Sexual rehabilitation in women with spinal cord injury: a critical review of the literature

Considerations for Contraception Following Spinal Cord Injury: A Systematic Review

Introduction

Counseling and education on women's health, specifically contraception, following spinal cord injury (SCI) is an important component of care for women with SCI. While a plethora of available contraceptive options exists, research in this area is scarce.

Objectives

This systematic review assesses the quality and quantity of research on contraception for individuals with SCI.

Methods

Literature searches of three medical databases were performed to identify articles that addressed contraception and family planning for women with SCI. Articles were then screened in a two-stage selection process and evaluated for content.

Results

Of 165 articles, 21 were identified that fit the inclusion criteria. The majority (66%) of articles were literature reviews or professional practice guidelines. Fourteen (66%) included information on short-acting hormonal oral contraception, 11 (52%) included information on long-acting reversible contraception, 15 (71%) included information on barrier methods, 6 (29%) included information on fertility awareness, 9 (43%) included information on permanent contraception, and one (5%) included information on emergency contraception.

Discussion

This systematic review demonstrates a paucity of evidence-based information on contraception tailored to women with SCI. It highlights a need for research and comprehensive guidelines on primary and emergency contraception in this population.

Factors affecting sexual health in individuals with spinal cord injury: A systematic scoping review

PURPOSE

This study aims to review the literature to explore some factors affecting sexual and partnership adjustment in individuals with spinal cord injury (SCI).

METHODS

This study was based on the methodological framework of scoping reviews, including 3 methodological steps: (1) identifying relevant studies (searching for related studies); (2) selecting related studies; (3) collecting key findings, summarizing, and reporting the results. The electronic databases were searched including Medline (PubMed), Scopus, Web of Science, Embase, and Cochrane Library. Studies were included if they reported data about the related factors of sexual and partnership adjustment in individuals with SCI. No limitations were considered in terms of time or methodology of the search.

RESULTS

After the full-text screening, 52 studies were included from the year of 1978 - 2019 with various methodologies. The present review demonstrated that proper sexual health among individuals with SCI is related to several factors including the anatomical factor, level of the injury, completeness of the injury, psycho-social factor, socio-economic status, and type of relationship.

CONCLUSION

With consideration of factors affecting sexual and partnership adjustment in individuals with SCI, a better estimation of sexual health can be achieved in clinical to improve the relationship and quality of life.

Nitric oxide-induced lipophagic defects contribute to testosterone deficiency in rats with spinal cord injury

Introduction

Males with acute spinal cord injury (SCI) frequently exhibit testosterone deficiency and reproductive dysfunction. While such incidence rates are high in chronic patients, the underlying mechanisms remain elusive.

Methods and results

Herein, we generated a rat SCI model, which recapitulated complications in human males, including low testosterone levels and spermatogenic disorders. Proteomics analyses showed that the differentially expressed proteins were mostly enriched in lipid metabolism and steroid metabolism and biosynthesis. In SCI rats, we observed that testicular nitric oxide (NO) levels were elevated and lipid droplet-autophagosome co-localization in testicular interstitial cells was decreased. We hypothesized that NO impaired lipophagy in Leydig cells (LCs) to disrupt testosterone biosynthesis and spermatogenesis. As postulated, exogenous NO donor (S-nitroso-N-acetylpenicillamine (SNAP)) treatment markedly raised NO levels and disturbed lipophagy via the AMPK/mTOR/ULK1 pathway, and ultimately impaired testosterone production in mouse LCs. However, such alterations were not fully observed when cells were treated with an endogenous NO donor (L-arginine), suggesting that mouse LCs were devoid of an endogenous NO-production system. Alternatively, activated (M1) macrophages were predominant NO sources, as inducible NO synthase inhibition attenuated lipophagic defects and testosterone insufficiency in LCs in a macrophage-LC co-culture system. In scavenging NO (2-4-carboxyphenyl-4,4,5,5-tetramethylimidazoline-1-oxyl-3-oxide (CPTIO)) we effectively restored lipophagy and testosterone levels both in vitro and in vivo, and importantly, spermatogenesis in vivo. Autophagy activation by LYN-1604 also promoted lipid degradation and testosterone synthesis.

Discussion

In summary, we showed that NO-disrupted-lipophagy caused testosterone deficiency following SCI, and NO clearance or autophagy activation could be effective in preventing reproductive dysfunction in males with SCI.

Effects of Sexual Rehabilitation on Sexual Dysfunction in Patients with Cardiovascular Disease: A Systematic Review and Meta-Analysis

PURPOSE

Cardiovascular disease (CVD) is one of the leading causes of death, accounting for one-third of all deaths worldwide. Patients with CVD are three times more likely to complain of sexual dysfunction than healthy people. Causes of sexual dysfunction in patients with CVD include physical/mental changes and drug side effects. The prevalence of sexual dysfunction in patients with CVD has been estimated to be up to 89%. Ordinary treatments such as pharmacotherapy cannot effectively reduce sexual problems. Therefore, sexual rehabilitation has a broad spectrum, including exercise therapy such as pelvic floor muscle treatment, appropriate counseling, a multidisciplinary approach, and partner rehabilitation. In this study, systematic review and meta-analysis was performed to investigate the effect of sexual rehabilitation on sexual problems in patients with CVD.

MATERIALS AND METHODS

Comprehensive literature searches were conducted using MEDLINE, Cochrane Library electronic database, and EMBASE through June 2022. Questionnaire scores at the end point as outcomes of the study were recorded as were standardized mean difference (SMD) with their 95% confidence intervals (CIs). Meta-regression analysis was conducted for each moderator. We performed a risk of bias evaluation for included studies using the RoB 2 tool.

RESULTS

The overall SMD in the meta-analysis for sexual rehabilitation versus no-sexual rehabilitation was 0.430 (95% CI, 0.226-0.633). There was a statistical difference between groups. SMD changes were 0.674 (95% CI, 0.308-1.039) at one month and 0.320 (95% CI, 0.074-0.565) at six months. The regression analysis with all variables (number of patients, study duration, and questionnaire types) revealed no significance.

CONCLUSIONS

This study indicates that sexual rehabilitation is an effective method with high therapeutic potential for sexual dysfunction of patients with CVD. However, for clinical application, well-designed studies with many patients should be conducted in the future and the standardization of rehabilitation protocols is required.

Introducing a Clinical Practice Guideline in Physiotherapy to Address Sexuality in Adults with a Neuromuscular Disorder

Purpose:

We present the development and the key elements of a clinical practice guideline (CPG) in physiotherapy aiming to address sexuality, more specifically impairments and limitations that can interfere with sexual activity in adults with a neuromuscular disorder (NMD).

Method:

The CPG was based on the Rare Knowledge Mining Methodological Framework (RKMMF) and included a literature review, consultation with physiotherapists, and validation by an interdisciplinary team. The EX-PLISSIT (extended, permission, limited information, specific suggestions, intensive therapy) model and the Competency Profile for physiotherapists in Canada were also used as frameworks to divide the CPG into sections. Here, we present the methodology for the CPG development and key elements related to physiotherapy assessment and treatment related to sexual activity in people with NMDs.

Results:

An extensive CPG was developed through a literature review, consultations, and a validation process. A total of 75 articles were included in the review. Twelve physiotherapists and four health professionals reviewed the CPG. Physiotherapists should address the following in their assessment: relationships; assistance required during sexual activity; urinary, vaginal, or anorectal symptoms; erectile dysfunction; pain; fatigue; and the impact of the NMD on sexuality. Interventions can target physical activity, positioning, muscle weakness, fatigue, decreased range of motion, erectile dysfunction, sensitivity disorders, lubrication, pain, incontinence, and cardiorespiratory implications.

Conclusions:

The CPG promotes the importance of addressing sexuality and proposes different interventions that physiotherapists should integrate into their practice.

Transcranial Photobiomodulation Therapy for Sexual Dysfunction Associated with Depression or Induced by Antidepressant Medications

Sexual dysfunction (SD) is frequently encountered in patients suffering from depression. There is a bidirectional relationship between various types of SD and depression, so the presence or treatment of one condition may exacerbate or improve the other condition. The most frequent sexual problem in untreated depressed patients is declining sexual desire, while in treated depressed patients it is difficulties with erection/ejaculation and with orgasm. Numerous classes of neuropsychiatric medications, commonly used in depressed patients—such as antidepressant, antipsychotic, alpha sympathetic, and opioid drugs—may cause SD. Photobiomodulation (PBM) therapy, also called low-level light/laser therapy, is a novel neuromodulation technique for neuropsychiatric conditions, such as depression. Transcranial PBM (tPBM) targets the cellular metabolism—through the mitochondrial respiratory enzyme, cytochrome c oxidase—and has numerous cellular and physiological beneficial effects on the central nervous system. This paper represents a comprehensive review of the application of tPBM to SD, coexisting with depression or induced by antidepressant medications.

The contribution of bio-psycho-social dimensions on sexual satisfaction in people with spinal cord injury and their partners: an explorative study

STUDY DESIGN

Cross-sectional explorative observational study.

TITLE

Sexual satisfaction in people with spinal cord injury and their partners: an explorative study.

OBJECTIVE

To investigate the determinants of sexual satisfaction among individuals with spinal cord injury and relative partners by assuming a bio-psycho-social perspective.

SETTING

Online survey.

METHODS

Thirty-eight individuals (22 individuals with SCI and their partners) were provided with an anonymous self-report questionnaire. Bio-psycho-social dimensions were investigated by using the Barthel Modified Index, Beck Depression Inventory-II, Short Form Health Survey (SF-36). Sexual attitudes of participants were assessed via the Multidimensional Sexual Self-Concept Questionnaire (Snell, 1993).

RESULTS

While no differences were observed between individuals with SCI and their partners, women with SCI were overall more satisfied about their sexual life when compared to men with SCI. Coping strategies promoting self-efficacy and an active role in the sexual issues were predictive of Sexual Satisfaction in the couples of persons with SCI and their partners. No significant contribution was played by physical variables.

CONCLUSION

A tailored-made approach assessing the needs of both individuals with SCI and partners is a key aspect for effective sexual rehabilitation protocols. According to the needs and features of each couple, health professionals should drive individuals with SCI and partners to cope with their sexuality within a bio-psycho-social framework underlying it.

Talking about post-injury sexual functioning: The views of people with spinal cord injuries-A qualitative interview study

AIM

This study aimed to explore perceptions of people with spinal cord injuries regarding the information they received during their rehabilitation programme on post-injury sexual functioning.

BACKGROUND

Spinal cord injury is a traumatic, life-altering event that is associated with loss of motor and sensory function and sexual impairment. Existing evidence suggests that sexual issues are poorly handled during the rehabilitation phase of the patient's journey.

DESIGN

A descriptive qualitative design was utilized in this study.

METHODS

Twenty-nine people with spinal cord injury participated in qualitative in-depth interviews between November 2017 and April 2018, and data were analysed using the Burnard (1991, https://doi.org/10.1016/0260-6917(91)90009-y) thematic analysis framework.

RESULTS

Some participants indicated they were sexually inactive prior to their spinal cord injury. They testified that they had not received information on post-injury sexual functioning. Many participants who received post-injury information on sexual functioning reported dissatisfaction with the content and timing of this information.

CONCLUSION

Personal conversations between spinal cord injured patients and dedicated members of the interdisciplinary health team can enhance the quality of rehabilitation care and patients' satisfaction with rehabilitation care. Nurses are central clinicians in the rehabilitation programme of spinal cord injured patients and should engage in individually designed conversations about post-injury sexual functioning.

Sexual dysfunction in women with spinal cord injury living in Greece

STUDY DESIGN

Cross-sectional study.

OBJECTIVES

To provide data on the rates of sexual dysfunction (SD) among the Greek spinal cord injury (SCI) women and to investigate any association with demographic and clinical variables.

SETTING

Greek territory.

METHODS

Our sample was enrolled from rehabilitation institutes throughout Greece and included 30 women with SCI living in the community for at least 1 year after the primary inpatient rehabilitation program. They were assessed for SD using the Female Sexual Function Index (FSFI). Pearson's test was performed to examine the correlation of SD with clinical-demographic parameters as defined by specific questionnaires: Satisfaction With Life Scale (SWLS), World Health Organization Quality of Life-BREF (WHOQOL-BREF), Spinal Cord Independence Measure (SCIM), Patient Health Questionnaire (PHQ-9), Craig Handicap Assessment and Reporting Technique (CHART).

RESULTS

SD was revealed in 63.3% of the study participants. The mean FSFI score was 14.4. Pearson's analysis showed that age was negatively correlated with FSFI scores (p = 0.006), while pain had a negative impact only on desire scores (p = 0.04). FSFI scores were negatively correlated with PHQ-9 (p = 0.04), while there was a positive correlation with SWLS (p = 0.003), SCIM (p = 0.013), and specific domains of WHOQOL-BREF (psychological, relations, environment), and CHART (mobility, social integration).

CONCLUSIONS

The rate of SD (63.3%) generally agrees with the findings of high rates in most of the literature, although it is rather lower, in comparison to other populations. Old age and depressive symptoms were the major identified determinants of SD.

Altered sexual function after central neurological system trauma is reflective of region of injury; brain vs spinal cord

OBJECTIVE

To compare and contrast the contributory effects of traumatic brain injury (TBI) and spinal cord injury (SCI) on sexual function and social relationship opportunities, hypothesizing that patterns of change in sexual function would follow etiology.

DESIGN

Cross-sectional, case-matched survey of community living individuals with TBI, SCI or both (termed dual diagnosis).

PARTICIPANTS

Consecutive sample of participants with TBI (n = 25), SCI (n = 24) and dual diagnosis (n = 28), an average 3.6 years post-rehabilitation discharge.

METHODS

Participants were interviewed using a modified version of the 'Sexuality after Spinal Injury Questionnaire.'

RESULTS

Almost all respondents (97%) perceived adverse post-injury change in their experience of neurosexual function and/or social relationships. Physiological aspects of sexual function (e.g., erection, orgasm) were most affected by SCI whereas social relationships appeared more affected by TBI. People with dual diagnoses exhibited a combination of features. Participants with SCI (with or without TBI) were significantly more likely to have their concerns about sexual function discussed during rehabilitation than the TBI group.

CONCLUSION

TBI and SCI produce predictable impacts upon sexual function following injury, the impact of which were less frequently addressed during inpatient rehabilitation for those with TBI.

Efficacy of biofeedback, repetitive transcranial magnetic stimulation and pelvic floor muscle training for female neurogenic bladder dysfunction after spinal cord injury: a study protocol for a randomised controlled trial

INTRODUCTION

Neurogenic bladder dysfunction is prevalent in female patients with spinal cord injury (SCI), and previous guidelines have recommended pelvic floor muscle training (PFMT) for first-line conservative treatment. However, the actual regimen of PFMT varies widely and the single treatment does not satisfy the need of some patients. Therefore, this study aims to provide a detailed rationale and methodology for comparing the effectiveness of PFMT, biofeedback and repetitive transcranial magnetic stimulation (rTMS) as adjunct treatments for neurogenic bladder dysfunction.

METHODS AND ANALYSIS

This trial is a single-centre randomised controlled trial for female patients with urinary incontinence (UI) in phase of chronic SCI. Eligible participants will be randomised to one of four arms: (1) PFMT, (2) PFMT with biofeedback, (3) PFMT and rTMS and (4) PFMT with biofeedback and rTMS. There will be 44 participants in each arm and all the subjects will undergo 20 treatment sessions, five times a week for 4 weeks. The outcomes will be evaluated at 4 weeks, 3 months and 6 months after randomisation. The primary outcome is the International Consultation on Incontinence Questionnaire-Urinary Incontinence Short Form, and the secondary outcomes include bladder diary, pelvic floor muscle function and the International Spinal Cord Injury Quality of Life Basic Data Set.

ETHICS AND DISSEMINATION

The Clinical Research and Biomedical Ethics Committee of the West China Hospital, Sichuan University has approved this trial and the approval number is 2019-885. All participants will be provided written informed consent after verification of the eligibility criteria. The results of this study will be accessible in peer-reviewed publications and be presented at academic conferences.

TRIAL REGISTRATION NUMBER

Chinese Clinical Trial Registry (ChiCTR1900026126).

Metabolic syndrome is the key determinant of impaired vaginal lubrication in women with chronic spinal cord injury

PURPOSE

Spinal cord injury (SCI) affects sexual health of both male and female, but little attention has been given to sexuality of SCI women. Similar to penile erection, vaginal lubrication represents a neurovascular event and then both denervation and vascular damage might contribute to its impairment. Nevertheless, the relative weight of lesion location/degree and vascular risk factors in determining hypolubrication in women with SCI has not yet been investigated. The aim of this study was to recognize among putative determinants of poor sexual arousal in women with SCI, neurogenic and vascular/metabolic independent predictors of vaginal hypolubrication.

METHODS

Twenty-eight consecutive female patients admitted to a rehabilitation program because of chronic SCI (≥ 1 year) underwent clinical and biochemical evaluations, including assessment of vaginal lubrication by the Female Sexual Function Index (FSFI). As, in people with SCI, waist circumference overestimates visceral fat mass due to abdominal muscle paralysis, metabolic syndrome (MetS) was defined according to specific criteria proposed for SCI population: BMI ≥ 22 kg/m² and two or more of the following: triglycerides ≥ 150 mg/dL (or actual treatment), HDL < 50 mg/dL, hypertension (or actual treatment), fasting glucose ≥ 100 mg/dL or diabetes mellitus type 2.

RESULTS

A FSFI lubrication sub-score < 3.6, suggestive for impaired vaginal lubrication, was exhibited by 53.7% of the study population. When compared to the group with normal lubrication, a significantly higher proportion of these women had paraplegia (93.3% vs 38.5%, p = 0.003) and met the SCI-specific criteria for MetS (73.4% vs 7.6%, p = 0.0006), whereas, no significant differences were found between the two groups in the proportion of women exhibiting the single components of MetS. At the multiple logistic regression analysis, only the presence of MetS exhibited a significant independent association with impaired vaginal lubrication (OR = 3.1, 95% CI 1.2, 5.8, p = 0.01).

CONCLUSIONS

In women with SCI, a clustering of modifiable vascular/metabolic risk factors, constituting the MetS, could contribute to sexual dysfunctions by affecting the vaginal lubrication, independently of the level of the spinal cord lesion.

Enhancing Psychological Sexual Health of People With Spinal Cord Injury and Their Partners in an Italian Unipolar Spinal Unit: A Pilot Data Study

Like the slogan of the American Consortium for Spinal Cord Medicine says, “No injury, no matter how serious, can take away your ability to have a relationship, experience love, and experience the attraction between two people.” However, people with spinal cord injury (SCI) have to fight with their own and societal attitudes and stereotypes that limit sexuality to the physiological functions of genitalia, phallocentric primacy of sexual pleasure, and sexual attractiveness of perfect bodies. The scope of the present study is to evaluate the impacts of a psychoeducational intervention in a personal growth group on the sexual life of seven people with SCI and four of their partners particularly their sexual interest and satisfaction, depression, and anxiety. Due to the small samples size, nonparametric statistical tests were used to compare pre- and post-outcome measures for all participants: patients and the partners group. Possible effects of gender were also considered. The effectiveness of the psychoeducational intervention was clearly apparent, showing a high effect size in improving sexual interest and satisfaction, and the opportunity and ability to enjoy sexuality. A reduction of anxiety was also observed for all participants, although it may not have been related to the psychoeducational intervention. Moreover, the intervention significantly improved the opportunity and ability to enjoy sexuality for the partner and patient group. No effect was found on depression. This was the first initiative in Italy aiming to address the sexual life and not only to cure the sexual dysfunction of people with SCI. The positive, clear evidence of the validity of the Love & Life project’s intervention bodes well for new psychoeducational initiatives that in Italy meet the sexual needs of people with SCI and their partners, providing adequate education and psychological support, involving partners, and creating a space to talk among peers.

How Do Iranian People with Spinal Cord Injury Understand Marriage?

Background: Spinal cord injury (SCI) is a life-altering experience. There is little information about the perspectives of people with SCI toward marriage. Purpose: To explore the understandings of Iranian adults with SCI about marriage. Methods: In this qualitative inquiry, using a semi-structured interview guide, we collected data from 53 single adults with SCI (41 men and 12 women) who were referred to the Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences in Tehran. Barun and Clarke's thematic analysis approach was applied for data analysis. Results: "Marriage" was thematized in outer and inner scenarios. The outer scenario was explored in terms of physical disability identified as a seminal determinant in successful marriage. "Attractiveness," "able body for breadwinning," "sexually active," and "reproduction" were dominant concepts extracted from the participants' narratives. The participants' inner scenarios revealed that marriage would be welcomed if a potential partner accepted them as a "whole person" regardless of their SCI condition. Conclusion: The findings suggest that adults with SCI do not ignore or reject marriage, however it was not their life priority due to major concerns that they had internalized. Considering the quality of care, people with SCI must be reassured about their potential to get married. SCI-based sexuality education and premarital counseling support the patients in their postmarital lives. Our findings will provide decision makers and health providers with significant insight for utilizing culturally appropriate services for people with SCI.

Women's experiences of sexuality after spinal cord injury: a UK perspective

STUDY DESIGN

Cross-sectional phenomenological qualitative study.

OBJECTIVES

To investigate women's experience of sexuality after spinal cord injury (SCI) with a focus on rehabilitation and manging practical impact.

SETTING

Women with SCI living in the community in United Kingdom (UK).

METHODS

Participants were recruited via three UK SCI centres, ensuring tetraplegia, paraplegia and cauda equina syndrome representation. Single semi-structured interviews exploring individual's experiences around sexuality following SCI were recorded and transcribed for thematic analysis.

RESULTS

Twenty-seven women aged 21-72 years, sexually active since SCI were interviewed, each lasting 17-143 min (mean 55 min). Six key themes emerged: physical change, psychological impact, dependency, relationships and partners, post injury sexual life and sexuality rehabilitation.

CONCLUSIONS

Sexuality remains an important, valued aspect of female identity following SCI; sexual activity continues and though altered remains enjoyable and rewarding. Sexuality rehabilitation should commence early, preparing women for altered sexual sensation, disclosure of altered sexual function to partners, and encouraging early self-exploration. Techniques optimising continence management in preparation for and during sex should be taught. Participants identified a need for women-only education and support groups, increased peer support, self-esteem, communication and social skills training and even fashion advice and pampering sessions during rehabilitation. Support and education for partners are needed. Staff require support to be knowledgeable and confident in addressing women's sexuality needs. Use of the Ex-PLISSIT model for psychosexual support could help staff to better meet these needs.

Important Clinical Rehabilitation Principles Unique to People with Non-traumatic Spinal Cord Dysfunction

Background: Non-traumatic spinal cord dysfunction (SCDys) is caused by a large range of heterogeneous etiologies. Although most aspects of rehabilitation for traumatic spinal cord injury and SCDys are the same, people with SCDys have some unique rehabilitation issues. Purpose: This article presents an overview of important clinical rehabilitation principles unique to SCDys. Methods: Electronic literature search conducted (January 2017) using MEDLINE and Embase (1990-2016) databases for publications regarding SCDys. The focus of the literature search was on identifying publications that present suggestions regarding the clinical rehabilitation of SCDys. Results: The electronic search of MEDLINE and Embase identified no relevant publications, and the publications included were from the authors' libraries. A number of important clinical rehabilitation principles unique to people with SCDys were identified, including classification issues, general rehabilitation issues, etiology-specific issues, and a role for the rehabilitation physician as a diagnostic clinician. The classification issues were regarding the etiology of SCDys and the International Standards for Neurological Classification of Spinal Cord Injury. The general rehabilitation issues were predicting survival, improvement, and rehabilitation outcomes; admission to spinal rehabilitation units, including selection decision issues; participation in rehabilitation; and secondary health conditions. The etiology-specific issues were for SCDys due to spinal cord degeneration, tumors, and infections. Conclusions: Although there are special considerations regarding the rehabilitation of people with SCDys, such as the potential for progression of the underlying condition, functional improvement is typically significant with adequate planning of rehabilitation programs and special attention regarding the clinical condition of patients with SCDys.

Evidence-based position paper on Physical and Rehabilitation Medicine (PRM) professional practice for persons with spinal cord injury. The European PRM position (UEMS PRM Section)

INTRODUCTION

Spinal cord injury (SCI) is a devastating condition and a challenge for every health system and every society. This EBPP represents the official position of the European Union through the UEMS PRM Section and designates the professional role of PRM physicians for people with SCI. The aim of the paper was to improve Physical and Rehabilitation Medicine (PRM) physicians' professional practice for persons with SCI in order to improve their functionality, social and community reintegration, and to overcome activity limitations and/or participation restrictions.

EVIDENCE ACQUISITION

A systematic review of the literature and a consensus procedure by means of a Delphi process have been performed involving the delegates of all European countries represented in the UEMS PRM Section.

EVIDENCE SYNTHESIS

The systematic literature review is reported together with thirty-eight recommendations resulting from the Delphi procedure.

CONCLUSIONS

The professional role of PRM physicians who have expertise in the rehabilitation of SCI is to run rehabilitation programmes in multi-professional teams, working in an interdisciplinary way in a variety of settings to improve the functioning of people with SCI.

Women's Sex Life After Spinal Cord Injury

INTRODUCTION

After spinal cord injury (SCI), individuals are typically considered by the general public to be asexual. Handicapped women have more problems with socio-sexual adaptation, stemming from low self-confidence, low self-esteem, and the absence of spontaneity.

AIMS

To determine changes in the sexual lives of women after SCI.

METHODS

A self-constructed questionnaire was used to map sexual function after SCI. We retrospectively compared sexual function in 30 women with SCI with that in 30 without SCI who led an active sexual life. Descriptive and inductive statistics were applied using the Student paired and non-paired t-tests and the Levene test.

MAIN OUTCOME MEASURES

The main variables were presence vs absence of sexual dysfunction in a group of women after SCI and a comparison of the incidence of sexual dysfunctions in women after SCI with that of a control group.

RESULTS

A significant difference was ascertained in women with SCI in sexual desire (P < .001), lubrication (P < .001), and reaching orgasm before and after injury (P = .030). A comparison of the two groups showed a significant difference in the realization of coital sexual activity (P < .001), erotogenous zones of the mouth (P = .016), nipples (P = .022), and genitals (P < .001), and in the ability to reach orgasm (P = .033). The negative impact of incontinence on the sexual life of women with SCI proved significant (P < .001). Negative factors for sexual activity in women with SCI were lower sensitivity in 16 (53%), spasms and mobility problems in 12 (40%), lower desire in 11 (36%), pain in 4 (13%), and a less accommodating partner in 3 (10%).

CONCLUSION

Intercourse was the preferred sexual activity in women with SCI. Compared with the period before injury, there was significant lowering of sexual desire, impaired lubrication, and orgasmic ability after SCI. A comparison of the two groups showed a difference in erotogenous zones and in reaching orgasm. Sramkova T, Skrivanova K, Dolan I, et al. Women's Sex Life After Spinal Cord Injury. Sex Med 2017;5:e255-e259.

Development of a Sexual Needs Rehabilitation Framework in Women Post-Spinal Cord Injury: A Study From Iran

OBJECTIVE

To develop a sexual needs rehabilitation framework in women after spinal cord injury (SCI).

DESIGN

Mixed-methods study. The study consisted of 3 steps: (1) a primary needs assessment with quantitative and qualitative methods; (2) prioritization of identified needs by expert panels; and (3) development of a framework.

SETTING

Multi-dimensional clinical referral center.

PARTICIPANTS

Married women (N=31) with an SCI that occurred at least 1 year ago.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

Development of sexual needs rehabilitation framework.

RESULTS

The quantitative phase in the first phase showed that the total mean ± SD score of the Sexual Quality of Life-Female questionnaire was 60.47±1.53, and the total mean ± SD score of the Female Sexual Function Index was 50.54±11.35. Moreover, women's sexual understanding post-SCI in the qualitative assessment revealed the following 3 main themes: (1) "dilemma leading to limited sexual activity"; (2) "seeking positive sexual adjustment"; and (3) "lack of client-based sexual and reproductive education/counseling in the rehabilitation process." Results from prioritizing identified needs in the second step indicated that the most important needs related to sexual aspects of life. In the final step, the framework for Iranian woman with post-SCI sexual rehabilitative needs developed with focus on sexual behavior complication post-SCI as a main need.

CONCLUSIONS

It is important to assess probable unmet needs before designing, planning, and implementing an interventional rehabilitative health care program, especially when focusing on issues of sexuality. A developed framework can be applied by the rehabilitation team during initial caregiving and can be continued as long as needed.

Improving Sexual Satisfaction in Persons with Spinal Cord Injuries: Collective Wisdom

Sexuality is an important part of life, and it is necessary for clinicians to have a specific format in which to address sexual issues with their patients. A systematic approach to working with patients with spinal cord injury (SCI) to improve their sexual functioning and response is presented. Nonjudgmental communication about sexual concerns is followed by a detailed pre- and postinjury medical, psychosocial, and sexual history. If preexisting sexual issues are present, it is recommended that the patient be referred for assessment and treatment of these separate from the patient's SCI-related concerns. Physical examination, with special attention to issues that could impact the patient's sexuality, is followed by a detailed neurologic assessment with specific attention to the T11-L2 and S3-5 spinal segments. Education of the patient with regard to his or her sexual potential and the need to be flexible in his or her sexual repertoire is followed by self-exploration and practice. Routine follow-up is suggested after patient's initial sexual exploration. Treatment of confounding and iatrogenic factors related to SCI is followed by more sexual experience. Afterwards the clinician is encouraged to use simple techniques to treat sexual issues and follow-up with the patient to assess the outcome. A structured program utilizing vibratory stimulation with or without midodrine is described as a way to achieve ejaculation and potentially orgasm, and techniques for treating severe autonomic dysreflexia are discussed. If these interventions do not alleviate the patient's sexual concerns, the clinician should refer the patient for more specialized consultation.

Women's Sexual Health and Reproductive Function After SCI

Sexual function and to a lesser extent reproduction are often disrupted in women with spinal cord injuries (SCI), who must be educated to better understand their sexual and reproductive health. Women with SCI are sexually active; they can use psychogenic or reflexogenic stimulation to obtain sexual pleasure and orgasm. Treatment should consider a holistic approach using autonomic standards to describe remaining sexual function and to assess both genital function and psychosocial factors. Assessment of genital function should include thoracolumbar dermatomes, vulvar sensitivity (touch, pressure, vibration), and sacral reflexes. Self-exploration should include not only clitoral stimulation, but also stimulation of the vagina (G spot), cervix, and nipples conveyed by different innervation sources. Treatments may consider PDE5 inhibitors and flibanserin on an individual basis, and secondary consequences of SCI should address concerns with spasticity, pain, incontinence, and side effects of medications. Psychosocial issues must be addressed as possible contributors to sexual dysfunctions (eg, lower self-esteem, past sexual history, depression, dating habits). Pregnancy is possible for women with SCI; younger age at the time of injury and at the time of pregnancy being significant predictors of successful pregnancy, along with marital status, motor score, mobility, and occupational scores. Pregnancy may decrease the level of functioning (eg, self-care, ambulation, upper-extremity tasks), may involve complications (eg, decubitus ulcers, weight gain, urological complications), and must be monitored for postural hypotension and autonomic dysreflexia. Taking into consideration the physical and psychosocial determinants of sexuality and childbearing allows women with SCI to achieve positive sexual and reproductive health.

Delivering care under uncertainty: Swiss providers' experiences in caring for women with spinal cord injury during pregnancy and childbirth - an expert interview study

BACKGROUND

When different health problems such as pregnancy and spinal cord injury (SCI) occur together, providing adequate care becomes even more challenging. Women with SCI may encounter a variety of specific problems and symptoms during pregnancy and childbirth, including urinary tract infections, pressure ulcers, constipation, autonomic dysreflexia, and preterm labour. Therefore, expertise from different medical specialties, especially spinal cord medicine and gynaecology are required. What is totally normal for experts of one specialty could cause a problem for experts from another specialty. Therefore, this study aimed to reconstruct the perceptions and experiences of healthcare providers in Switzerland in caring for women with SCI during pregnancy and childbirth.

METHODS

The perception and experience of healthcare professionals toward providing care for women with SCI during pregnancy and labour were elicited using qualitative expert interviews and analysed using grounded theory techniques. Fifteen health professionals were interviewed, including gynaecologists (n = 4), midwives (n = 3), physical medicine and rehabilitation professionals (n = 4), urologists (n = 3), and a peer counselor (n = 1).

RESULTS

Care delivery experiences of health professionals could be described as a forced reaction to decision making under uncertainty. However, health professionals seemed to express three different attitudes while handling the situation: (i) protective concerned attitude, (ii) 'no big deal' attitude, or (iii) precautionary attitude. The applied strategies were influenced by the conditions of the healthcare system, policies in place, and health professionals' behaviours. Consequently, health professionals faced with uncertainty felt like actors in a fragmented treatment process and called for interdisciplinary collaborations.

CONCLUSIONS

Our findings highlight the diversity of perspectives among different healthcare professionals with respect to the approach to care and delivery services for pregnant women with SCI. A need for more specific services, information, guidance, and guidelines for health professionals caring for woman with SCI during pregnancy and childbirth was identified. We strongly recommend further research on the development of integrated care concepts as well as clinical studies for establishing a more profound knowledge base.

Spinal cord injury and women's sexual life: case-control study

Study design :This is a case-control study.

OBJECTIVE

The objective of this study was to estimate the magnitude of association between spinal cord injury (SCI) and women's quality of sexual life and sexual function.

SETTING

This study was conducted in the Brain and Spinal Cord Injury Research Center, Tehran University of Medical Sciences, Tehran, Iran.

METHODS

From the referral university-based clinics, we used simple random sampling to recruit 62 women: 31 women with SCI and 31 women without SCI. Socio-demographic and reproductive traits questionnaire, Sexual Quality of life-Female (SQOL-F), Female Sexual Function Index (FSFI) and Spinal Cord Independence Measure (SCIM) were completed using telephone and face-to-face interviews in the cases and controls. After univariate analyses, multivariate linear and proportional odds regression models were conducted to investigate the relation between SCI and women's quality of sexual life, as well as sexual function.

RESULTS

The mean age of cases and controls was 35.42±6.51 and 33.77±4.02 years. Most women were high school-educated and housewives. Adjusting for probable confounders, the proportional odds regression model showed a significant relationship between the spinal cord injury (AOR=4.2, 95% CI: 1.8-9.2), non-college-educated (AOR=3.1, 95% CI: 1.2-5.9) and employed (AOR=1.8, 95% CI: 1.1-1.8) variables and being in one of the moderate or poor quality of life classes. Scores of SQOL-F and FSFI domains, except satisfaction, were significantly worse in cases versus controls (P<0.001).

CONCLUSION

Although our participants showed low sexual dysfunction, they tended to report moderate to poor quality of sexual life. Our findings support the implication that sexual rehabilitation must be provided for women with SCI soon after injury.

Sociodemographic factors associated with sexual dysfunction in Mexican women with spinal cord injury

OBJECTIVES

No studies have reported sexual dysfunction in Mexican women with a spinal cord injury (SCI).The objective of the present study was to determine the association between sociodemographic factors and sexual dysfunction characteristics in Mexican females with SCI.

METHODS

An observational, cross-sectional, descriptive study was conducted in different rehabilitation centers in Mexico City from July 2013 to November 2014. Adult females with a SCI without any gynecologic structural abnormalities, which by itself produced sexual dysfunction, were included. The Female Sexual Function Index (FSFI) was answered personally by all participants. Other variables such as AIS (American spinal injury association Impairment Scale), neurologic level, time since injury, age, relationship status, socioeconomic status, spasticity, use of antispasticity drugs, education level, antidepressant medication, Spinal Cord Independence Measure III score, offspring, work activities and neuropathic pain were considered.

RESULTS

There is a high percentage of sexual dysfunction among Mexican woman with SCI (81.9%). Age range went from 18- to 78-year old (42.8±15.87-year old). Time since injury went from 2 to 708 months (65.16±117.65 months). The study showed a negative correlation between age and the FSFI questionnaire (correlation coefficient (CC)=-0.384, P<0.001).There was no significant difference between the means (analysis of variance) of the different groups for neurologic level, socioeconomic status, spasticity and education level.

CONCLUSION

Results showed that the younger the person is, the better sexual function they have, and offspring decreased sexual function and work activities increased it. Some variables showed small comparative groups (use of antidepressives/antispastics and comorbilities), which may be the reason we could not see significative differences in the means.

Sexual Health of Polish Athletes with Disabilities

The purpose of this study was to determine sexual functioning of Polish athletes with disabilities (including paralympians). The study encompassed 218 people with physical disabilities, aged between 18 and 45 (149 men and 69 women). The entire research population was divided into three groups: Polish paralympians (n = 45), athletes with disabilities (n = 126) and non-athletes with disabilities (n = 47). The quality of sexual life of Polish paralympians was measured by using the Polish version of Female Sexual Function Index and International Index of Erectile Function. Clinically significant erectile dysfunctions were most often diagnosed in non-athletes (83.33%) with 50% result of severe erectile dysfunctions, followed by athletes and paralympians with comparable results of 56.98% and 54.17% respectively (p = 0.00388). Statistically significant clinical sexual dysfunctions concerned lubrication, orgasm as well as pain domains, and prevailed among female non-athletes (68.42%, 68.42% and 57.89%). Practising sports at the highest level has a favourable effect on the sexuality of men and women with physical disabilities. Men with physical disabilities manifest more sexual disorders than women, an aspect which should be considered by health-care professionals working with people with disabilities.

Sexual satisfaction in women with spinal cord injuries

STUDY DESIGN

Structured interview based on a predesigned survey.

OBJECTIVE

To examine the factors that affect the degree of sexual satisfaction in a sample of women with spinal cord injury (SCI).

SETTING

The study participants were women with SCIs, from the area of the SCI Unit of A Coruña, a reference unit for the Community of Galicia in the northwest of Spain. All study participants were selected consecutively in the outpatient clinic in 2013.

METHODS

The study included women with the American Spinal Injury Association (ASIA) A-D spinal injuries, between the ages of 18 and 65 years, who completed rehabilitation therapy and live in the community. A total of 32 women formed the final study group.

RESULTS

When comparing the group of women who were sexually active with those who were not, variables such as age, neurological level, time since the SCI, ASIA or Spinal Cord Independence Measure score, urinary incontinence, chronic pain and spasticity were not related to sexual activity. The only factors that we found to be related to sexual activity were not having a stable partner (P=0.017) and a lack of sensation in the genital area (P=0.039).

CONCLUSION

The only variables related to sexual activity were not having a partner and a lack of sensation in the genital area. Improving sexual satisfaction, information and specific programs during rehabilitation can help women with SCI explore and investigate new erotic possibilities, thereby improving their self-esteem and social relationships.

Sexuality of Disabled Athletes Depending on the Form of Locomotion

The main purpose of this study was to determine sexuality of disabled athletes depending on the form of locomotion. The study included 170 disabled athletes, aged between 18 and 45. The entire population was divided into 3 research groups depending on the form of locomotion: moving on wheelchairs (n=52), on crutches (n=29) and unaided (n=89). The research tool was a questionnaire voluntarily and anonymously completed by the respondents of the research groups. The questionnaire was composed of a general part concerning the socio-demographic conditions, medical history, health problems, a part dedicated to physical disability as well as the Polish version of the International Index of Erectile Function (IIEF) and the Female Sexual Function Index (FSFI) evaluating sexual life. STATISTICA 10.0 for Windows was used in the statistical analysis. Subjects moving on crutches were significantly older than ones moving on wheelchairs and unaided (34.41 ±11.00 vs. 30.49 ±10.44 and 27.99 ±10.51 years, respectively) (p=0.018). Clinically significant erectile dysfunctions were most often diagnosed in athletes moving on wheelchairs (70.27%), followed by athletes moving on crutches and moving unaided (60% and 35.42%, respectively; p=0.048). Clinical sexual dysfunctions were diagnosed on a similar level among all female athletes. It was concluded that the form of locomotion may determine sexuality of disabled men. Males on wheelchair revealed the worst sexual functioning. Female athletes moving on wheelchairs, on crutches and moving unaided were comparable in the aspect of their sexual life.

Sexual dysfunction in patients with spinal cord lesions

Many aspects of sexuality can be disrupted following a spinal cord lesion (SCL). It can alter an individual's self-esteem and body image, interfere with positioning and mobility, introduce unexpected problems with incontinence and spasticity, decrease pleasure, and delay orgasm. Sexual concerns in men can involve erectile function, essential for intercourse, ejaculation function, necessary for fertility, and the ability to reach orgasm. In women they can involve concerns with vaginal lubrication, genital congestion, and vaginal infections, which can all go unnoticed, and orgasm, which may be lost. All of these concerns must be addressed during rehabilitation as individuals with SCL continue to live an active sexual life, and consider sexuality among their top priority for quality of life. This chapter describes the impact of SCL on various phases of men's and women's sexual responses and on various aspects of sexuality. Treatments are described in terms of what is currently available and what is specific to the SCL population. New approaches in particular for women are described, along with tips from sexual counseling which consider an overall approach, taking into account the primary, secondary, and tertiary consequences of the SCL on the individual's sexuality. Throughout the chapter, attempts are made to integrate neurophysiologic knowledge, findings from the literature on SCL, and clinical experience in sexual rehabilitation.

Female sexual dysfunction in patients with spinal cord injury: a study from Iran

OBJECTIVES

We assess the prevalence of sexual dysfunction in patients with spinal cord injury (SCI), compare sexual function and sexual distress between female patients with SCI and gender-matched healthy controls, and address risk factors associated with sexual dysfunction among Iranian female patients with SCI.

SETTING

Brain and Spinal Cord Injury Research Center, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran.

METHODS

Eligible Iranian female patients with SCI were included in this cross-sectional study. They were asked to provide sociodemographic information, and complete the Female Sexual Function Index, Hospital Anxiety and Depression Scale and Female Sexual Distress Scale-Revised questionnaire.

RESULTS

Of the 105 patients participated in this study, the average age was 41.0 (s.d.=10.1) years. Women with SCI reported significantly higher levels of sexual dysfunction compared with normal controls. Approximately, 88% of SCI patients reported at least one type of sexual dysfunction, whereas only 37% of healthy controls reported sexual dysfunction. Lack of vaginal lubrication was reported more frequent in SCI patients compared with controls. Women with SCI reported a significantly higher level of sexual distress compared with healthy women. Sexual dysfunction was observed to be significantly higher in older patients, those with less education, patients with complete lesions, those with sexual distress and patients who were anxious and depressed.

CONCLUSION

Sexual dysfunction is highly prevalent among Iranian women with SCI. Sexual dysfunction is associated with age, education, symptoms of depression and anxiety and level of injury. Sexual counseling during the rehabilitation period may help to prevent sexual dysfunction following SCI.

Need for a comprehensive epidemiologic study of spinal cord injury in Poland: findings from a systematic review

STUDY DESIGN

Systematic literature review

OBJECTIVE

To review and assess the quality of available epidemiologic data of spinal cord injury (SCI) in Poland in the context of general International Classification of Functioning (ICF) domains and to answer the question whether there is a need for a comprehensive epidemiologic study of SCI in Poland.

METHODS

Databases Medline, Embase and Polish Medical Bibliography were searched using keywords 'spinal cord injury', 'paraplegia', 'tetraplegia' and 'Poland'.

INCLUSION CRITERIA

studies on humans, original papers, publication in 1979 or later. Case reports and studies with unclear inclusion criteria or performed on a population other than Polish were excluded. Full texts were reviewed for data on incidence, prevalence, etiology, mortality, natural history and outcome of comprehensive treatment. Quality of studies was assessed according to the modified Downs and Black criteria. The ICF model was applied to group the studies according to the ICF components.

RESULTS

Out of 536 identified papers, 224 articles were extracted and reviewed. Mean quality score was 11.04 points based on a 28-grade scale. Body functions and structures were assessed in 81.6%, activities in 22.4%, participation in 14.8%, environmental factors in 15.2% and personal factors in 47% of the studies reviewed.

CONCLUSION

Current epidemiologic data on SCI in Poland are insufficient and biased toward biomedical aspects. There is a need to develop a long-term research strategy for SCI in Poland in the form of a comprehensive cohort study.

Transverse myelitis

Transverse myelitis (TM) includes a pathobiologically heterogeneous syndrome characterized by acute or subacute spinal cord dysfunction resulting in paresis, a sensory level, and autonomic (bladder, bowel, and sexual) impairment below the level of the lesion. Etiologies for TM can be broadly classified as parainfectious, paraneoplastic, drug/toxin-induced, systemic autoimmune disorders, and acquired demyelinating diseases. We discuss the clinical evaluation, workup, and acute and long-term management of patients with TM. Additionally, we briefly discuss various disease entities that may cause TM and their salient distinguishing features, as well as disorders that may mimic TM.