Sexual function in spinal cord lesioned men

Which PDE5 inhibitor is the most effective in the treatment of erectile dysfunction in men with spinal cord injury? A systematic review and network meta-analysis

BACKGROUND

Phosphodiesterase 5 inhibitors (PDE5i) are the first-line drugs for erectile dysfunction (ED) but differences among available molecules should drive therapy personalization. Choosing one PDE5i over another is a challenge in men with spinal cord injury (SCI), as the evidence of efficacy for each molecule is derived from few studies and comparative "head-to-head" trials are lacking.

OBJECTIVE

To assess the efficacy of the different PDE5i for SCI-related ED with a network meta-analysis (NMA) approach.

MATERIALS AND METHODS

Databases from PubMed, Web of Science, Scopus, and Cochrane Library were checked for randomized controlled trials (RCTs) comparing any PDE5i to each other or placebo in men with traumatic SCI lasting ≥6 months. Data were incorporated in a random-effect NMA, where treatments' efficacy was ranked using the surface under the cumulative ranking curve (SUCRA).

RESULTS

The 10 RCTs included provided information about 1,492 men with ED due to traumatic SCI. Intervention arms included sildenafil, tadalafil, and/or vardenafil. Overall, at the pairwise meta-analysis, PDE5i were four times more effective than placebo in improving erectile function (risk ratio: 4.13, 95% CI: 2.76, 6.19). The comparative analysis from NMA revealed that tadalafil was associated with the highest SUCRA value (81%), followed by vardenafil (68%) and sildenafil (49%).

DISCUSSION AND CONCLUSION

Within the grading of comparison network, tadalafil appeared to be the best PDE5i in the treatment of SCI-related ED. Further focused studies are warranted to confirm these findings and define optimal doses and duration of therapy.

Consequences of spinal cord injury on the sympathetic nervous system

Spinal cord injury (SCI) damages multiple structures at the lesion site, including ascending, descending, and propriospinal axons; interrupting the conduction of information up and down the spinal cord. Additionally, axons associated with the autonomic nervous system that control involuntary physiological functions course through the spinal cord. Moreover, sympathetic, and parasympathetic preganglionic neurons reside in the spinal cord. Thus, depending on the level of an SCI, autonomic function can be greatly impacted by the trauma resulting in dysfunction of various organs. For example, SCI can lead to dysregulation of a variety of organs, such as the pineal gland, the heart and vasculature, lungs, spleen, kidneys, and bladder. Indeed, it is becoming more apparent that many disorders that negatively affect quality-of-life for SCI individuals have a basis in dysregulation of the sympathetic nervous system. Here, we will review how SCI impacts the sympathetic nervous system and how that negatively impacts target organs that receive sympathetic innervation. A deeper understanding of this may offer potential therapeutic insight into how to improve health and quality-of-life for those living with SCI.

Couples' experiences with sexuality after spinal cord injury

PURPOSE

To explore sexuality after spinal cord injury (SCI) from the perspectives of individuals with SCI and their romantic partners.

METHODS

A sample of 8 Canadian adults with SCI (6 men, 2 women) and their partners participated in this study (N = 16). Semi-structured dyadic and individual interviews were conducted, discussions surrounding sexuality and intimacy were extracted, and a qualitative description of the interview data was performed using thematic analysis.

RESULTS

Three major themes were identified: the changing definition of sex; emotions; and practical support. Couples' conversations around the changing definition of sex after SCI addressed the taboo topic of sexuality and the importance of communication between couples, peers, and healthcare providers. Emotions included fears of losing intimacy, embarrassment in managing bladder and bowel interference, and acceptance in balancing being a romantic partner and a caregiver. Finally, couples reported challenges accessing practical support including medical interventions and sexual health nurses, but saw value in peer mentorship programs.

CONCLUSION

Couples explored a changing definition of sex following SCI that was complicated by the taboo nature of discussing sexuality, experienced a range of emotions throughout the recovery process, and had difficulties navigating the healthcare system for appropriate support.IMPLICATIONS FOR REHABILITATIONHealthcare professionals should promote discussion and provide support for sexuality following SCI, but during initial rehabilitation may be too early.Healthcare providers should prepare people with SCI and their partners for the inevitable trial-and-error process involved in sexual rehabilitation.Rehabilitation professionals could direct couples to SCI peer mentorship programs to help normalize the experiences and emotions of sexual rehabilitation.

Prostaglandins as a Topical Therapy for Erectile Dysfunction: A Comprehensive Review

INTRODUCTION

Erectile dysfunction (ED) is a substantial cause of dissatisfaction among many men. This discontentment has led to the emergence of various drug treatment options for this problem.

OBJECTIVES

Unfortunately, due to various interactions, contraindications, and side effects, systemic therapies such as phosphodiesterase-5 inhibitors (including sildenafil, tadalafil, vardenafil, avanafil, etc.) are not welcomed in many patients. These problems have led researchers to look for other ways to reduce these complications.

METHODS

This article holistically reviews the efficacy of topical prostaglandins and their role in treating ED. We sought to provide a comprehensive overview of recent findings on the current topic by using the extensive literature search to identify the latest scientific reports on the topic.

RESULTS

In this regard, topical and transdermal treatments can be suitable alternatives. In diverse studies, prostaglandins, remarkably PGE1 (also known as alprostadil), have been suggested to be an acceptable candidate for topical treatment.

CONCLUSION

Numerous formulations of PGE1 have been used to treat patients so far. Still, in general, with the evolution of classical formulation methods toward modern techniques (such as using nanocarriers and skin permeability enhancers), the probability of treatment success also increases.

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.

Experiences of patients and their partners with sexual problems after spinal cord injury: A phenomenological qualitative study

Objective: This study aimed to examine the experiences of patients and their partners about their sexual lives after Spinal Cord Injury (SCI).Design: This qualitative study was based on Heidegger's hermeneutic phenomenological approach.Setting: The Physical Medicine and Rehabilitation Outpatient Clinic of a city hospital in the Central Anatolia Region in Turkey.Participants: The study consisted of seven female and six male patients with spinal cord injury and their partners.Outcome measures: The textual analysis was carried out in three stages: (1) a naive reading, (2) a structural analysis, and (3) a comprehensive understanding of the text including a discussion. The sample size was calculated by using the criterion sampling technique.Results: As a result of the in-depth interviews with individuals with SCI about their sexual experiences, five themes were derived: (1) first confrontation with SCI, (2) experienced sexual problems, (3) coping, (4) partners' views on sexual problems, and (5) other people.Conclusion: It was found that the sex life of individuals with SCI was negatively affected, they were left helpless in dealing with their problems, and that some patients had difficulties in coping with this condition.

Physiology of Erection and Pathophysiology of Erectile Dysfunction

The science of penile erection, including recent advances in its molecular physiology and neuroanatomic pathways, is described. The pathophysiology of erectile dysfunction is presented, acknowledging associated disease states, and accordingly follows a practical classification scheme: vasculogenic, neurogenic, endocrine, and psychogenic.

Neurogenic Erectile Dysfunction. Where Do We Stand?

Erectile Dysfunction (ED) is the persistent inability to attain and maintain an erection sufficient to permit satisfactory sexual performance, causing tremendous effects on both patients and their partners. The pathophysiology of ED remains a labyrinth. The underlying mechanisms of ED may be vasculogenic, neurogenic, anatomical, hormonal, drug-induced and/or psychogenic. Neurogenic ED consists of a large cohort of ED, accounting for about 10% to 19% of all cases. Its diversity does not allow an in-depth clarification of all the underlying mechanisms nor a “one size fits all” therapeutical approach. In this review, we focus on neurogenic causes of ED, trying to elucidate the mechanisms that lie beneath it and how we manage these patients.

Erectile dysfunction in common neurological conditions: A narrative review

Neurogenic erectile dysfunction (NED) can be defined as the inability to achieve or maintain an erection due to central or peripheral neurologic disease. Neurologic diseases can also affect the physical ability and psychological status of the patient. All these factors may lead to a primary or secondary NED. Medication history plays an important role since there are many drugs commonly used in neurologic patients that can lead to ED. The assessment of NED in these patients is generally evolving with the application of evoked potentials technology in the test of somatic and autonomic nerves, and functional magnetic resonance imaging. With the electrophysiological examinations, neurogenic causes can be determined. These tools allow to categorize neurologic lesion and assess the patient prognosis. The first-line treatment for NED is phosphodiesterase inhibitors. Second-line treatments include intracavernous and intraurethral vasoactive injections. Third-line treatments are penile prostheses. The efficacy and safety of each treatment modality depend on the specific neurologic condition. This review discusses the physiology, pathophysiology, diagnosis, and treatment of ED in multiple peripheral and central neurologic conditions, as well as for future research.

Sexual dysfunction and rehabilitation of patients with spinal cord injury

In the rehabilitation of patients with spinal cord injuries, sexual rehabilitation is a pertinent issue that should not be ignored. Although they may not openly discuss sexual issues with their doctor at first, patients consider these issues to be very important. Therefore, doctors should ask their patients about their sexual problems in order to provide them with consultation and treatment. For males with spinal cord injuries, erectile dysfunction is the most significant problem. Patients are looking for a doctor who can help them to solve their problem of erectile dysfunction. Fortunately, there are a variety of effective methods that can help with erectile dysfunction in patients with spinal cord injuries. Oral medications, such as sildenafil, are very effective. However, if medications prove ineffective, intracavernosal injections may be considered. Couples with spinal cord injury are, of course, still capable of sexual intercourse. A couple in which the patient is a male may use the woman-on-top position. If the aim is conception, women with spinal cord injuries should be informed that their fertility is likely unaffected. Doctors may recommend that males with spinal cord injuries be treated in a fertility clinic. Hospitals with full-time sexual rehabilitation personnel and sexual rehabilitation programs can be of great help to patients with spinal cord injuries. The scope of such sexual rehabilitation should include not only medical help but also strategies for restoring sexual life, eliminating conflicts, and ensuring the happiness of couples.

Performance and safety of treatment options for erectile dysfunction in patients with spinal cord injury: A review of the literature

BACKGROUND

For a large proportion of patients with spinal cord injury, sexuality and reproduction are important issues. However, sparse data exist regarding available treatment options for this patient population.

OBJECTIVES

We sought to review performance and safety rates of all currently available treatment options for erectile dysfunction in spinal cord injury men.

MATERIALS AND METHODS

A systematic literature review without time restrictions was performed using PubMed/EMBASE database for English-, Italian-, German-, and Spanish-language articles. Articles' selection was performed according to the PRISMA guidelines. Relevant papers on erectile dysfunction in spinal cord injury patients were included in the final analyses.

RESULTS AND DISCUSSION

Overall, 47 studies were eligible for inclusion in this review. Of these, most evidence dealt with phosphodiesterase 5-inhibitors and intracavernous drug injection. Both treatment options are associated with high levels of performance and with patients/partners' satisfaction; side effects are acceptable. Overall, penile prostheses and vacuum erection devices are in general less approved by spinal cord injury patients and are correlated with increased rates of complications in comparison with phosphodiesterase 5-inhibitors and intracavernous drug injection. Sacral neuromodulation, transcutaneous electrical nerve stimulation, and intraurethral suppositories have been poorly studied, but preliminary studies did not show convincing results.

CONCLUSION

The best treatment options for erectile dysfunction in spinal cord injury patients emerged to be phosphodiesterase 5-inhibitors and intracavernous drug injection. The choice of erectile dysfunction treatment should be based on several aspects, including residual erectile function, spinal cord injury location, and patients' comorbidities. Future studies assessing the applicability of less well-studied treatments, as well as evaluating innovative options, are needed in this specific population.

Postdeployment Fertility Challenges and Treatment in the Modern Era

Current war-fighting environments have shifted dramatically over the past decade, and with this change, new types of injuries are afflicting American soldiers. Operative Enduring Freedom and Operation Iraqi Freedom have noted an increased use of sophisticated improvised explosive devices by adversaries. Injuries not frequently seen in previous conflict are dismounted complex blast injuries, which involve multiple proximal amputations, pelvic fractures, and extensive perineal wounds. Thus, an unforeseen consequence of the decreased mortality rate after these complex blast injuries is a new wave of U.S. service members facing the challenges of recovering from the catastrophic amputations and genitourinary injuries. New applications of sperm retrieval methods may be used in these specific populations, as they recover and wish to purse family-building goals. Spinal cord injuries, traumatic brain injuries, and considerations unique to the female soldier are explored in this review of urologic care in wounded veterans.

Telemetric monitoring of penile pressure during mating in rats after chronic spinal cord injury

In men with a spinal cord injury (SCI), erectile function, ejaculation, and fertility are severely impaired. The present study utilized a telemetric pressure transducer implanted into the corpus cavernosum of the penis to examine sexual function during awake mating behavior in a rat contusion model with a range of Infinite Horizon Impactor forces distributed between 150 and 215 kdyn. The mating behavior paradigm included examination of the counts, average pressure, and average duration for mounts, intromissions, and ejaculations. Male Wistar rats were mated with receptive females in 30-min sessions preinjury (sexual acclimation) and once per week for 6 wk beginning after a 2-wk recovery period post-SCI. All SCI animals had significant deficits in sexual function in the parameters measured. These deficiencies were more prevalent in a subset having less than 20% white matter sparing, likely a reflection of the extent of bilateral spino-bulbo-spinal sexual circuitry disruption at the lesion epicenter. The resulting discoordination of the autonomic and somatic reflex control of erection and ejaculation recorded using telemetry devices in an awake, behaving animal model provides an effective means of gauging sexual function deficits after SCI and could have utility for quantifying recovery after a therapeutic intervention.

Central pattern generators in the brainstem and spinal cord: an overview of basic principles, similarities and differences

Central pattern generators (CPGs) are generally defined as networks of neurons capable of enabling the production of central commands, specifically controlling stereotyped, rhythmic motor behaviors. Several CPGs localized in brainstem and spinal cord areas have been shown to underlie the expression of complex behaviors such as deglutition, mastication, respiration, defecation, micturition, ejaculation, and locomotion. Their pivotal roles have clearly been demonstrated although their organization and cellular properties remain incompletely characterized. In recent years, insightful findings about CPGs have been made mainly because (1) several complementary animal models were developed; (2) these models enabled a wide variety of techniques to be used and, hence, a plethora of characteristics to be discovered; and (3) organizations, functions, and cell properties across all models and species studied thus far were generally found to be well-preserved phylogenetically. This article aims at providing an overview for non-experts of the most important findings made on CPGs in in vivo animal models, in vitro preparations from invertebrate and vertebrate species as well as in primates. Data about CPG functions, adaptation, organization, and cellular properties will be summarized with a special attention paid to the network for locomotion given its advanced level of characterization compared with some of the other CPGs. Similarities and differences between these networks will also be highlighted.

Interferential electrical stimulation for improved bladder management following spinal cord injury

Patients with spinal cord injury (SCI) with neurogenic bladder (NB) represent a major medical problem, which initiated the search for a non-invasive and effective treatment that is easy to apply and without side effects. A study was performed using interferential medium frequency current electrical stimulation (IMFC ES) on 332 patients shortly after SCI diagnosed with NB dysfunction. All subjects received standard care and patients of the experimental group additionally received IMFC ES. Urinary management results included volitional control of voiding, intermittent catheterization, post-voidance residuum (PVR) quantity and quantity of urine lost (LOSS). Results were assessed based on the American spinal cord injury association impairment scale (AIS). The IMFC ES included two channels of medium frequency stimulation that were marginally different. Within the body, a low frequency field was generated through the interaction of the medium frequencies, which stimulated the urinary structures. In the IMFC ES group, interference stimulation was applied for 10 min with frequencies cycling from 0-100 Hz and back in 10 sec intervals. The strength of the low frequency stimulation, achieved by the interference of the two medium-frequency fields, was adjusted to the patients' vibration sensation. The intensities triggering vibration sensation were between 20-80 mA for patients with AIS levels B, C and D. For patients with AIS level A intensities <20 mA were used for therapeutic effects without causing skin injuries. Safety of IMFC ES was based on occurrence of adverse events of which none were recorded in the experimental group. IMFC ES was effective in patients with AIS levels B and C, significantly decreasing PVR and LOSS compared with patients receiving standard care No significant improvements in urinary management were observed following IMFC ES treatment of patients with AIS level A. Patients with SCI and NB classed as AIS levels B and C that exhibit preserved sensitivity were the best beneficiaries of IMFC ES therapy.

Activity-Based Training Alters Penile Reflex Responses in a Rat Model of Spinal Cord Injury

INTRODUCTION

Multisystem functional gains have been reported in males with spinal cord injury (SCI) after undergoing activity-based training (ABT), including increases in scoring of sexual function and reports of improved erectile function.

AIM

This study aims to examine the effect of daily 60-minute locomotor training and exercise in general on sexual function in a rat SCI contusion model.

METHODS

Male Wistar rats received a T9 contusion SCI. Animals were randomized into 4 groups: a quadrupedal stepping group (SCI + QT), a forelimb-only exercise group (SCI + FT), a non-trained harnessed group (SCI + NT), and a home cage non-trained group (SCI + HC). The 2 non-trained groups were combined (SCI) post hoc. Daily training sessions were 60 minutes in duration for 8 weeks. Urine samples were collected during bi-weekly 24-hour metabolic cage behavioral testing. Latency, numbers of penile dorsiflexion, and glans cupping were recorded during bi-weekly penile dorsiflexion reflex (PDFR) testing. Terminal electromyography (EMG) recordings of the bulbospongiosus muscle (BSM) were recorded in response to stimulation of the dorsal nerve of the penis (DNP).

OUTCOMES

ABT after SCI had a significant effect on PDFR, as well as BSM EMG latency and burst duration.

RESULTS

SCI causes a significant decrease in the latency to onset of PDFR. After 8 weeks of ABT, SCI + QT animals had a significantly increased latency relative to the post-SCI baseline. BSM EMG response to DNP stimulation had a significantly decreased latency and increase in average and maximum amplitude in SCI + QT animals. SCI animals had a significantly longer burst duration than trained animals. Time between PDFR events, penile dorsiflexion, glans cupping, and urine testosterone were not affected by ABT.

CLINICAL IMPLICATIONS

ABT has a positive influence on sexual function and provides a potential therapy to enhance the efficacy of current sexual dysfunction therapies in the male SCI population.

STRENGTHS AND LIMITATIONS

Several significant small improvements in sexual function were found in a clinically relevant rat model of SCI using a readily available rehabilitative therapy. The limited findings could reflect insensitivity of the PDFR as a measure of erectile function.

CONCLUSIONS

These results indicate that task-specific stepping and/or loading provide sensory input to the spinal cord impacting the neural circuitry responsible for sexual function. Steadman CJ, Hoey RF, Montgomery LR, et al. Activity-Based Training Alters Penile Reflex Responses in a Rat Model of Spinal Cord Injury. J Sex Med 2019; 16:1143-1154.

Penile Prosthesis Infection: Myths and Realities

Penile prosthesis infection is the most significant complication following prosthesis implant surgery leading to postoperative morbidity, increased health care costs, and psychological stress for the patient. We aimed to identify risk factors associated with increased postoperative penile prosthesis infection. A review of the literature was performed via PubMed using search terms including inflatable penile prosthesis, penile implant, and infection. Articles were given a level of evidence score using the 2011 Oxford Centre for Evidence-Based Medicine Guidelines. Multiple factors were associated with increased risk of post-prosthesis placement infection (Level of Evidence Rating) including smoking tobacco (Level 1), CD4 T-cell count <300 (Level 4), Staphylococcus aureus nasal carriage (Level 2), revision surgery (Level 2), prior spinal cord injury (Level 3), and hemoglobin A1c level >8.5 (Level 2). Factors with no effect on infection rate include: preoperative cleansing with antiseptic (Level 4), history of prior radiation (Level 3), history of urinary diversion (Level 4), obesity (Level 3), concomitant circumcision (Level 3), immunosuppression (Level 4), age >75 (Level 4), type of hand cleansing (Level 1), post-surgical drain placement (Level 3), and surgical approach (Level 4). Factors associated with decreased rates of infection included: surgeon experience (Level 2), "No Touch" technique (Level 3), preoperative parenteral antibiotics (Level 2), antibiotic coated devices (Level 2), and operative field hair removal with clippers (Level 1). Optimization of pre-surgical and intraoperative risk factors is imperative to reduce the rate of postoperative penile prosthesis infection. Additional research is needed to elucidate risk factors and maximize benefit.

Comprehensive Care for Persons with Spinal Cord Injury

Spinal cord injury results in multiple secondary comorbidities, which vary based on injury severity and other characteristics. Persons with spinal cord injury are at lifelong risk for many complications, most of which are at least partially preventable with proper medical care. The Veterans Health Administration Spinal Cord Injury and Disorders (SCI&D) System of Care offers these evaluations to all persons in their registries. Annual evaluations are performed at any of the 24 SCI&D Veterans Administration Centers nationwide. This allows veterans to receive the care from an interdisciplinary team that specializes in the care of veterans with spinal cord injury.

Dartos reflex as autonomic assessment in persons with spinal cord injury

Study design

Prospective clinical series.

Objectives

The dartos reflex (DR) produces unilateral elevation of the testis with vermicular contraction of the scrotal skin and penile retraction. It is a somato-autonomic reflex that depends on the T11-L2 sympathetic segment. Its presence was analysed in men with various levels and severities of spinal cord injury (SCI).

Setting

France.

Methods

Male patients with SCI undergoing urodynamic or sexual assessment were included. DR of the scrotum and penis were systematically assessed in addition to the usual neurological examination that included assessment of the autonomic system, cremaster, and sacral reflexes. The DR was evoked by applying a small ice pack on the scrotum, separately to each side.

Results

Forty-six patients were assessed. DRs were always present when the T11-L2 segment was intact above the lesion (low paraplegia below L2) or below the lesion in an upper motor neuron (UMN) syndrome (spastic paraplegia above T10). They were more pronounced in the case of UMN syndrome. In the case of lower motor neuron (LMN) syndrome that included the T11-L2 segment, DRs disappeared in all but one patient. Patients with a LMN lesion were more prone to retrograde or absent ejaculation, loss of psychogenic erection, and open bladder neck.

Conclusions

The DR is a valuable test for the assessment of the integrity and excitability of the T11-L2 spinal segment. It is easy to perform and is predictive of some aspects of sexual and bladder neck function in men. DR should be considered as an addition to the autonomic standards.

Prediction of sexual function following spinal cord injury: a case series

INTRODUCTION

Spinal Cord Injury (SCI) affects sexual response based on the level and degree of completeness of injury. By using the International Standards for the Neurologic Classification of SCI in conjunction with lumbo-sacral reflexes these effects can be predicted. The International Standards for the Assessment of Autonomic Function after SCI (ISAFSCI) document the impact of SCI on sexual responses including psychogenic and reflex arousal (erection or lubrication), orgasm, ejaculation, and sensation of menses. Responses are described based upon a 0 to 2 scale with 0 being absent, 1 altered, and 2 normal response. Additionally, the lesion is described as supraconal, conal or infraconal.

CASE PRESENTATION

We present 4 representative cases of the impact of SCI on sexual responses and course of treatment. Case 1 describes a complete supraconal lesion above T6 with upper motor neuron syndrome. Case 2 describes a supraconal complete lesion including the T11-L2 segment. Case 3 describes an infraconal (cauda equina) lesion with lower motor neuron syndrome. Case 4 is theoretical and describes a supraconal lesion above T6 with upper motor neuron syndrome, partial sensation in T11-L2 dermatomes, and other medical comorbidities.

DISCUSSION

Neurologic examination combined with reflex testing allows prediction of sexual responses after SCI. It would be useful for version 2.0 of the ISAFSCI to assist clinicians in determining the anticipated changes, whether their patients are functioning as anticipated sexually after SCI or whether other concerns also require treatment.

Ejaculation and sperm characteristics in men with cauda equina and conus medullaris syndromes

STUDY DESIGN

Retrospective.

OBJECTIVES

The objective of the study was to describe the type of ejaculation in patients with cauda equina (CE) and conus medullaris (CM) lesions, and to analyse sperm quality.

SETTING

France.

METHODS

One hundred sixty-six patients with CE and CM lesions were included. Diagnosis was based on clinical (no motor responses, sensation or sacral reflexes) and urodynamic assessments (no detrusor activity). Vibromassage (VM) was used to induce ejaculation according to the recommendations for patients with spinal cord injury. If ejaculation did not occur, oral midodrine was administered in progressive doses. Retrograde ejaculation was systematically sought. Sperm parameters were analysed according to World Health Organisation recommendations (2010).

RESULTS

Eighty-nine patients were included. Eleven ejaculated on the first VM trial (four anterograde (AE), six retrograde (RE) and one antero-retrograde (ARE)). Five patients continued trials of VM alone, two of whom ejaculated following a mean 1.9 trials (one RE, one ARE). Twenty-six patients underwent trials of VM+ midodrine, 18 of whom ejaculated following a mean 4.4 trials with a mean dose of 22.5 g of midodrine (2 AE, 13 RE and 5 ARE). Fifty-three ejaculates from 26 patients were analysed. Sperm concentration was low in 90.6% of samples; total necrospermia was found in 65% and asthenospermia in 95% of samples.

CONCLUSION

Ejaculation is difficult to induce using VM in patients with CE and CM lesions, and requires high doses of midodrine. Sperm counts were generally low, and asthenospermia and necrospermia were found in the majority of specimens. Cryopreservation of sperm should be systematic in case of medically assisted procreation.

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.

Evidence of a new pattern of ejaculation in men with spinal cord injury: ejaculation dyssynergia and implications for fertility

OBJECTIVES

To describe the presence of sperm in the prostatic urethra as a stand-alone ejaculation entity and to assess its characteristics.

METHODS

Thirty-three patients with anejaculation during sexual stimulation were enroled. Penile vibratory stimulations were carried out following bladder catherization and instillation of a pink buffering medium (Ferticult). Two-step catheterisation was then performed: a catheter was inserted through the urethral sphincter into the prostatic urethra to aspirate its content, and then bladder catheterisation was performed to collect the Ferticult. The procedure was repeated in some patients after at least 1 week. The characteristics of the semen collected from each organ were analysed and compared.

RESULTS

A total of 42 trials were obtained from 22 patients. Sperms were found in the prostatic urethra in 21 samples (50%) from 12 patients (11 with spinal cord injury, 1 with diabetes). The colour of all 21 prostatic urethra sperm samples differed from the Ferticult. Sperm motility was greater in 8 samples, sperm count was higher in 10 and pH was different in 10, compared with the bladder samples. The higher overall quality of the sperm allowed cryopreservation in 10 prostatic urethra samples compared with only 5 bladder samples. Four of the five patients who underwent repeated trials had a reproducible pattern of prostatic urethra ejaculation.

CONCLUSION

The presence of sperm in the prostatic urethra most probably results from 'ejaculation dyssynergia', a lack of coordination between bladder neck and external sphincter. Sperm from the prostatic urethra should be systematically sought to improve the outcome of assisted reproduction.

Fertility treatment in spinal cord injury and other neurologic disease

Infertility in individuals with neurologic disorders is complex in etiology and manifestation. Its management therefore often requires a multimodal approach. This review addresses the implications of spinal cord injury (SCI) and other neurologic disease on fertility, including the high prevalence of sexual dysfunction, ejaculation disorders and compromised semen parameters. Available treatment approaches discussed include assisted ejaculation techniques and assisted reproductive technology including surgical sperm retrieval and intracytoplasmic sperm injection (ICSI).

Efficacy and safety of phosphodieterase-5 inhibitors for treatment of erectile dysfunction secondary to spinal cord injury: a systemic review and meta-analysis

STUDY DESIGN

Systemic reviewObjective:We carried out a systematic review and meta-analysis to assess the efficacy and safety of phosphodieterase-5 (PDE5) inhibitors on erectile dysfunction (ED) secondary to spinal cord injury (SCI).

METHODS

A literature review was performed to identify all published randomized, double-blind, placebo-controlled trials of PDE5 inhibitors for treatment of ED secondary to SCI. The search included the following database: MEDLINE, EMBASE and the Cochrane Library. The outcomes and complications analyzed involved the Global Efficacy Question (GEQ), sexual encounter profile diary question 2 and 3 (SEP2 and SEP3) and adverse events. All statistical analysis was performed using Stata 12.0 software (Stata Corp., College Station, TX, USA).

RESULTS

Six publications were used in analysis, including six randomized controlled trials that compared PDE5 inhibitors with placebo. Compared with placebo, PDE5 inhibitors were associated with significant improvements in GEQ (OR 11.997, 95% CI 8.073-17.830, P<0.0001), SEP2 (RR 1.847, 95% CI 1.561-2.185, P<0.0001) and SEP3 (RR 2.738, 95% CI 2.084-3.598, P<0.0001). Despite significant greater incidences of some adverse events observed (headache: RR 3.717, 95% CI 2.309-5.982, P<0.0001; flushing: RR 9.281, 95% CI 2.858-30.147, P<0.0001; gastrointestinal discomfort: RR 9.064, 95% CI 2.116-38.827, P=0.003), most adverse events were mild to moderate and transient.

CONCLUSIONS

This systematic review and meta-analysis indicate that PDE5 inhibitors are effective and well tolerated to treat ED secondary to SCI compared with placebo, as measured by response to GEQ, SEP2, SEP3 and incidence of adverse events. PDE5 inhibitors could be considered as the first choice in the treatment of ED patients with SCI.

Sexual Functioning in Men Living with a Spinal Cord Injury-A Narrative Literature Review

BACKGROUND

Sexual dysfunction is a major concern for Indian men living with a spinal cord injury.

OBJECTIVES

To examine the literature related to sexuality traumatic cord injury and its impact on sexual functioning.

MATERIALS AND METHODS

Databases using Cumulative Index to Nursing and Allied Health Literature (CINAHL) 2000-2012, Medline 1989-2012, Applied Social Sciences Index and Abstracts (ASSIA) 1989-2012 and Google Scholar were the search engines used used for literature review.

RESULTS

The search yielded a total of 457 articles and only 75 of them were found relevant. The minimum number of articles required to meet the inclusion criteria for this review was 25-30 articles. Out of the 75 articles, 33 were considered relevant or related to the topic of sexual functioning, spinal cord injury, and paraplegia. Six areas were identified: Sexual stigmatization, physiological barriers to sexual satisfaction, clinical aspects of sexual functioning, biomedical approaches to sexual dysfunction, partner satisfaction, and lack of accessibility to sexual education.

CONCLUSION

Spinal cord injury and sexual functioning affects a large segment of the male Indian population, yet most current research focuses on quantitative measurement with the emphasis on ejaculatory dysfunction, orgasm impairment, incontinence, and other physiological dysfunction. Further research is needed to address the subjective accounts of patients themselves with respect to the emotional and social impact of sexual disability. This would help to identify the best possible outcomes for both treatment and rehabilitation.

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.

Sexual function and autonomic dysreflexia in men with spinal cord injuries: how should we treat?

STUDY DESIGN

Systematic review.

OBJECTIVES

Review the literature on the acute or prophylactic treatment of autonomic dysreflexia in the context of sexual activities.

SETTING

International.

METHODS

Medline search using AD and spinal cord injury and all years of publication.

RESULTS

Thirty-seven papers on the specific treatment of AD showed that nifedipine, prazosin, captopril and clonidine are candidates in the context of sexual activities. Prazosin, however, has an initial hypotensive effect requiring to begin treatment 12 h before intercourse, which makes it less ideal for spontaneous sexual activities. Captopril has an initial hypotensive effect and was only studied in acute AD. Its usefulness in prophylaxis remains to be demonstrated. Clonidine has successfully been used clinically for decades, but never studied in randomized control trials. Nifedipine remains the most widely studied and significant treatment of AD whether in acute or prophylactic conditions. Recent concerns suggest increased cardiovascular risks with sublingual nifedipine in non-SCI populations, but negative long-term effects have not been reported in the SCI population.

CONCLUSION

Sexual function is a priority for men with SCI. As sexual activities, in particular ejaculation, can be a source of AD, adequate treatments and prophylaxis must be considered in the context of sexual activities. Experts must meet and conclude on the thresholds, parameters and treatments that should be considered in the long-term management of AD in the context of sexual function in men with SCI.

Impact of spinal cord injury on sexuality: broad-based clinical practice intervention and practical application

This study focuses on the impact a spinal cord injury may have on achieving physical and emotional intimacy, and potential to maximize sexual ability and quality of life. Spinal cord injury is a traumatic, life-altering event that is usually associated with loss of motor and sensory function, as well as sexual impairment. At the time of injury, the individual is faced with devastating loss and an abundance of new information in a setting of extreme stress and challenge. In the acute rehabilitation setting, there is often a considerable void in providing education and resources regarding sexual concerns and needs. There is a positive relationship between sexual education and sexual activity. The impact of inadequate sexual counseling and education as a part of rehabilitation can be deleterious.

Management of ejaculatory disorders in infertile men

Ejaculatory dysfunction is a highly prevalent clinical condition that may be classified along a continuum that ranges from premature ejaculation (PE), through retarded or delayed ejaculation (DE), to complete anejaculation (AE). Retrograde ejaculation (RE) represents a distinct entity in which ejaculate is expelled either partially or completely into the bladder. While DE and PE are significant sources of sexual dissatisfaction among men and their partners, patients with these disorders retain normal fertility in most cases. Conversely, men with AE and RE are unable to deliver sperm into the female genital tract and are therefore rendered subfertile. Therefore, in reviewing ejaculatory disorders as they relate to fertility, this paper will primarily focus on the diagnosis and management of AE and RE. Physiology, diagnostic strategies, pharmacological treatments, and procedural interventions relevant to AE and RE are discussed.

Erectile dysfunction is the main determinant of psychological distress in men with spinal cord injury

INTRODUCTION

The weight of erectile dysfunction (ED) among the various determinants of psychological distress in men with spinal cord injury (SCI) remains to be clarified.

AIM

The aim of this article was to evaluate psychological distress features in SCI men with or without ED.

METHODS

Forty consecutive patients with neurologically stable SCI were included in the study. Functional independence (FI) was assessed by Barthel Index (BI), which was divided into global score (questions 1-10) and bowel/bladder subscore (questions 5 and 6). Erectile function was evaluated with Sexual Health Inventory for Men (SHIM).

MAIN OUTCOME MEASURES

Psychological distress was assessed with the Symptom Checklist-90-revised (SCL-90-R), scoring nine primary dimensions and their combination as Global Severity Index, a global index of psychological distress.

RESULTS

All SCL-90-R scores and the percentage of patients with scores >75th percentile of the entire study population were significantly higher in the group with ED (N=21) than without ED (N=19). Most of SCL-90-R subscales were inversely correlated with SHIM score. ED was exhibited by a high proportion (84%) of men with thoracolumbar lesions but by no patients with cervical lesions. Men with cervical lesions exhibited significantly lower SCL-90-R scores than those with thoracolumbar lesions, in spite of lower FI. However, the thoracolumbar group also reported a more severe bowel/bladder dysfunction. At multivariate logistic regression analysis, ED score significantly explained the variance of most of SCL-90-R dimension scores, whereas no association was revealed between global BI and any score of SCL-90-R dimensions. Bowel/bladder BI explained only to a very low extent the variance of depressive symptoms.

CONCLUSIONS

Healthcare providers should be aware of the importance of managing ED in spinal cord-injured men, as it represents a major determinant of their psychological distress, independently of the degree of FI impairment.