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Neurogenic Bladder, Neurogenic
Bowel, and Sexual Dysfunction in
People With Spinal Cord Injury
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў The purpose of this article is to review the literature related to theeffects of spinal cord injuries on genitourinary, gastrointestinal, andsexual function. These important areas of function are profoundlyaffected by spinal cord injuries, with the effects of injury beingdependent on the specific level and degree of neurologic dysfunction.
Our ability to manage neurogenic bladder dysfunctions and neuro-genic bowel dysfunctions has improved over the past few years;however, in general the techniques used have not significantlychanged. In contrast, a significant amount of new information hasbeen made available regarding the effects of specific neurologic injuries on sexual response, particularly female sexual response. More-over, techniques to remediate erectile dysfunction and infertility in themale have vastly improved the fertility potential of men with spinalcord injuries. Further research is warranted in all of these areas.
[Benevento BT, Sipski ML. Neurogenic bladder, neurogenic bowel, and sexual dysfunction in people with spinal cord injury. Phys Ther.
2002;82:601– 612.] Key Words: Spinal cord injuries.
Barbara T Benevento, Marca L Sipski
ўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўўў Physical Therapy . Volume 82 . Number 6 . June 2002 One of the most important sequelae
after spinal cord injury is the loss of
One of the most important sequelae after
spinal cord injury (SCI) is the loss of genito- genitourinary and gastrointestinal
urinary1 and gastrointestinal function. In thisarticle, we will briefly describe the anatomy, function.
physiology, and management of bladder, bowel, andsexual dysfunction. Recent research will be reviewed, With SCI, central lesions can interrupt the pontine and and recommendations for further research will be sacral micturition centers. In addition, peripheral lesions can affect the parasympathetic supply to the Neurogenic Bladder
detrusor muscle or the sympathetic supply to the blad-der neck as well as somatic innervation to the external Normally, the bladder stores urine until the proper time urethral sphincter.1,7 Usually, patients with SCI do not for voiding and then empties in a coordinated fashion.2 lose the cortical control of the pontine mesencephalic In order to understand the neurogenic bladder, it is reticular formation unless there is concomitant head useful to understand how the bladder is innervated and controlled by the brain and then examine how SCIaffects normal bladder function.
In order to explain the different types of voiding dys-function, several different classification systems have The bladder’s parasympathetic efferent nerve supply, been described, which are based on site and extent of which governs the contraction of the bladder, originates the neurologic lesion, urodynamic findings, and classifi- from the sacral cord at S2-S4 and travels to the bladder cation of bladder function.8–12 We believe that the most via the pelvic nerve. The effect of parasympathetic helpful method is to consider the dysfunction as falling stimulation is detrusor contraction. The sympathetic into 1 of 2 categories: (1) failure to store and (2) failure efferent nerve, which increases bladder storage, origi- to empty. These 2 categories are further subdivided nates at T11-L2 and travels to the bladder and urethra based on whether the failure is due to a problem with via the hypogastric nerve. The ␤-adrenergic receptors in the detrusor or due to the bladder outlet. Examples of the body of the bladder cause relaxation of smooth failure to store would be detrusor hyperreflexia (or muscle, and the ␣ receptors in the base of the bladder uninhibited bladder contractions) or an areflexic blad- and urethra cause contraction of the smooth muscle.
der outlet.8–13 In contrast, failure to empty may be due to Somatic efferents originate from the sacral segments at an areflexic bladder or a sphincter that is unable to S1-S4 and travel through the pudendal nerve and inner- relax.2,3 Detrusor-sphincter dyssynergia—impaired coor- vate the external urethral sphincter.1–4 dination between bladder contraction and sphincterrelaxation—is also a common finding in patients with The main coordination center is located in the pontine SCIs. Any of these problems may occur at different stages mesencephalic reticular formation.5 An intact pathway of the acute and chronic period of SCI. Therefore, between the pontine and sacral micturition centers during the course of a patient’s life, bladder manage- allows for coordinated voiding by relaxation of the ment may have to change depending on the bladder urethral sphincter and contraction of the detrusor muscle. Volitional control of micturition is controlledby the medial frontal lobes and corpus callosum. In The goals of bladder management are to prevent upper suprapontine lesions, micturition occurs, but it is and lower urinary tract complications, including hydro- nephrosis, renal calculi, bladder calculi, and vesi-coureteral reflux.14 The type of voiding dysfunction, BT Benevento, MD, is Clinical Chief of Spinal Cord Injury Services, Kessler Institute for Rehabilitation, and Assistant Professor, Physical Medicineand Rehabilitation, UMDNJ-New Jersey Medical School, 1199 Pleasant Valley Way, West Orange, NJ 07052 (USA). Address all correspondence toDr Benevento.
ML Sipski, MD, is Director, VA Rehabilitation Research Center of Excellence in Functional Recovery in Chronic SCI, Department of VeteransAffairs, Miami, Fla, and Associate Professor, Department of Neurological Surgery, Miami Project to Cure Paralysis, University of Miami School ofMedicine.
Dr Sipski provided concept/idea, and both authors provided writing.
This work was supported in part by R 01 HD 30149 from the National Institutes of Health to Dr Sipski.
This article was submitted January 19, 1999, and was accepted January 15, 2002. Physical Therapy . Volume 82 . Number 6 . June 2002 ўўўўўўўўўўўўўўўўўўўўўўўў level of injury, and patient’s ability to perform self- therefore, failure to empty have been helped with ␣ catheterizations, dressing and transfers. are considered blockers such as Hytrin* and Minipress.†,3 in designing bladder management. Urodynamic evalua-tion is helpful in defining urologic problems associated These medications, however, have side effects. This is with SCI. This test studies the filling and voiding phases especially true of the anticholinergic drugs, which can of bladder function. In addition, the detrusor pressure, cause dry mouth and constipation.16,17 If these medica- duration of detrusor contraction, and compliance of the tions are required and these patients drink large detrusor can be measured. As spinal shock resolves by amounts of liquids, an indwelling catheter may be pre- approximately 3 months after injury, detrusor activity is ferred. In our opinion, patients who perform intermit- noted.15 This is often indicated by the presence of tent catheterization may require fluid restriction of incontinence. Therefore, performing the urodynamic approximately 2 L per day, and this may be difficult study after that time will provide the most useful infor- because of the side effects of the drugs.
mation regarding the bladder dysfunction.1 In addition,cystoscopy may be performed to evaluate bladder and Once catheters and medical management have been tried, surgical options also exist. In patients with incon-tinence caused by the detrusor hyperreflexia, the follow- Bladder drainage is achieved through indwelling cathe- ing methods have been suggested. An augmentation ters, intermittent catheterizations, suprapubic catheters, cystoplasty may increase bladder capacity and lower condom sheath catheters, or a combination of these intravesical pressure.21 In this procedure, a portion of methods.1,2 We believe the choice of catheter or type of the bladder is removed and a larger segment of bowel is bladder drainage should be made on an individual basis, attached to the remaining bladder. Intermittent cathe- taking into account many factors such as patient prefer- terization is then performed on a regular basis. There is ence, sex of the patient, level of injury, functional status, often mucus in the urine from the bowel segment that financial concerns, and the patient’s desire for sexual was used to create the new bladder.3,22–24 Denervation of intercourse. For example, in a person with a high the bladder such as cordectomy or rhizotomy has been cervical-level SCI, an indwelling catheter, in our opinion, tried and is sometimes successful.25–27 Erectile dysfunc- is probably the most useful (at least during the acute tion, however, may occur after the procedure. Neuro- phase), because this will allow the patient more indepen- stimulation for control of bladder function has also been dence than the use of other techniques. In a person with used. The most widely used technique is to apply elec- paraplegia who can be taught to self-catheterize, we trodes to the sacral anterior roots within the cauda believe that intermittent catheterization may be the first equina.28,29 These techniques have often been accompa- nied by surgical division of the sacral posterior rootswhich reduces reflex incontinence29; however, concern Pharmacologic management of specific bladder dysfunc- for the effects of this procedure on sexual response have tions may also be required, and many medications are currently available. For instance, when there is a failureto store due to bladder dysfunction, anticholinergics In those patients with incontinence due to incompe- such as oxybutynin and propantheline have an antispas- tence of the sphincter, artificial sphincters may be modic effect on the smooth muscle.16 Tricyclic antide- implanted.31,32 These devices are usually not used in pressants such as imipramine are thought to have a people with SCI, because upper urinary tract damage peripheral anticholinergic effect. These medications may result in hyperreflexia or increased intravesical suppress uninhibited bladder contractions, increase bladder capacity, and increase urethral resistance.3,16–18Alpha adrenergics including ephedrine and phenylpro- Other methods to aid in the treatment of incontinence panolamine may be used for treatment of failure to store are timed voiding, pelvic-floor exercises, and biofeed- due to relaxation of the sphincter.3,18 In women with back.3 Valsalva manuevers, suprapubic tapping, Crede´’s atrophy of the urethral epithelium, estrogen may method, and anal stretch aid in voiding in a patient with improve the local mucosal seal.19 Supportive treatment problems of urinary retention.1,3 External sphincterot- with diapers or a condom sheath catheter may also be omy via surgical procedure or laser is sometimes per- formed in patients with detrusor areflexia and detrusor-sphincter dyssynergia. Urethral stent placement has also Patients with failure to empty due to bladder dysfunctionmay be treated with cholinergics such as bethanechol.20People with a sphincter that is unable to relax and, * Abbott Laboratories Inc, Pharmaceutical Products Div, North Chicago, IL60064.
† Pfizer Inc, 235 E 42nd St, New York, NY 10017.
Physical Therapy . Volume 82 . Number 6 . June 2002 been performed in patients with retention due to prob- The colon absorbs fluids, electrolytes, and short-chain fatty acids; provides for growth of symbiotic bacteria;secretes mucus for lubrication of feces; and slowly pro- Neurogenic Bowel
pels stool toward the anus.4 The contents in the distal Bowel dysfunction is one of the most devastating colon are retained until bowel evacuation. Transport of sequelae of SCI, because it not only affects morbidity but contents may take 12 to 30 hours from the ileocecal valve it also can severely disrupt a person’s quality of life.
There are numerous gastrointestinal complications ofbowel dysfunction, including ileus, gastric ulcers, gastro- Small and large intestinal movements are mainly auton- esophageal reflux, autonomic dysreflexia, pain, disten- omous, with some spinal cord and minimal brain influ- tion, diverticulosis, hemorrhoids, nausea, loss of appe- ence. Peristaltic waves travel both toward and away from tite, impaction, constipation, diarrhea, and delayed or the ileocecal valve in the ascending colon, but in the unplanned evacuation.34–37 With proper care, however, descending colon the waves travel mainly to push the these complications can be minimized. In order to better understand the neurogenic bowel, a brief reviewof normal anatomy and physiology is needed.
The motility of the colon is performed by 3 primarymechanisms: myogenic, chemical, and neurogenic.4,45 The colon is bounded proximally by the ileocecal valve The myogenic transmission of signals occurs between and distally by the anal sphincter. The internal anal enteric smooth muscle cells that are interconnected by sphincter (IAS) is a continuous smooth muscle layer of gap junctions, which produces transmission from cell to the rectum at the end of the colon. The external anal cell. Most intestinal muscle displays autorhythmicity that sphincter (EAS) is a circumferential band of striated muscle that is continuous with the pelvic floor andlocated proximal to the anus. The puborectalis muscle Chemical control is through the activity of neurotrans- loops around the rectum and maintains the anorectal mitters and hormones. The chemicals influence the angle by tethering the rectum toward the pubic bone.4,38 promotion or inhibition of contractions through the The puborectalis muscle is positioned like a sling around action of the central nervous system, autonomic nervous the posterior rectal wall and is attached to the pubic system, or direct action on muscle cells.38,45,46 bone. When the puborectalis muscle contracts, it lifts therectum upward and forms an angle between the rectum The local neurogenic mechanism of colonic control is and anus.4,39,40 The EAS, IAS, and puborectalis muscle the enteric nervous system, which coordinates all seg- act together to maintain fecal continence. In the resting mental motility and some propagated movement.46 The state, continence is maintained by the tonic activity of intestinal wall is stretched or dilated. The nerves in the the IAS.4,41 To prevent incontinence with cough or myenteric plexus cause the muscles above the dilation to Valsalva maneuver, the EAS and puborectalis muscle constrict and those below the dilation to relax, and this helps propel the contents caudally. The extrinsic ner-vous system including the vagus nerve, sacral parasym- The intrinsic nervous system of the gastrointestinal tract, pathetics, and pelvic nerve—all help increase colonic which includes Auerbach’s plexus, is situated in the colonic wall between the longitudinal and circular mus-cle layers. This nerve supply helps coordinate colonic The gastrocolonic response or “gastrocolic reflex” is wall movement and the advancement of stool through initiated by fatty or proteinaceous meal, which increases the colon. The extrinsic nervous system also innervates propulsive small intestine and colonic motility. The the colon and includes the parasympathetic, sympa- mechanism of this action is not fully understood.4,38 thetic, and somatic nerves.4 The vagus nerve providesparasympathetic innervation from the esophagus to the In the resting state, both anal sphincters are active and splenic flexure of the colon. The pelvic nerve carries the anal-rectal canal is maintained in an acute angle by parasympathetic fibers from S2-S4 to the descending the puborectalis muscle. As the rectum distends, relax- colon and rectum. Some pelvic nerve branches travel ation of the IAS occurs and the muscle tone in the EAS proximally and innervate the transverse and ascending increases. Voluntary contraction of the EAS also helps to colon. Sympathetic innervation is supplied by the supe- maintain continence. The IAS maintains continence of rior and inferior mesenteric (T9-T12) and hypogastric liquid and gas, and the EAS maintains continence of (T12-L2) nerves.4 The somatic pudendal nerve (S2-S4) solids. Increased intra-abdominal pressure also causes the EAS to reflexively contract.4,39 Defecation occurswith relaxation of the puborectalis muscle and the EASresulting from involuntary advancement of stool into the Physical Therapy . Volume 82 . Number 6 . June 2002 ўўўўўўўўўўўўўўўўўўўўўўўў rectum.46 This creates a straighter anorectal tunnel for neurologic examination can reveal the extent of the stool to pass, which is aided by peristalsis and increased nerve damage and the completeness of the SCI. The abdomen should be inspected for distention, increasedabdominal muscle tone indicative of spasticity and bowel A neurogenic bowel occurs when there is a dysfunction sounds. The rectal examination can provide information of the colon due to lack of nervous control. The enteric regarding external sphincter tone, stool in the rectal nervous system remains intact after SCI; however, vault, and the presence of hemorrhoids or masses, and it depending on the level of the injury, different bowel assesses the tone and ability to produce voluntary con- problems and complications may arise. Stiens et al38 traction of the puborectalis muscles. We contend that it described 2 main types of neurogenic bowel. The lower is also important to take into account the patient’s motor neuron (LMN) bowel syndrome or areflexic strength in the upper and lower extremities; his or her bowel results from a lesion affecting the parasympathetic sitting balance and ability to transfer; the length of the cell bodies in the conus medullaris, the cauda equina, or patient’s arms, legs, and trunk; and the patient’s weight.
the pelvic nerve. No spinal cord–mediated peristalsis These factors will help determine whether the patient occurs, and there is slow stool propulsion. Only the can perform his or her own bowel program or whether myenteric plexus coordinates segmental colonic peristal- he or she will need assistance.4 Berkowitz et al47 found sis, and a dryer, rounder stool shape occurs. Due to the that 37% of all patients with SCI need assistance with denervated EAS, there is increased risk for incontinence.
bowel care. People with tetraplegia (59%) were more The levator ani muscles lack tone, and this reduces the than 3 times as likely to need assistance as people with rectal angle and causes the lumen of the rectum to open.
The LMN bowel syndrome produces constipation and asignificant risk of incontinence due to the lax EAS.
Prolonged bed rest interferes with bowel motility. Theseated position reduces the anorectal angle and facili- A lesion above the conus medullaris causes an upper tates defecation. If it is possible to perform the bowel motor neuron (UMN) bowel syndrome or hyperreflexic program in the seated position, after taking into account bowel. There is increased colonic wall and anal tone.
all the previously mentioned factors, the seated position The voluntary control of the EAS is discontinued, and the sphincter remains tight thereby retaining stool. Thenerve connections between the spinal cord and the The time when the person conducts his or her bowel colon, however, remain intact; therefore, there is reflex regimen will be determined by his or her lifestyle, and it coordination and stool propulsion. The UMN bowel is arranged around work, school, or other activities.
syndrome produces constipation and fecal retention at Many people prefer to perform the bowel regimen in the least in part due to the activity of the EAS.4,38,39 morning and have the rest of the day free. Some peoplecan be assisted only at certain times of the day, and that In designing a bowel program for a patient with SCI, a will determine when the bowel regimen is performed.
variety of factors must be considered. First, does thepatient have UMN or LMN bowel dysfunction? A history There are numerous medications used to aid in the is used to determine whether any gastrointestinal prob- management of the neurogenic bowel. The 4 main lems or any other medical conditions—such as diabetes, categories of medications are stool softeners, colonic irritable bowel syndrome, lactose intolerance, inflamma- stimulants, contact irritants, and bulk formers. An exam- tory bowel disease, or rectal bleeding— existed before ple of a stool softener is docusate sodium, which emul- the SCI. These disorders may affect the choice of med- sifies fat in the gastrointestinal tract and, therefore, ications used in the bowel regimen. Medications fre- softens the stool. Senna tablets are colonic stimulants quently used by patients with SCI for other problems— that stimulate Auerbach’s plexus to induce peristalsis.
such as anticholinergics for treatment of neurogenic Bisacodyl tablets and suppositories act as contact irri- bladder, antidepressants, narcotics, and antispasticity tants in the mucosa of the colon and produce peristalsis.
medications—may also affect the bowel. In addition, we Psyllium is a type of bulk former.4,38,39 believe the person’s dietary habits and preferences aswell as the amount of fluid intake allowed should be A usual bowel program will consist of a stool softener addressed as part of the bowel management. The diet administered 3 times per day—2 senna tablets and a should be nutritional and provide high-residue foods bisacodyl enema daily. The times that these medications such as fruits, vegetables, grains, and cereals. Drinking will be given depends on the time of day the bowel program begins. Many people have had good resultswith this method; however, most times the medications A full physical examination including rectal examination will require adjustments in order to achieve proper and should be performed to help devise a bowel regimen. A regular evacuation. In adjusting the medical regimen, Physical Therapy . Volume 82 . Number 6 . June 2002 the effects of other medications the patient is taking are the phases has particular genital and peripheral physio- considered as are the person’s diet and the position in logic characteristics. When we discuss the topic of male which the person performs the bowel program.4,38,39 sexual response, the components that most frequentlycome to mind include the occurrence of erections For a reflexic bowel, the chemical stimulant is placed during the arousal phase and ejaculation during the into the rectum with the patient in the upright or left orgasm phase. As may be expected, most of the literature lateral decubitus position, and digital stimulation is pertaining to the impact of SCI on male sexual response relates to these 2 phenomena. Nevertheless, in both increases peristalsis and relaxes the EAS. It is performed sexes, heart rate, blood pressure, and respiratory rate by inserting a gloved, lubricated finger into the rectum also progressively increase during the arousal, plateau, and slowly rotating the finger in a circular movement.
and orgasm phases of sexual response and then return Other assistive techniques such as the Valsalva maneu- to baseline levels during the resolution phase.60 ver, push-ups, abdominal massage, or leaning forwardmay also be used. A bowel care regimen for an areflexic In order to predict the impact of SCI on male erection, bowel consists of performing gentle Valsalva maneuvers knowing the level and degree of a person’s injury and or manual evacuation in the upright or side-lying whether the injury is in the UMN or LMN and is affecting the sacral reflex arc is critical.61,62 In addition,the status of the neurologic pathways that control erec- Medication management also depends, in part, on the tion determines function. Erectile function can occur 2 type of bowel dysfunction. In a reflexic bowel, the ways: (1) reflexively through sacral stimulation and a medical regimen should work to produce a soft, formed parasympathetic neurologic pathway and (2) psychogen- stool that can be evacuated with rectal stimulation. In an ically under control of the hypogastric plexus originat- areflexic bowel, firm, formed stool is required to allow ing at T11-L2 and also involving the sacral segments.63–65 the stool to be retained between bowel regimens and to Men with complete UMN injuries above the level of T11 can have reflex erections but not psychogenic erections,whereas men with complete LMN injuries will most likely A surgical approach to bowel management is the place- not have reflex erections but may have psychogenic ment of a colostomy or ileostomy. The time spent in erections, depending on the degree of preserved neuro- bowel care has been reported to decrease from 11 hours logic function in the T11-L2 region of the spinal to 4 hours per week with ostomies, and fecal inconti- cord.66,67 Men with incomplete UMN injuries may retain nence is prevented.4,49 Biofeedback has been used to the capacity for psychogenic function, depending on the treat fecal incontinence in people with some rectal degree of preserved neurologic function in the T11-L2 sensation and voluntary anal sphincter contraction. Most region of the spinal cord, and they should retain the patients with SCI do not meet these criteria, and, there- capacity for reflexive erectile function. Men with a fore, biofeedback does not appear to be beneficial.4 complete LMN injury should not experience reflex There is a strong social and sexual aspect of bowel erections but may experience psychogenic erection, management. Bowel accidents were noted to be the most depending on the degree of preserved neurologic func- socially distressing situation in people with SCIs, and tion affecting the T11-L2 region of the spinal cord.66,67 bowel and bladder accidents were of primary concernwhen related to sexual activity.50,51 Ejaculation is a more complicated neurologic processand is more profoundly affected by SCI. Coordinated Neurogenic Sexual Function
efforts of the sympathetic, parasympathetic, and somaticnervous systems result in the production of a man’s ejaculate. In men with SCI, any of these neurologic The impact of SCI on sexual response depends on the pathways can be interrupted, depending on where the degree of injury and its location in the spinal cord.52 injury is located, and the result will often be a retrograde Furthermore, it depends on whether the person is male ejaculation in which semen is forced into the bladder or female and what aspect of sexual response is being instead of out the urethra. According to statistics on the evaluated. Most of the information available about male effect of SCI on ejaculation, 4% of men with complete sexual response is based on questionnaire studies,52–54 UMN lesions and 32% of men with incomplete UMN whereas most of the data available about women comes lesions retain the ability to ejaculate.52 In men with from laboratory-based research.30,55–59 complete LMN SCIs, 18% are reported to ejaculate, anda greater likelihood of ejaculation is associated with the Masters and Johnson60 provided a framework for study- capacity for psychogenic erection. Seventy percent of ing human sexual response and divided its components men with incomplete LMN injuries reportedly can ejac- into arousal, plateau, orgasm, and resolution. Each of ulate.52 These estimates of how often men with SCI can Physical Therapy . Volume 82 . Number 6 . June 2002 ўўўўўўўўўўўўўўўўўўўўўўўў ejaculate are based on ejaculation that occurs naturally similar between subjects with and without SCIs. Further- through masturbation or sexual contact and without the more, at no time were unsafe blood pressure responses use of augmentative techniques such as electroejacula- noted in women with SCI. Latency to orgasm was greater tion or penile vibratory stimulation.63 These stimulation in women with SCIs than in women without SCI. Descrip- techniques, which are relatively new and used primarily tions of orgasm were indistinguishable between women for fertility purposes, are able to produce ejaculation in with and without SCI.30 Another group of researchers59 a greater percentage of men than the above figures reported on the orgasms of 3 women with complete SCIs below T6 after a controlled type of stimulus. Based onthe above research,30 it is hypothesized that an intact Orgasm in men with SCI has only been studied by sacral reflex arc is needed to achieve orgasm and that questionnaire.53,54 Nevertheless, the findings in these orgasm may be a reflex response of the autonomic reports have been quite similar. Using self-defined defi- nervous system. Currently, a comprehensive assessment nitions of orgasm, researchers in one study54 noted that of the orgasms of men with SCIs is under way to 42% of men reported achieving orgasms, whereas determine whether the impact of neurologic injuries on researchers in another study53 indicated that 47% of sexual response will be similar to those of women.
men reported achieving orgasm. In addition, it wasnoted that 38% of men with complete SCIs reported that they had orgasms.53 Unfortunately, none of these Although men remain interested in sexual activity after reports provided detailed information about the feelings SCI,53,54,70 their level of desire has been shown to decrease.53 Most men with SCIs resume sexual activitywithin 1 year of injury53; however, their frequency of In women, the arousal phase of sexual response is sexual activity has been shown to decrease after injury. In characterized by lubrication of the vagina; clitoral swell- one study,35 52% of men had sex 2 to 3 times per week ing; increases in heart rate, respiratory rate, and blood before injury compared with 30% after injury; 48% of pressure; and other changes.60 Hypotheses have been men had sex once a week or less prior to injury com- made about how the sexual function of women with pared with 70% after the injury. Other researchers71 different types of injuries should be affected; these noted a decrease in the frequency of intercourse in men hypotheses were initially based on information regard- from 3 to 4 times per week to 1 to 2 times per week.
ing men with SCIs. Most of these effects have been Reasons for the decrease in the frequency of sexual confirmed in the laboratory. For women with complete activity have included fewer opportunities for sex,54 but UMN injuries affecting the sacral segments, the ability the level and degree of injury have not been found to for reflex but not psychogenic lubrication should be affect frequency of sexual activity.53 The types of sexual maintained.68,69 This hypothesis has been tested in a activities men engage in after SCI are similar, although laboratory-based analysis,56 and the results, although not they occur at a slightly different frequency, to those conclusive, supported the hypothesis that lubrication before their injuries. In one study,53 men reported the occurs reflexively. For women with incomplete UMN following frequencies of sexual activity before and after injuries affecting the sacral segments, it is thought that injury: intercourseϭ97% before injury and 61% after they may retain the capacity for reflex lubrication and injury, kissingϭ97% before injury and 84% after injury, may maintain the capacity for psychogenic lubrication.68 huggingϭ89% before injury and 79% after injury, and Laboratory studies have shown that those women with touchingϭ87% before injury and 76% after injury. In greater ability to perceive a combination of light touch addition, although 99% of men reported penile-vaginal and pinprick sensation in the T11-L2 dermatomes will intercourse as their favorite sexual activity before injury, have a greater likelihood of achieving psychogenic lubri- only 16% of men indicated that this was true after injury; cation.30 This holds true regardless of the level or degree furthermore, after injury, most men preferred oral sex, of injury and regardless of whether the injury to the kissing, and hugging.53 Sexual satisfaction has been sacral segments is to the UMN or LMN.
Orgasm in women with SCIs has also been studied in The sexuality of women with SCI received little attention laboratory settings.30,55 Although 100% of women with- until the 1990s. As in men, women’s desire for sexual out SCIs were able to stimulate themselves to orgasm, activity seems to decrease after injury. One group of only 52% of women with SCIs were able to do likewise.55 researchers72 found that 46% of women with SCIs Women with SCIs are less likely to achieve orgasms if (Nϭ231) indicated that sex was less important after they have a complete LMN injury affecting the sacral injury, whereas other researchers73 found that 44% of segments than if they have any other levels and degrees women with SCIs (Nϭ25) rated their level of desire as of injury.30 Autonomic responses, including blood pres- “none” to “low” after injury compared with 20% prior to sure, heart rate, and respiratory rate, were generally injury. Frequency of sexual activity is also known to Physical Therapy . Volume 82 . Number 6 . June 2002 decrease in women with SCIs.72,74 Little difference has blood vessels may bulge, the size of the penis may be been noted in the sexual activities that women with SCI wider than with a regular erection, and the penis tends participate in after injury compared with the sexual to pivot at the junction where the constricting ring lies.
activities they participate in before injury.72,73 A decrease The device also must not be used for more than 30 in the frequency of masturbation, however, has been minutes, because the lack of blood flow can result in noted after injury.63 Preferred sexual activities after SCI necrosis of the penile skin and other injuries. Further- have been reported to be kissing, hugging, and more, use of the device in conjunction with anticoagu- lation medication is contraindicated.81 As an alternativeto the use of the pump, those men who are able to achieve a reflex erection may use the ring to maintain an Aside from studies examining treatment of erectile erection. Men who use this method should observe the dysfunction, essentially no studies have focused on treat- same precautions given for the use of the pump and the ment of male or female sexual dysfunction after SCI.
Although studies have been performed to determinewhether there could be increases in the ability of men to Injections of vasoactive drugs into the penis have also ejaculate, these studies were performed with a medical been used as a means to improve erectile function.82,83 focus rather than focusing on whether sexual pleasure This method is cosmetically superior to the use of a improved.75–78 Part of the reason may be that many vacuum pump; however, some men dislike the idea of people have decreased sexual desire after an SCI, and, placing a needle in their penis, and this method cer- therefore, they may not seek treatment for their inability to become aroused or have orgasms. In addition, the including phenoxybenzamine, phentolamine, papaver- lack of available treatment methods may be part of the ine, and prostaglandin E1, have been utilized to improve reason. Our comments, therefore, will focus on the erectile function. Currently, prostaglandin E1 remains remediation of erectile dysfunction, an area where much the only medication that is approved by the Food and Drug Administration (FDA) for this purpose. The doc-umented side effects to the use of injection to achieve Although many men with SCI are able to have some type erections in men with SCIs include dysesthesias, pria- of erectile function, many report that the quality of their pism, seizures, and intracorporeal fibrosis.65,82,83 erections is insufficient for intercourse.79 In addition,some men are unable to have erections. Therapies for A new means to improve erectile function in men with remediation of erectile dysfunction have improved since SCIs occurred with the development and FDA approval the recommendations for “stuffing” the penis into the of the drug sildenafil (Viagra†).84 The drug has been vagina that were still popular in the 1970s.
shown to be efficacious in men with varying types oferectile dysfunction, including those resulting from The penile prosthesis was the first reliable method SCIs.79 Adverse events occurred in 6% to 18 % of men developed to ensure adequate erection.80 Prostheses are and most commonly included headache, flushing, and available in both semirigid and malleable forms. These dyspepsia.84 Use of the drug in men with SCIs has shown devices, however, are the most invasive treatment for that it is generally safe and effective.66,85 erectile dysfunction and have been found to have a highrate of complications in men with SCIs. Complications Early after the FDA approval of sildenafil, concerns include (1) erosion of the device due to a lack of emerged, including cardiovascular dysfunction (which sensation and (2) infections due to the patients’ predis- was temporally associated with use of the drug), pria- position to infection. Researchers in one report80 noted pism, and ocular effects.86 More recently in a random- that 25% of the men with SCI that they studied required ized crossover trial using exercise echocardiography, it removal of the device due to erosion or infection.
has been shown that, even in men with stable coronaryartery disease, there were no effects of sildenafil on Another type of device to improve erectile function in symptoms, exercise duration, presence or extent of men with SCIs is the vacuum erection device.81 Negative exercise-induced ischemia.87 Due to potential drug inter- pressure produced by either manual pumping or battery actions, the use of nitrates, either on a regular basis or operation is used to cause engorgement of the penile intermittently, is an absolute contraindication to the use corpora. The erection is then maintained through the of the drug.86 Sildenafil is also contraindicated in men application of a constricting ring at the base of the penis.
with a history of retinitis pigmentosa. Overall, the rela- Although these devices have the advantage of being tively young age of men with SCIs and their overall good noninvasive, the resultant erection is not as aesthetically health makes them generally good candidates for the pleasing as that produced by other means. The penis drug. Furthermore, premarket studies are being con- may appear discolored due to the engorgement, surface Physical Therapy . Volume 82 . Number 6 . June 2002 ўўўўўўўўўўўўўўўўўўўўўўўў ducted on several other oral medications designed to research group95 noted that alterations in sperm count occur within weeks of SCI. Another group’s96 analysis of638 specimens from 125 men with SCI revealed an initial In our opinion, remediation of sexual dysfunction in decline in semen quality, which probably occurs in the women with SCI should focus on the improvement of first few weeks after injury; however, they found no the physiologic changes brought on by SCI and in evidence for a progressive decline in semen quality in improving the subjective aspects of sexual response. We believe treatments should focus on improving the abilityof women with SCI to become aroused and to achieve Stimulation to obtain ejaculate for insemination of a orgasm. A recent double-blind, placebo-controlled study partner is now routinely performed, usually through the of women with SCI indicated that sildenafil may improve use of penile vibratory stimulation or electroejaculation.
female sexual arousal.88 Another recent study89 showed a For most men with SCIs, the process of penile vibratory beneficial effect of false positive feedback in improving stimulation is probably superior to that of electroejacu- subjective sexual arousal and genital arousal as mea- lation because it is less invasive and the semen quality sured by vaginal pulse amplitude. We recommend that obtained is better.75 In addition, penile vibratory stimu- future studies should focus on improving sexual respon- lation may be performed in a home or office setting.
siveness and satisfaction for women with SCIs and that Optimal settings for penile vibratory stimulation have similar studies should be performed for men with SCIs.
been determined76 and are an amplitude of 2.5 mm anda frequency of 100 Hz. Furthermore, it has been reported that there is no difference between high- or The impact of SCI on procreation is more severe for low-amplitude vibratory stimulation in the quality of the men than for women. The majority of men with SCI have poor sperm quality and ejaculatory dysfunction, makingreproduction via sexual intercourse virtually impossible.
Not all men with SCIs are able to ejaculate with vibratory Researchers have examined the reasons for this decline stimulation, and a neurologically intact lower lumbar in sperm quality. The inability to control scrotal temper- spinal cord may be necessary for ejaculatory success.78 ature was thought to contribute to the poor quality of For those men unable to ejaculate with vibratory stimu- sperm in men with SCIs64; however, this theory has lation, the use of electroejaculation may be a viable recently been tested and disproved.90 Endocrine profiles option.64 The downside of electroejaculation is that it and their relationship to semen quality also have been must always be performed in a clinic or office setting.
studied. Mean levels of gonadotropins were lower inmen with SCI compared with men without SCI; more- Once a semen specimen is obtained, insemination of a over, the frequency of abnormal endocrine profliles was woman may occur. This may be performed via ovulation greater in men with SCI compared with men without induction in combination with intrauterine insemina- SCI.91 In men with SCI, no semen parameter correlated tion,97 in-vitro fertilization, gamete intrafallopian trans- with any hormone profile except in men with SCI who fer, or intracytoplasmic sperm injection.64 These meth- had abnormal follicle-stimulating hormone levels. All ods are listed in terms of increasing cost. Despite the these men were azoospermic.91 The researchers felt that procedures may need to be performed, the positive these abnormalities were probably not the only reason prognosis for men with SCIs to father children is one of the recent advances of medicine, and ongoing researchwill certainly continue to improve the probability for The seminal plasma of men with SCIs also was tested and found to inhibit the motility of the sperm of menwithout SCI.92 Therefore, it appears that the seminal Unlike men with SCIs, the ability of women with SCIs to plasma of men with SCIs contributes to the poor sperm conceive is thought to be unchanged. Of the 231 women motility that they exhibit. Furthermore, it was found that studied by Charlifue et al,72 60 experienced an average the level of reactive oxygen species in the semen of men of 5 months of temporary amenorrhea after injury. After with SCI were negatively correlated with sperm motili- this time period, the women’s fertility should have ty.93 In addition to poor sperm motility but unrelated to returned to normal levels; however, in the same group of the level of their SCI, the semen of men with SCI has subjects, the pregnancy rate was 0.34 pregnancy per been found to have a significantly higher percentage of person compared with 1.3 pregnancies per person dead sperm than that of men without SCI.94 Because of before injury. Furthermore, those women who had the finding of a high percentage of dead sperm in men higher and more complete neurological injuries were with SCI, a pathological mechanism for sperm cell death the least likely to become pregnant compared with those may exist. The timing of sperm retrieval was thought to with the lowest degree of neurologic impairment. This be another factor possibly related to sperm quality. One may reflect the fact that women are avoiding having Physical Therapy . Volume 82 . Number 6 . June 2002 children because of the overall difficulties they may have 10 Krane RJ, Siroky MB. Classification of neuro-urologic disorders.
In: Krane RJ, Siroky MB, eds. Clinical Neuro-urology. 2nd ed. Boston,Mass: Little, Brown & Co; 1979:143–158.
For those women who have SCIs and are interested in 11 Wein, AJ. Classification of neurogenic voiding dysfunction. J Urol 1981;
birth control, little research has examined their options.
Only 4 of 70 women with SCIs who took birth control 12 Abrams P, Blaivas JG, Stanton SL, Andersen JT. Standardization of
pills for an undetermined period of time developed terminology of lower urinary tract function. Neurourol Urodyn. 1988;7: thrombophlebitis98; however, this should not be taken as an overall approval for women with SCI to use birth 13 Comarr AE. Diagnosis of the traumatic cord bladder. In: Boyarski S,
control pills because of the known associations between ed. The Neurogenic Bladder. Baltimore, Md: Williams & Wilkins; 1967:147–152.
both birth control pills and SCI with thrombophlebitis.
Instead, in our opinion, the individual nuances of the 14 Bissonette DJ. Sorting out spinal cord syndromes. J Am Acad Phys
woman’s injury and her psychosocial status must be taken into account. For instance, those women who are 15 Rudy DC, Awad SA, Downie JW. External sphincter dyssynergia: an
unsure of the status of their sexual relationships should abnormal continence reflex. J Urol. 1988;140:105–110.
be counseled to use condoms. If they do not have good 16 Brown JH. Atropine, scopolamine and related antimuscarinic
hand function and sensation, a diaphragm is not a drugs. In: Gilman AG, Rall TW, Nies AS, Taylor P, eds. Goodman and reasonable choice. In addition, because pelvic inflamma- Gilman’s the Pharmacologic Basis of Therapeutics. 8th ed. New York, NY:Pergamon Press; 1990:150 –165.
tory disease has been associated with intrauterine deviceuse,99 women with SCIs and those who have probable 17 Baldessarini RJ. Drugs and the treatment of psychiatric disorders.
In: Gillman AG, Rall TW, Nies AS, Taylor P, eds. Goodman and Gilman’s
urinary tract infections should use intrauterine devices the Pharmacologic Basis of Therapeutics. 8th ed. New York, NY: Pergamon with caution. The effects of levonorgestrel implants in women with SCIs are yet to be studied; however, this may 18 Wyndaele JJ. Pharmacotherapy for urinary bladder dysfunction in
prove to be a safe, appropriate means of contraception spinal cord injury patients. Paraplegia. 1990;28:146 –150.
19 Walter S, Wolf HL, Barlebo H, Jensen HK. Urinary incontinence in
post-menopausal women treated with estrogens. Urol Int. 1978;33:135.
A discussion of management of pregnancy in the womanwith SCI is beyond the scope of this article. However, the 20 Finkbeiner AE. Is bethanechol chloride clinically effective in pro-
moting bladder emptying? A literature review. J Urol. 1985;134:
reader is referred to a recent review100 for an excellent 21 Linder A, Leach GE, Raz S. Augmentation cystoplasty in the
treatment of neurogenic bladder dysfunction. J Urol. 1983;129:
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