Since a spinal cord injury (SCI) affects virtually every system of the human body, many people who sustain SCI have serious concerns about how their injuries have affected their ability to participate in and enjoy a sexual relationship. This document attempts to address some of the more common questions that arise on the topic of sex after a SCI.
Sexual function in humans is controlled by parts of the central nervous system (CNS), particularly the brain and spinal cord. Interruption to the CNS through injury to the spinal cord will therefore have some effect on sexual function. The extent to which sexual function is impaired, however, depends on a variety of factors including the level of injury, the severity of damage to the spinal cord, and whether the individual is male or female.
2. Female Sexuality After SCI
At only the most basic level, a female's ability to engage in sexual activity is less likely to be affected by SCI, by virtue of the way the female body is constructed. A woman is often able to have intercourse as easily after SCI as before, although additional lubrication may be needed to avoid chafing and to make the act of intercourse easier to initiate. Alternative positioning of one's body may have to be considered as well.
While certain aspects of female sexual functioning may be changed after SCI, the ability to conceive, carry and give birth is usually not impaired. (I know multiple women personally who have had several children after their injury vaginally, although some do it by a C-section)
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Yo! You click on the words up there to read it!
Birth control is an issue of great interest to women in general and the woman with an SCI has additional reasons to be concerned. Unless a woman develops sensitivity to latex, her male partner's use of condoms may be the easiest method of birth control. Using foam, the sponge or a diaphragm and jelly is still possible, but women with quadriplegia may now find this difficult, if not impossible. While only a few assistive devices are available to help perform these tasks, a woman's partner may wish to assist or even perform these tasks, helping to make the responsibility for birth control a shared function.
Other methods of birth control, such as IUD's, the pill and Norplant, should only be used with great caution after consultation with an experienced gynecologist or physiatrist. Both SCI and the pill are known to cause vascular complications in certain individuals and one may contraindicate the use of the other. IUD's are particularly worrisome because a lack of sensation or inability to check its positioning may cause a woman to be unaware of slippage or puncture. Slippage may decrease the effectiveness of preventing a pregnancy and a puncture can be life threatening.
Many women are concerned about their ability to have children following a SCI. Although there may be precautions to guard against complications such as autonomic dysreflexia (I will explain what this is later), most women are able to bear children following a SCI. A competent physician who is experienced in labor and delivery with women with SCI is essential when contemplating having children.
3. Male Sexual Function After SCI
For males, the situation of sexual functioning is a little more complicated. Some men are able to achieve erections quite easily, while others can achieve erections occasionally and some are unable to achieve erections at all after a SCI. Two basic kinds of erections are possible. Psychogenic (the kind of erection that occurs as a result of having sexy thoughts or by looking at erotic pictures) and reflexogenic (erections that occur as a result of direct physical stimulation of the penis or surrounding area).
There are several ways to achieve an erection after SCI. Vacuum-Induced Erections employ tubes with a vacuum pump that, when placed over the penis and activated, pulls the air out of the tube often causing blood to inflate the penis. A band is then placed around the base of the penis to maintain erection. Most urologists suggest this method as a first step as it is the least invasive of the available procedures. Another option is the Injected Vasoactive Drug. A very fine needle is used prior to sexual activity to inject a prescribed dosage of medication into the base of the penis. The extremely fine needle causes little or no discomfort. The drug causes the blood vessels in the penis to enlarge, thereby stimulating an erection that can last from 15 minutes to an hour or more, depending on the dosage injected. Some potential side effects include bruises and erection for a dangerously long period of time. The cost per injection can range from $10 to $20 depending on the medication used, and insurance coverage may be available.
Penile Implants, or penile prostheses are sometimes considered. This procedure is extremely invasive as it involves surgical implantation of a rod or an inflatable tube into the penis. Inflatable implants have several chambers that are filled with fluid to achieve erection and are then emptied following intercourse. The pump, chambers to be filled with fluid, and connecting tubes are all implanted. Semi-rigid implants consist of two implants made of a flexible material that causes a permanent rigid state. The penis can be bent against the pelvis when not engaged in intercourse.
Although the level and severity of injury may give some indication as to how likely a man is to be able to have erections, the best way to find out is to get to know your body and learn how it reacts to certain situations. A doctor can give you more information about whatever physiological limitations may exist, but the person and their partner need to explore their body's response to sexual situations. Although talking about sexual function is sometimes difficult, complete and open communication between partners is the best way to explore sexual possibilities available after injury (just as it was before injury, by the way!)
4. Sexual Sensation After Spinal Cord Injury
As with other basic physiological functions after a SCI, sexual sensations can also be altered. Some of the nerves you once counted on to provide pleasurable feelings in sexual organs and other erotic areas of your body may no longer be working as they did before injury. Some people retain specific sexual sensations in the genital areas, while others notice they are diminished or absent. However, many others have reported heightened sensations in different parts of the body-the neck, earlobes, nipples, arms or other areas of skin.
Editor's Note: I know of men and women who lost all genital sensation but are able to achieve something called a "phantom orgasm" where they might have someone kiss or touch an area of their body where they still have normal sensation, like the neck, earlobes or nipples mentioned above. What will happen is, the brain will take the intense sensation from those areas and "reassign" them to the genitals, so they feel like they are having a regular orgasm. I personally know a girl who is able to achieve orgasm by having someone kiss her hand.
Wouldn't that be NICE?? If I were her, I would just go up to random strangers and put my hand in their mouths.
Many people who have sustained a SCI have indicated that their total enjoyment of the sexual experience after SCI is as good as, if not better than, their pre-injury sexual experiences. Necessity in many cases encourages them to concentrate on "holistic" sexual experiences rather than on genital-specific sex. Many individuals report that they can still achieve climax although frequently not in the same way as before their injury.
A key component of sexuality is how one perceives one's body. A person who is able to see themselves as attractive and desirable is far more likely to engage in a healthy and satisfying sex life. Some people experience issues of lowered self esteem and a resulting poor self image following a spinal cord injury. As a person with SCI adjusts to a new physical reality, it may be difficult to change self perceptions to accommodate the injury in a positive way.
One common misconception following a spinal cord injury is that a single man or woman will never find a life partner, or that an existing partner will leave a relationship due to the complications of an injury. This is not the case. The divorce rate following spinal cord injury is only slightly higher than in other populations, and thousands of people have been married and begun families after a spinal cord injuries.
Note: Not every person with an SCI struggles with the following issues.
POOP & PEE:
We'll discuss pee first.
Paralysis at any level usually, but not always, affects bladder control. The nerves controlling these organs attach to the very base of the spinal cord (levels S2–S4) and are therefore cut off from brain input. Although it may not be possible to regain the control one had before paralysis, a wide range of techniques and tools are available to manage what is termed a neurogenic bladder.
Here's how an unaffected bladder works: Urine, the excess water and salts that are extracted from the bloodstream by the kidneys, is piped down thin tubes called ureters, which normally allow urine to flow only in one direction. The ureters connect to the bladder, which is basically a storage bag that does not like pressure. When the bag is full, pressure rises and nerves send a message via the spinal cord to the brain. When one is ready to empty the bladder, the brain sends a message back down the spinal cord to the bladder, telling the detrusor muscle (the bladder wall) to squeeze and the sphincter muscle (a valve around the top of the urethra) to relax and open. Urine then passes down the urethra to exit the body.
It is a rather elegant (like how I italicized that?) process of muscle coordination just to go pee.
After paralysis, however, the body's normal system of control can go haywire; messages can no longer pass between the bladder muscles and the brain. Both the detrusor and the sphincter may be overactive due to lack of brain control. An overactive detrusor can contract at small volumes against an overactive sphincter; this leads to high bladder pressures, incontinence, incomplete emptying, and reflux -- along with recurrent bladder infections, stones, hydronephrosis (kidney distention), pyelonephritis (kidney inflammation), and renal failure.
The neurogenic bladder is usually affected in one of two ways:
1. Spastic (reflex) bladder: when the bladder fills with urine, an unpredictable reflex automatically triggers it to empty; this usually occurs when the injury is above the T12 level. With a spastic bladder you do not know when, or if, the bladder will empty. Physicians familiar with spinal cord injury often recommend a bladder relaxing medication (anticholinergic) for reflexive bladder; oxybutynin (Ditropan) is common, with a primary side effect of dry mouth. Tolterodine, propiverine, or transdermal oxybutinin may result in less dry mouth. Botulinum toxin A (Botox) may be an alternative to anticholinergics. It has been FDA approved for detrusor overactivity treatment in individuals with SCI and multiple sclerosis. The advantage: Botox is used focally in the bladder, thus avoiding systemic side effects, including dry mouth.
2. Flaccid (non-reflex) bladder: the reflexes of the bladder muscles are sluggish or absent; it can become over-distended, or stretched. Stretching affects the muscle tone of the bladder. A flaccid bladder may not empty completely. Treatments may include sphincter relaxing medications (alpha-adrenergic blockers) such as terazosin (Hytrin) or tamsulosin (Flomax). Botox (hey, that means your bladder will never age!) injected into the external urinary sphincter may improve bladder emptying. Also, surgery is an option to open the sphincter. Bladder outlet surgery, or sphincterotomy, reduces pressure on the sphincter and thus allows urine to flow out of the bladder easier. An alternative to sphincterotomy is placement of a metal device called a stent through the external sphincter, thus ensuring an open passage. One drawback to both sphincterotomy and stenting is that sperm from an ejaculation ends up in the bladder (retrograde), rather than coming out the penis. This doesn't rule out having a child but complicates it; sperm can be collected from the bladder but can be damaged by urine.
Dyssynergia occurs when the sphincter muscles do not relax when the bladder contracts. The urine cannot flow through the urethra, which can result in the urine backing up into the kidneys (called reflux), which can lead to serious complications.
The most common method of bladder emptying is an intermittent catheterization program (ICP), which drains the bladder on a set schedule (every four to six hours is common). A catheter is inserted in the urethra to drain the bladder, then removed. An indwelling catheter (Foley) drains the bladder continuously. If drainage originates from a stoma (a surgically created opening) at the pubic bone area, bypassing the urethra, it's called a suprapubic catheter. Advantage: unrestricted liquid intake. Disadvantage: besides the need for a collection device, indwelling catheters are more prone to urinary tract infection. An external condom catheter, which also drains continuously, is an option for men. Condom catheters also require a collection device, e.g. legbag.
There are several surgical alternatives for bladder dysfunction. A Mitrofanoff procedure constructs a new passageway for urine using the appendix; this allows catheterization to be done through a stoma in the abdomen directly to the bladder, a great advantage for women and for people with limited hand function. Bladder augmentation is a procedure that surgically enlarges the bladder, using tissue from the intestines, to expand bladder capacity and thus reduce leaking and the need for frequent catheterization.
It is common for people with multiple sclerosis and other spinal cord diseases to have problems with bladder control. This can involve a little leaking after a sneeze or laugh, or loss of all control. For many people, appropriate clothing and padding can compensate for lack of control. Some women benefit from strengthening the pelvic diaphragm (Kegel exercises) to improve retention of urine.
Now POOP!
Paralysis can disrupt "the system."
There are two main types of neurogenic bowel, depending on level of injury: an injury above the conus medullaris (at L1) results in upper motor neuron (UMN) bowel syndrome; a lower motor neuron (LMN) bowel syndrome occurs in injuries below L1.
In a UMN or hyperreflexic bowel, voluntary control of the external anal sphincter is disrupted; the sphincter remains tight, which promotes constipation and retention of stool, which cannot be ignored; it is associated with episodes of autonomic dysreflexia. UMN connections between the spinal cord and the colon remain intact, thus reflex coordination and stool propulsion remain intact. Stool evacuation in people with UMN bowel occurs by means of reflex activity caused by a stimulus introduced into the rectum, such as a suppository or digital stimulation—best triggered at socially appropriate times and places.
LMN or flaccid bowel is marked by loss of stool movement (peristalsis) and slow stool propulsion. The result is constipation and a higher risk of incontinence due to lack of a functional anal sphincter. To minimize formation of hemorrhoids, use stool softeners, minimal straining during bowel efforts, and minimal physical trauma during stimulation.
Bowel accidents can happen for some people.
For those who struggle with this, the best way to prevent them is to follow a schedule, to teach the bowel when to have a movement. Most people perform their bowel program at a time of day that fits with their lifestyle. The program usually begins with insertion of either a suppository or a mini-enema, followed by a waiting period of approximately 15–20 minutes to allow the stimulant to work. After the waiting period, digital stimulation is performed every 10–15 minutes until the rectum is empty. Those with a flaccid bowel frequently start their programs with digital stimulation or manual removal. Bowel programs typically require 30–60 minutes to complete. Preferably, a bowel program can be done on the commode. Two hours of sitting tolerance is usually sufficient. But those at high risk for skin breakdown
(When you're paralyzed, you lose the ability to move around and shift accordingly when you are uncomfortable, so oftentimes, your skin may develop pressure sores that can be life-threatening.)
Here's a picture that shows the different stages.
need to evaluate if it's better care to be in a seated position, versus a side-lying position in bed.Constipation is a problem for many people with neuromuscular-related paralysis. Anything that changes the speed with which foods move through the large intestine interferes with the absorption of water and causes problems. There are several types of laxatives that help with constipation. Laxatives such as Metamucil supply the fiber necessary to add bulk, which holds water and makes it easier to move stool through the bowels. Stool softeners, such as Colace, also keep the water content of the stool higher, which keeps it softer and thus easier to move. Stimulants such as bisacodyl increase the muscle contractions (peristalsis) of the bowel, which moves the stool along. Frequent use of stimulants can actually aggravate constipation – the bowels become dependent on them for even normal peristalsis.
Now on to Autonomic Dysreflexia. It is an abnormal, overreaction of the involuntary (autonomic) nervous system to stimulation. This reaction may include:
