19. Sexuality in SCI

A systematic approach is recommended for addressing sexual activity, sexual function and reproductive issues as part of an annual examination.

The Problem

A variety of disruptions to sexuality, sexual functioning and fertility may occur after spinal cord injury (SCI), particularly for those with complete lesions affecting S3-5. Issues for men typically include: erectile dysfunction, ejaculatory dysfunction and potential for biological fatherhood. Issues for women typically include: birth control, urinary and yeast infections, vaginal lubrication, menstrual irregularities, fertility, pregnancy & delivery, and menopause. The majority of individuals with SCI report that sexual function is important to quality of life, and have had at least one sexual relationship post-injury.

Evidence-based Best Practice

Family physicians and nurse practitioners should be prepared to have candid, non-judgemental preliminary discussions with their patients with SCI about issues and expectations regarding sexual functioning and reproduction. A structured format should include: interviewing re: sexual concerns, sexual history, physical and neurological exam, education re: sexual and reproductive potential, self-exploration and practice using a variety of tools and techniques. Sparing of the T11-12 dermatome is particularly salient for the potential for psychogenic arousal and orgasm. Primary care providers may wish to refer to a rehabilitation specialist for expert information on sexual and reproductive options. Numerous options are available for sexual expression and fertility for both sexes.

There is evidence in favour of safety and effectiveness of Phosphodiesterase-5 inhibitors (PDE5i; eg., sildenafil, viagra) for sexual dysfunction in men with SCI, with minor side effects (headache, UTI) in 10 – 15% of users.

Pregnancy in women with SCI should be closely monitored for complications such as: weight gain and implications for skin lesions and transfers, autonomic dysreflexia, urological complications, postural hypotension.

Screening for cancers of sexual and reproductive organs should follow standard guidelines, but has been shown to be significantly below guideline levels in the SCI population.

There is also increased risk for sexual abuse of patients with SCI, especially those who are dependent upon others (such as attendants or family members) for personal care.

Key Reference

Courtois, F. & Charvier, K. (2015). Sexual dysfunction in patients with spinal cord lesions. Handbook of Clinical Neurology, 130, 225-45.

Alexander, M. S., Aisen, C. M., Alexander, S. M., & Aisen, M. L. (2017). Sexual concerns after spinal cord injury: An update on management.Neurorehabilitation, 41(2), 343-357. doi:10.3233/NRE-172202

Actionable Nuggets (4th ed., 2019)

Additional References (since 2016)

Aikman, K., Oliffe, J. L., Kelly, M. T., & McCuaig, F. (2018). Sexual health in men with traumatic spinal cord injuries: A review and recommendations for primary health-care providers.American Journal of Men’s Health, 12(6), 2044-2054. doi:10.1177/1557988318790883

Alexander, M., Courtois, F., Elliott, S., & Tepper, M. (2017). Improving sexual satisfaction in persons with spinal cord injuries: Collective wisdom.Topics in Spinal Cord Injury Rehabilitation, 23(1), 57-70. doi:10.1310/sci2301-57

Courtois, F., Gérard, M., Charvier, K., Vodušek, D. B., & Amarenco, G. (2017;2018;). Assessment of sexual function in women with neurological disorders: A review.Annals of Physical and Rehabilitation Medicine, 61(4), 235-244. doi:10.1016/j.rehab.2017.04.004

Ohl, D. A., Carlsson, M., Stecher, V. J., & Rippon, G. A. (2017). Efficacy and safety of sildenafil in men with sexual dysfunction and spinal cord injury.Sexual Medicine Reviews, 5(4), 521.

Shridharani, A. N., & Brant, W. O. (2016). The treatment of erectile dysfunction in patients with neurogenic disease. Translational andrology and urology5(1), 88.

Sinha, V., Elliott, S., Ibrahim, E., Lynne, C. M., & Brackett, N. L. (2017). Reproductive health of men with spinal cord injury.Topics in Spinal Cord Injury Rehabilitation, 23(1), 31-41. doi:10.1310/sci2301-31