8- Sexual Dysfunction

Question 1

What test(s) would like to preform to check for erection (male) or lubrication (female)? (2)

Answer 1

If patient have higher SCI (lost mental stimuli) → check for sacral reflex preservation

1. Bulbocavernosus reflex
2. S4-S5 dermatome

Braddom

Question 2

Erection pathway. 🔑🔑
OSCE Q: Will this patient “ASIA A C6” have erection?

Answer 2

Answer

Yes he will have intact reflexogenic erection, but impaired psychogenic erection

Psychogenic Erection

• Sympathetic, Hypogastric nerve (T10-L2)
• Activated from the brain (erotic mental stimuli)
• Absent in complete lesions above T10 “UMN”

Reflexogenic Erections

• Parasymathetic (S2-4)
  
  • Afferent: Pudendal nerve.
  • Efferent: Pelvic nerve
• Reflex arc secondary to manual stimulation of the genital region
• Work independently of conscious awareness and supraspinal input
• Absent in complete lesions at S2-S4

Injuries at T10 and above

• Lose the ability to get an erection from sexual thoughts (a psychogenic erection).
• Able to get an erection through touch (a reflex erection).
• Sometimes reflex erections may happen in non-sexual situations (i.e. inserting a catheter).
• Women may lose the ability to become aroused from sexual thoughts (psychogenic arousal), but may still be able to experience arousal from touch (reflex arousal).

Injuries from L3 to S1

• May be able to have both psychogenic and reflex erections
• Although these responses may be poorly coordinated during sex
• Women may retain both psychogenic and reflex arousal.

Injuries from S2 to S4

• Able to have psychogenic erections.
• Lose the ability to have reflex erections
• Women lose reflex arousal, but may still have psychogenic arousal.

Cuccurollo 4th Edition Chapter 7 SCI pg578

https://community.scireproject.com/wp-content/uploads/SCIRE-C.-Sexual-Health.-3-Download.pdf

Question 3

List 4 method for managing erectile dysfunction 🔑🔑 OSCE & EXAM

Answer 3

MANUAL & DEVICES

1. Penile vacuum devices
2. Penile ring devices
3. Behavioural methods (perineal muscle training).

PHARMA

1. Oral pharmacotherapy with phosphodiesterases type 5 inhibitors – sildenafil (1st line)
2. Intracorporeal injections with prostaglandin E1, alpha-blockers, or vasodilators
3. Topical agents (prostaglandin, nitroglycerine, minoxidil, papaverine)

SURGICAL

1. Penile implants
2. Surgical penile implants

Cuccurollo 4th Edition Chapter 7 SCI pg578

Braddom 6th Edition Chapter 49 SCI Sexuality and Fertility pg1087

https://scireproject.com/evidence/sexual-and-reproductive-health/sexual-and-reproductive-health-in-men/male-erectile-response-and-enhancement/

Question 4

What is the dosing for sildenafil (viagra)? 🔑🔑

Answer 4

Starting dose 25 mg PO, Maximum dose 100 mg per day.

Give 0.5-4 hours prior to intercourse.

https://reference.medscape.com/drug/revatio-viagra-sildenafil-342834

Question 5

List 3 potential side effects of PDE-5 inhibitors (eg. Sildenafil, tadalafil). 🔑

Answer 5

1. Headache (8-15%)
2. Flushing (3-14%)
3. Visual disturbances (e.g. nonarteritic anterior ischemic optic neuropathy)
4. Dyspepsia
5. Nasal congestion
6. Dizziness
7. Back pain (infrequent)
8. UTI
9. Postural hypotension (at risk in studies of tetra or high-level para)

Ref: SCIRE - sexual health p9

Question 6

Ejaculation pathway 🔑🔑

Will i have normal ejaculation after SCI? 🔑🔑 (OSCE Q)

Answer 6

💡 Achieving ejaculation does not ensure successful reproduction, as sperm quality and motility are affected in SCI. An evaluation from a reproductive specialist may be needed.

Ejaculation Pathway

• Sympathetic nervous system
• Hypogastric plexus (T11–L2) similer to bladder

Ejaculation after SCI

• Inability to ejaculate during sex
• Unpredictable ejaculation
• Retrograde ejaculation: semen is propelled into the bladder during ejaculation because the bladder neck muscles do not close at the right time (injuries from T11 to L3)
• Trigger autonomic dysreflexia (injuries above T6)

Cuccurollo 4th Edition Chapter 7 SCI pg577

https://community.scireproject.com/wp-content/uploads/SCIRE-C.-Sexual-Health.-3-Download.pdf

Question 7

List 4 method for managing ejaculation dysfunction 🔑🔑

Answer 7

1. Manual or partner masturbation
2. Penile vibratory stimulation (PVS)
3. Electroejaculation
4. Prostate massage
5. Surgical sperm removal

Cuccurollo 4th Edition Chapter 7 SCI pg578 Braddom 6th Edition Chapter 49 SCI Sexuality and Fertility pg1087

Question 8

List 4 causes of poor semen quality in SCI. 4 marks. 🔑

Answer 8

1. Changes in hypothalamic–pituitary–testicular axis
2. Type of bladder management
3. Recurrent UTIs
4. Postinfective changes (testicular atrophy, epididymal duct obstruction)
5. Stasis of prostatic fluid (Decreases sperm motility)
6. Reduced total sperm count, sperm velocity, and total motile sperm
7. Testicular hyperthermia
8. Abnormal testicular histology
9. Long-term use of various medications

Cuccurollo 4th Edition Chapter 7 SCI pg579

Question 9

List 3 methods available for a couple to have a child if the father has a SCI.🔑

Answer 9

1. intravaginal insemination.
2. intrauterine insemination.
3. in vitro fertilization (IVF).
4. IVF plus intracytoplasmic sperm injection (ICSI).

Ref: http://www.scireproject.com/case-studies/case-5-mr-c-m/sexual-health/fertility-in-men

Question 10

How does SCI affect period & fertility? 🔑🔑 OSCE Dr. Haitham

Answer 10

• Immediately following SCI, amenorrhea occurs in 85% of women with cervical and high thoracic injuries and 50% to 60% of women overall.
• However, 50% and 90%, respectively, have return of menstruation within 6 to 12 months after injury.
• SCI does not affect female fertility once menses return

Cuccurollo 4th Edition Chapter 7 SCI pg580

Question 11

Advice for Birth Control in SCI 🔑🔑 (OSCE Q)

Answer 11

1. Condoms
2. Oral contraceptives
3. Intrauterine device (IUD)—can increase risk of pelvic inflammatory disease (PID), which can cause autonomic dysreflexia (AD)

Cuccurollo 4th Edition Chapter 7 SCI pg580

Question 12

Pregnant women with SCI, what challenges she might face? 🔑🔑 OSCE Dr. Haitham

Answer 12

Pregnancy

• Increased risk for preterm labour → Regular & close follow up
• Uterine innervation arises from T10–T12 level.
• Patients with lesions above T10 may not be able to perceive uterine contractions.

1st Trimester (Reflex)

• Autonomic dysreflexia (AD)
• Bowel management: water, fibers, medications
• Bladder management: CIC more frequent or Foly’s
• Urinary tract infection

2nd Trimester (Weight Gain)

• ADLs and Transfer → Wheelchair adjustment +/- Power
• Skin care & pressure relief
• Muscle spasms “spasticity”

3rd Trimester (Bed Bound)

• Dyspnea → Breathing exercises
• Thromboembolism: DVT & PE → Clexane, range-of-motion exercises, compression

https://www.archives-pmr.org/article/S0003-9993(15)01322-2/pdf

Question 13

Advice for labor in SCI 🔑🔑 OSCE Dr. Haitham

Answer 13

Women with SCI may also have many common signs of labor:

• Breathing easier
• Feelings of fear and worry
• Unusually strong, regular contractions
• Pressure in the pelvis
• Tightening in your abdomen
• Water breaks or mucus leakage
• Diarrhea

Risks

1. Slightly increased incidence of preterm labor
2. Small birth weight infants

Advice

• Voluntary hospital admission could be offered after 36 weeks for close monitoring

During labor

• Risk of AD is 85% to 90% of patients with lesions at T6 and above
• Treated by epidural anesthesia extending to T10 level
• If AD is refractory to epidural and regional anesthesia, urgent cesarean or operative vaginal delivery may be necessary

https://www.archives-pmr.org/article/S0003-9993(15)01322-2/pdf

Question 14

List 4 Advices to prevent DVT in pregnant SCI.🔑🔑 OSCE Dr. Haitham

Answer 14

1. Range of motion (ROM) exercises and changes in positioning to improve blood flow
2. Elevate lower limbs
3. Use sequential compression devices, or wear gradient elastic compression stockings
4. Low-molecular-weight heparin (LMWH) does not cross the placenta, is compatible with breastfeeding, and can be resumed hours after delivery

Cuccurollo 4th Edition Chapter 7 SCI pg581