1.37, 6.56), p = 0.003] and [β 1.77 (95%CI 0.73, 2.81), p = 0.01], respectively. We observed no significant changes in other androgens. Restricting our analysis to men with traumatic injury did not materially change our findings. During first inpatient rehabilitation over a median follow up of 5.6 months, we observed an increase in total testosterone and DHEA-S in men with SCI. Future studies need to explore whether these hormonal changes influence neurological and functional recovery as well as metabolic parameters during initial rehabilitation stay.

Endocrinological and inflammatory markers in individuals with spinal cord injury: A systematic review and meta-analysis

Spinal cord injury (SCI) can lead to dramatic physiological changes which can be a factor in developing secondary health conditions and might be reflected in biomarker changes in this elevated risk group. We focused specifically on the endocrine and inflammation profile differences between SCI and able-bodied individuals (ABI). Our aim was to determine the differences in inflammatory markers and endocrine profiles between SCI and ABI. We systematically searched 4 electronic databases for relevant studies. Human observational (cross-sectional, cohort, case-control) studies that compared biomarkers of interest between SCI and ABI population were included. Weighted mean difference between SCI and ABI was calculated using random-effects models. Heterogeneity was computed using I² statistic and chi-squared test. Study quality was evaluated through the Newcastle-Ottawa Scale. The search strategy yielded a total of 2,603 studies from which 256 articles were selected for full-text assessment. Sixty-two studies were included in the meta-analysis. SCI individuals had higher levels of pro-inflammatory C-reactive protein and IL-6 than ABI. Creatinine and 25-hydroxyvitamin D₃ levels were lower in SCI than ABI. Total testosterone levels and IGF-1 were also found to be lower, while cortisol and leptin levels were higher in SCI when compared to ABI. Accordingly, meta-regression, subgroup analysis, and leave-one-out analysis were performed, however, they were only able to partially explain the high levels of heterogeneity. Individuals with SCI show higher levels of inflammatory markers and present significant endocrinological changes when compared to ABI. Moreover, higher incidence of obesity, diabetes, osteoporosis, and hypogonadism in SCI individuals, together with decreased creatinine levels reflect some of the readily measurable aspects of the phenotype changes in the SCI group. These findings need to be considered in anticipating medically related complications and personalizing SCI medical care.

Physiological Considerations to Support Podium Performance in Para-Athletes

The twenty-first century has seen an increase in para-sport participation and the number of research publications on para-sport and the para-athlete. Unfortunately, the majority of publications are case reports/case series or study single impairment types in isolation. Indeed, an overview of how each International Paralympic Committee classifiable impairment type impact athlete physiology, health, and performance has not been forthcoming in the literature. This can make it challenging for practitioners to appropriately support para-athletes and implement evidence-based research in their daily practice. Moreover, the lack of a cohesive publication that reviews all classifiable impairment types through a physiological lens can make it challenging for researchers new to the field to gain an understanding of unique physiological challenges facing para-athletes and to appreciate the nuances of how various impairment types differentially impact para-athlete physiology. As such, the purpose of this review is to (1) summarize how International Paralympic Committee classifiable impairments alter the normal physiological responses to exercise; (2) provide an overview of "quick win" physiological interventions targeted toward specific para-athlete populations; (3) discuss unique practical considerations for the para-sport practitioner; (4) discuss research gaps and highlight areas for future research and innovation, and (5) provide suggestions for knowledge translation and knowledge sharing strategies to advance the field of para-sport research and its application by para-sport practitioners.

Priapism after spinal cord injury - a case report and review of the literature

Involuntary unwanted erections are extremely rare after spinal cord injury (SCI). A sudden loss of sympathetic tone to the pelvic vasculature following SCI causes an increase in the parasympathetic tone and uncontrolled arterial blood flow into the penile sinusoidal spaces. When occurring immediately after an acute SCI, it is generally self-limiting and settles within a few hours. In contrast, recurrent, unwanted erections in patients with chronic SCI are more unpredictable in frequency and duration and may require treatment. We present a case of recurrent involuntary unwanted erections in a patient with chronic SCI after a stab wound to his neck and review the pathophysiology and available management options.

Relationship of Vitamin D status with testosterone levels: a systematic review and meta-analysis

PURPOSE

Despite a biological plausibility of a direct link between low vitamin D and androgen deficiency, the association remains inconclusive in epidemiological studies. Therefore, this systematic review and meta-analysis of case-control studies aim to assess whether and in what populations such an association can be demonstrated.

METHODS

A systematic search was performed in PubMed, EMBASE, Cochrane Library, Web of science, Science Direct, and CINAHL. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) in total testosterone (TT) levels between men with 25-hydroxyvitamin D (25(OH)D) <20 and ≥20 ng/mL were combined using random-effects models. Funnel plot and trim-and-fill analysis were used to assess publication bias. Heterogeneity source was explored by a sub-group analysis according to health-related characteristics of the study populations.

RESULTS

Eighteen included studies collectively gave information on 9892 men with vitamin D deficiency and 10,675 controls. The pooled SMD revealed a slight, albeit just significant, positive association between 25(OH)D and TT (pooled SMD: -0.23, 95% CI: -0.45 to -0.01; P = 0.04) with a large between-study heterogeneity (I² = 98%, P_{for heterogeneity} < 0.00001). At the sub-group analysis, a significant positive association, along with noticeable decrease in heterogeneity, could only be demonstrated in studies of patients with frailty states (pooled SMD: -0.19; 95% CI: -0.27, -0.10,  P < 0.0001; I² = 51%, P_{for heterogeneity} = 0.06). A sensitivity analysis revealed a high stability of the result and the trim-and-fill adjustment for publication bias did not affect pooled estimate.

CONCLUSIONS

Both hypovitaminosis D and androgen deficiency should be regarded as markers of a poor health status, sharing common underlying aetiologies and risk factors.

Risk of Low Energy Availability in National and International Level Paralympic Athletes: An Exploratory Investigation

(1) Background: The purpose of this study was to examine the symptoms of low energy availability (LEA) and risk of relative energy deficiency in sport (RED-S) symptoms in para-athletes using a multi-parameter approach. (2) Methods: National level para-athletes (n = 9 males, n = 9 females) completed 7-day food and activity logs to quantify energy availability (EA), the LEA in Females Questionnaire (LEAF-Q), dual energy X-ray absorptiometry (DXA) scans to assess bone mineral density (BMD), and hormonal blood spot testing. (3) Results: Based on EA calculations, no athlete was at risk for LEA (females < 30 kcal·kg⁻¹ FFM·day⁻¹; and males < 25 kcal·kg⁻¹ FFM·day⁻¹; thresholds for able-bodied (AB) subjects). Overall, 78% of females were “at risk” for LEA using the LEAF-Q, and 67% reported birth control use, with three of these participants reporting menstrual dysfunction. BMD was clinically low in the hip (<−2 z-score) for 56% of female and 25% of male athletes (4) Conclusions: Based on calculated EA, the risk for RED-S appears to be low, but hormonal outcomes suggest that RED-S risk is high in this para-athlete population. This considerable discrepancy in various EA and RED-S assessment tools suggests the need for further investigation to determine the true prevalence of RED-S in para-athlete populations.

Recurrent priapism in spinal cord injury: A case report

Context: Recurrent priapism is characterized by repetitive episodes of erections which are unrelated to sexual interest or stimulation. It is extremely rare in patients with spinal cord injury (SCI). There are a number of conservative agents used in the treatment.Findings: We describe the case of a 20-year-old male with cervical-5 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A tetraplegia as a result of a diving accident 2 years ago. He declared that the recurrent penile erections occurred up to 15-20 times day and night every day and lasted up to 20 min each time unrelated to sexual interest or stimulation. He was prescribed baclofen 10 mg, twice daily. The frequency and duration of erections decreased to 3-5 times/day lasting for about 5 min each and the patient reported a high treatment satisfaction.Conclusion: The presentation of this case is to remind clinicians this rare but distressing condition of recurrent priapism seen in men with complete spinal cord lesions and to summarize the use of medications, most commonly baclofen, to alleviate the condition.

The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts

INTRODUCTION

Cardiometabolic syndrome (CMS), as a bunch of metabolic disorders mainly characterized by type 2 diabetes mellitus (T2DM), hypertension, atherosclerosis, central adiposity, and abdominal obesity triggering androgen deficiency, is one of the most critical threats to men. Although many significant preclinical and clinical findings explain CMS, new approaches toward common pathophysiological mechanisms and reasonable therapeutic targets are lacking.

AIM

To gain a further understanding of the role of androgen levels in various facets of CMS such as the constellation of cardiometabolic risk factors including central adiposity, dyslipidemia, insulin resistance, diabetes, and arterial hypertension and to define future directions for development of effective therapeutic modalities.

METHODS

Clinical and experimental data were searched through scientific literature databases (PubMed) from 2009 to October 2019.

MAIN OUTCOME MEASURE

Evidence from basic and clinical research was gathered with regard to the causal impact and therapeutic roles of androgens on CMS.

RESULTS

There are important mechanisms implicated in androgen levels and the risk of CMS. Low testosterone levels have many signs and symptoms on cardiometabolic and glycometabolic risks as well as abdominal obesity in men.

CLINICAL IMPLICATIONS

The implications of the findings can shed light on future improvements in androgen levels and add potentially predictive risk for CMS, as well as T2DM, abdominal obesity to guide clinical management in the early stage.

STRENGTHS & LIMITATIONS

This comprehensive review refers to the association between androgens and cardiovascular health. A limitation of this study is the lack of large, prospective population-based studies that analyze the effects of testosterone treatment on CMS or mortality.

CONCLUSION

Low testosterone levels have several common features with metabolic syndrome. Thus, testosterone may have preventive role in the progress of metabolic syndrome and subsequent T2DM, abdominal obesity, and cardiovascular disease and likely affect aging men's health mainly through endocrine and vascular mechanisms. Further studies are necessary to evaluate the therapeutic interventions directed at preventing CMS in men. Kirlangic OF, Yilmaz-Oral D, Kaya-Sezginer E, et al. The Effects of Androgens on Cardiometabolic Syndrome: Current Therapeutic Concepts. Sex Med 2020;8:132-155.

Independent Association of Erectile Dysfunction and Low Testosterone Levels With Life Dissatisfaction in Men With Chronic Spinal Cord Injury

BACKGROUND

The loss of global functional independence, along with bladder, bowel, and sexual dysfunctions, may contribute to psychological distress and life dissatisfaction after spinal cord injury (SCI).

AIM

To explore the relationship of erectile function and androgenic status with life satisfaction, independently from confounders recognizable in spinal cord-injured men.

METHODS

100 consecutive men (49 ± 17 years) admitted to a rehabilitation program because of chronic SCI (≥1 year) underwent clinical/biochemical evaluations, including the assessment of life and sexual satisfaction using the Life-Satisfaction Questionnaire-9 (LiSat-9), erectile function using the International Index of Erectile Function-5 (IIEF-5), global and bowel-bladder functional independence using the Spinal Cord Independence Measure (SCIM) and measurement of total testosterone (TT) levels. The free testosterone level was calculated using the Vermeulen formula.

OUTCOMES

The outcomes include the relationship between sexual health and life satisfaction in men with SCI.

RESULTS

A LiSat-9 score <4, suggestive for life dissatisfaction, was exhibited by 49% of men. When compared with the life-satisfied group, a significantly higher percentage of them had sexual dissatisfaction and erectile dysfunction (ED); they also exhibited significantly lower levels of TT and calculated free testosterone (cFT) and a more severe impairment of bowel-bladder function. The life satisfaction degree correlated with sexual satisfaction degree, IIEF-5 score, TT, cFT, and bowel-bladder function degree. At the logistic regression model, including sexual LiSat-9 subscore and bowel-bladder SCIM subscore, only the former exhibited a significant negative association with life dissatisfaction. In a further logistic regression model, including the putative key determinants of sexual satisfaction, erectile function, and cFT levels, a higher odd of life dissatisfaction was independently associated both with a lower IIEF-5 score (OR: 0.93; 95% CI: 0.88, 0.98) and lower cFT levels (OR: 0.98; 95% CI: 0.98, 0.99).

CLINICAL IMPLICATIONS

In men with chronic SCI, assessment of erectile function and testosterone levels can help to predict life satisfaction.

STRENGTHS & LIMITATIONS

This is the first demonstration of the independent association of androgen deficiency and ED with life satisfaction in men with SCI. Prospective studies are warranted to clarify the cause-effect relationships.

CONCLUSIONS

In men with SCI, ED and low testosterone levels exhibit a significant independent association with life dissatisfaction; longitudinal intervention studies could explore possible effects of their treatment in improving sexual and life satisfaction in this population. D'Andrea S, Minaldi E, Castellini C, et al. Independent Association of Erectile Dysfunction and Low Testosterone Levels With Life Dissatisfaction in Men With Chronic Spinal Cord Injury. J Sex Med 2020;17:911-918.

Lifestyle modifications and pharmacological approaches to improve sexual function and satisfaction in men with spinal cord injury: a narrative review

STUDY DESIGN

A narrative review describing various components of sexual dysfunction in men with spinal cord injury (SCI), as well as addressing potential therapeutic approaches.

OBJECTIVES

Restoration of sexual function is considered one of the most important health priorities for individuals with SCI. The purpose of this review is to provide information regarding the factors that are less appreciated when considering changes to sexual function in men with SCI. We also propose therapeutic approaches, with a focus on lifestyle modifications, which have been shown to improve sexual function.

METHODS

A literature search was performed and limited evidence for therapeutic approaches in individuals with SCI was supplemented by consistent findings from the able-bodied population.

RESULTS

We evaluated the less addressed factors known to contribute to sexual dysfunction in men with SCI, including hormonal influences (i.e., testosterone deficiency, thyroid hormone, and cortisol), psychological factors (i.e., pain, fatigue, depression, and body image), and secondary SCI complications (i.e., urinary tract infection, pressure sores, and autonomic dysreflexia). To address these factors beyond standard medical treatments for sexual dysfunction, options include physical activity/exercise, diet, and specific medications for symptom relief (i.e., testosterone replacement therapy and selective serotonin reuptake inhibitors for depression).

CONCLUSIONS

Physical activity's potential application, efficacy across multiple aspects of sexuality, and the lack of side effects, suggests that long-term exercise is a viable solution to directly or indirectly improve sexual function in males with SCI. Diet and supplemental medications may further promote body composition changes, which more broadly affect sexuality.

Laboratory evaluation of secondary causes of bone loss in Veterans with spinal cord injury and disorders

An electronic health record (eHR) review of Veterans with a spinal cord injury and disorder (SCI/D) was conducted to understand the extent to which Veterans Affairs (VA) providers pursue workups for secondary causes of osteoporosis in this population. Laboratory tests for secondary causes were ordered in only one-third of Veterans, with secondary causes identified in two-thirds of those tested, most frequently, hypogonadism and hypovitaminosis D.

PURPOSE

To identify workups for secondary causes of osteoporosis in SCI/D and the extent to which subspecialty consultations are sought.

METHODS

A total of 3018 prescriptions for an osteoporosis medication (bisphosphonate, calcitonin, denosumab, raloxifene, teriparatide) among 2675 Veterans were identified in fiscal years 2005-2015 from VA administrative databases. Approximately 10% of these prescriptions were selected for eHR review.

RESULTS

eHR records of 187 Veterans with a SCI/D who had received pharmacological treatment for osteoporosis were reviewed. Workups for secondary causes of osteoporosis were performed in 31.5% of Veterans (n = 59) with approximately 64.4% of those tested (n = 38) having at least one abnormality. Hypogonadism (52.0% of those tested) and hypovitaminosis D (50.0% of those tested) were the most common secondary causes of osteoporosis identified in this population. Approximately 10% of primary care and SCI providers consulted subspecialists for further evaluation and treatment of osteoporosis. Endocrinologists more frequently performed a workup for secondary causes of osteoporosis compared to other provider specialties.

CONCLUSIONS

Screening for secondary causes of osteoporosis, particularly for hypogonadism and hypovitaminosis D, should be considered in patients with a SCI/D.

Prevention and management of osteoporosis and osteoporotic fractures in persons with a spinal cord injury or disorder: A systematic scoping review

Objectives: The primary objective was to review the literature regarding methodologies to assess fracture risk, to prevent and treat osteoporosis and to manage osteoporotic fractures in SCI/D.Study Design: Scoping review.Settings/Participants: Human adult subjects with a SCI/D.Outcome measures: Strategies to identify persons with SCI/D at risk for osteoporotic fractures, nonpharmacological and pharmacological therapies for osteoporosis and management of appendicular fractures.Results: 226 articles were included in the scoping review. Risk of osteoporotic fractures in SCI is predicted by a combination of DXA-defined low BMD plus clinical and demographic characteristics. Screening for secondary causes of osteoporosis, in particular hyperparathyroidism, hyperthyroidism, vitamin D insufficiency and hypogonadism, should be considered. Current antiresorptive therapies for treatment of osteoporosis have limited efficacy. Use of surgery to treat fractures has increased and outcomes are good and comparable to conservative treatment in most cases. A common adverse event following fracture was delayed healing.Conclusions: Most of the research in this area is limited by small sample sizes, weak study designs, and significant variation in populations studied. Future research needs to address cohort definition and study design issues.

Correlation between thyroid function, testosterone levels, and depressive symptoms in females with spinal cord injury

Study Design

Prospective case series.

Objective

Investigate the association of testosterone and thyroid-stimulating hormone (TSH) levels with depressive symptoms in women after spinal cord injury (SCI).

Setting

Community SCI clinic.

Methods

Twenty-seven participants were enrolled in this study. Total testosterone (Total T) and TSH levels as well as the Center for Epidemiological Studies Depression Scale (CES-D) survey and monthly sexual activity were obtained from only 20 participants. Pearson's correlations were used to assess the relationship between age, time from injury, Total T level, TSH level, and CES-D total score. Follow-up analyses investigating the role of monthly sexual activity was also explored.

Results

Participants' average age and time from injury was 44.4 ± 12.7 years old and 11.7 ± 8.89 years, respectively. Low Total T was observed in four participants and one of those participant's presented with low TSH as well. Nine women were classified as "at risk for clinical depression" on the CES-D (total score >15). Pearson's correlations revealed a significant association between time from injury and TSH (r = .536, p = .015), as well as CES-D total score (r = -.547, p = .013). Total T was associated with CES-D total score (ρ = -.541, p = .02).

Conclusions

This study provides preliminary results on abnormal hormone levels and depressive symptoms in women after SCI. Twenty percent of this sample presented with low Total T, which was associated with increased depressive symptoms after accounting for time from injury. Further research is needed to investigate the impact of SCI on hormone function and mental health in women post SCI.

Sponsorship

Sally Rynne National Association of Women's Health Quality Award 2002.

Can the positive association of osteocalcin with testosterone be unmasked when the preeminent hypothalamic-pituitary regulation of testosterone production is impaired? The model of spinal cord injury

PURPOSE

Osteocalcin (OCN), released from the bone matrix during the resorption phase, in its undercarboxylated form, stimulates testosterone (T) biosynthesis in mouse and a loss-of-function mutation of its receptor was associated with hypergonadotropic hypogonadism in humans. Nevertheless, when population-based studies have explored the OCN-T association, conflicting results have been reported. Hypothesizing that the evidence of a positive association between OCN and T could have been hindered by the preeminent role of a well-functioning hypothalamus-pituitary axis in promoting T biosynthesis, we explored this association in men with chronic spinal cord injury (SCI), exhibiting high prevalence of non-hypergonadotropic androgen deficiency.

METHODS

Fifty-five consecutive men with chronic SCI underwent clinical/biochemical evaluations, including measurements of total T (TT), OCN and 25(OH)D levels. Free T (FT) levels were calculated by the Vermeulen formula. Comorbidity was scored by Charlson comorbidity index (CCI).

RESULTS

A biochemical androgen deficiency (TT < 300 ng/dL) was observed in 15 patients (27.3%). TT was positively correlated with OCN, 25(OH)D and leisure time physical activity and negatively correlated with age, BMI and CCI. OCN was also positively correlated with calculated FT and negatively correlated with BMI and HOMA-IR. At the multiple linear regression analyses, a positive association of OCN with TT and calculated FT persisted after adjustment for confounders.

CONCLUSIONS

The positive association here found between OCN and T levels in men with chronic SCI reinforces the notion that a bone-testis axis is also functioning in humans and suggests that it can be unmasked when the preeminent hypothalamic-pituitary regulation of T production is impaired.

Longitudinal Examination of Bone Loss in Male Rats After Moderate-Severe Contusion Spinal Cord Injury

To elucidate mechanisms of bone loss after spinal cord injury (SCI), we evaluated the time-course of cancellous and cortical bone microarchitectural deterioration via microcomputed tomography, measured histomorphometric and circulating bone turnover indices, and characterized the development of whole bone mechanical deficits in a clinically relevant experimental SCI model. 16-weeks-old male Sprague-Dawley rats received T₉ laminectomy (SHAM, n = 50) or moderate-severe contusion SCI (n = 52). Outcomes were assessed at 2-weeks, 1-month, 2-months, and 3-months post-surgery. SCI produced immediate sublesional paralysis and persistent hindlimb locomotor impairment. Higher circulating tartrate-resistant acid phosphatase 5b (bone resorption marker) and lower osteoblast bone surface and histomorphometric cancellous bone formation indices were present in SCI animals at 2-weeks post-surgery, suggesting uncoupled cancellous bone turnover. Distal femoral and proximal tibial cancellous bone volume, trabecular thickness, and trabecular number were markedly lower after SCI, with the residual cancellous network exhibiting less trabecular connectivity. Periosteal bone formation indices were lower at 2-weeks and 1-month post-SCI, preceding femoral cortical bone loss and the development of bone mechanical deficits at the distal femur and femoral diaphysis. SCI animals also exhibited lower serum testosterone than SHAM, until 2-months post-surgery, and lower serum leptin throughout. Our moderate-severe contusion SCI model displayed rapid cancellous bone deterioration and more gradual cortical bone loss and development of whole bone mechanical deficits, which likely resulted from a temporal uncoupling of bone turnover, similar to the sequalae observed in the motor-complete SCI population. Low testosterone and/or leptin may contribute to the molecular mechanisms underlying bone deterioration after SCI.

Spinal cord injury and male infertility-a review of current literature, knowledge gaps, and future research

Spinal cord injury (SCI) affects nearly half a million new patients worldwide, with 17,700 in the US each year, and disproportionately impacts young males of reproductive age. Almost every aspect of male reproduction is affected by SCI, resulting in: erectile, endocrine and sexual dysfunction, decreased sperm motility despite an often-normal count, and abnormal semen emission and ejaculation. The aim of this review is to focus on how SCI impacts testicular spermatogenesis, sperm function, semen quality, and overall fecundity while discussing what is not known, and future avenues for research.

Activity-Based Physical Rehabilitation with Adjuvant Testosterone to Promote Neuromuscular Recovery after Spinal Cord Injury

Neuromuscular impairment and reduced musculoskeletal integrity are hallmarks of spinal cord injury (SCI) that hinder locomotor recovery. These impairments are precipitated by the neurological insult and resulting disuse, which has stimulated interest in activity-based physical rehabilitation therapies (ABTs) that promote neuromuscular plasticity after SCI. However, ABT efficacy declines as SCI severity increases. Additionally, many men with SCI exhibit low testosterone, which may exacerbate neuromusculoskeletal impairment. Incorporating testosterone adjuvant to ABTs may improve musculoskeletal recovery and neuroplasticity because androgens attenuate muscle loss and the slow-to-fast muscle fiber-type transition after SCI, in a manner independent from mechanical strain, and promote motoneuron survival. These neuromusculoskeletal benefits are promising, although testosterone alone produces only limited functional improvement in rodent SCI models. In this review, we discuss the (1) molecular deficits underlying muscle loss after SCI; (2) independent influences of testosterone and locomotor training on neuromuscular function and musculoskeletal integrity post-SCI; (3) hormonal and molecular mechanisms underlying the therapeutic efficacy of these strategies; and (4) evidence supporting a multimodal strategy involving ABT with adjuvant testosterone, as a potential means to promote more comprehensive neuromusculoskeletal recovery than either strategy alone.

Management of Erectile Dysfunction and Infertility in the Male Spinal Cord Injury Patient

PURPOSE OF REVIEW

Men with spinal cord injury (SCI) commonly suffer from erectile dysfunction and ejaculatory dysfunction. The literature regarding the causes and treatment of these two important problems was reviewed.

RECENT FINDINGS

Many of the erectile dysfunction treatments applied to able bodied individuals are also useful in the SCI population, although there are differences in the goals and results of treatment. Ejaculatory dysfunction can be treated with either penile vibratory stimulation or electroejaculation with high success rates. Pregnancies are possible, but poor quality sperm quality in male SCI patients leads to pregnancy rates lower than is observed in the able-bodied population. Although effective treatments are available for erectile and ejaculatory dysfunction in men with SCIs, many challenges remain in optimizing the treatment of these individuals.

Relationship Between Gonadal Function and Cardiometabolic Risk in Young Men With Chronic Spinal Cord Injury

BACKGROUND

We reported previously that young men with chronic spinal cord injury (SCI) have a greater prevalence of testosterone deficiency compared with an age-matched, healthy control population. Young men with SCI also are at increased risk for developing cardiometabolic dysfunction after injury. It is unclear whether testosterone deficiency is associated with heightened cardiometabolic risk in men with SCI.

OBJECTIVE

To investigate associations among levels of testosterone in young men with chronic SCI and surrogate markers of cardiometabolic risk.

DESIGN

Secondary cross-sectional analysis.

SETTING

Rehabilitation research centers in Washington, DC, and Miami, Florida.

PARTICIPANTS

Men (n = 58) aged 18-45 years with chronic (≥1 year), motor complete SCI without comorbidities or use of testosterone therapy.

METHODS

Plasma concentrations of testosterone, lipids, inflammatory markers (C-reactive protein and interleukin-6), percent hemoglobin A1c, glucose, and insulin were measured in a fasting state using standard assays. A 2-hour oral glucose tolerance test and Framingham Risk Score were assessed for each subject. Body composition was assessed by dual X-ray absorptiometry scan.

MAIN OUTCOME MEASUREMENTS

Surrogate markers of cardiometabolic risk among men based on the level of total testosterone (TT; ≤300, 301-500, or >500 ng/dL) and free testosterone (fT; ≤9 or >9 ng/dL). Comparisons were made between men with normal and low TT or fT.

RESULTS

Framingham Risk Score was significantly greater in men with low fT (P < .05). Percent body fat (P < .05) and waist-to-hip ratio (P < .05) but not body mass index (P > .08), were greater in men with low TT or low fT. Men with low TT or low fT had lower high-density lipoprotein cholesterol levels (P < .05) without differences in fasting triglycerides (P > .1) or low-density lipoprotein cholesterol (P > .07). Men with low TT had greater levels of inflammatory markers C-reactive protein (P < .05) and interleukin-6 (P < .05). Men with low TT or low fT had greater fasting glucose (P < .05) and greater insulin resistance (P < .04), without differences in percent hemoglobin A1c (P > .8).

CONCLUSIONS

In young men with chronic SCI who undergo an accelerated aging process postinjury, hypogonadism is associated with an unfavorable cardiometabolic risk profile. Further research is needed to determine whether a causal relationship exists between hypogonadism and heightened cardiometabolic risk in men with SCI and whether routine screening for testosterone deficiency is warranted in this population.

LEVEL OF EVIDENCE

IV.

Administration of increasing doses of gonadotropin-releasing hormone in men with spinal cord injury to investigate dysfunction of the hypothalamic-pituitary-gonadal axis

STUDY DESIGN

Prospective.

OBJECTIVES

To determine the optimum gonadotropin-releasing hormone (GnRH) dose to identify dysfunction of the hypothalamic-pituitary-gonadal axis in men with spinal cord injury (SCI).

SETTING

Metropolitan Area Hospitals, New York and New Jersey, USA.

METHODS

SCI men (16 hypogonadal (HG = serum testosterone <12.1 nmol/l) and 14 eugonadal (EG)) and able-bodied (AB) men (27 HG and 11 EG) were studied. GnRH (10, 50, and 100 μg) was randomly administered intravenously on three separate visits. Blood samples were collected post-GnRH for serum-luteinizing hormone (LH) and follicular-stimulating hormone (FSH).

RESULTS

HG and EG men had a similar proportion of clinically acceptable gonadotropin responses to all three GnRH doses. The incremental gonadotropin responses to GnRH were not significantly different across the groups. However, in the SCI-HG group, GnRH of 100 μg resulted in the greatest integrated FSH response, and in the SCI-EG group, GnRH of 50 μg resulted in the greatest integrated LH response compared with the AB groups. A consistent, but not significant, absolute increase in gonadotropin release was observed in the SCI groups at all GnRH doses.

CONCLUSIONS

Lower doses of GnRH did not improve the ability to identify the clinical dysfunction of the hypothalamic-pituitary-gonadal axis. However, the absolutely higher SCI-HG FSH response to GnRH of 100 μg and a higher SCI-EG LH response to GnRH of 50 μg, along with a higher gonadotropin release at all GnRH doses, albeit not significant, suggests a hypothalamic-pituitary dysfunction in persons with SCI.