The Hard Truth: An Overview of Erectile Dysfunction for Men with Spinal Cord Injuries
Erectile dysfunction (ED) is an important issue to many men after a spinal cord injury (SCI), according to research conducted at Toronto Rehab’s Lyndhurst Centre. However, most men with SCI are reluctant to talk about it and, in the past, received little information about it from their health care team. Here are some basic facts:
- About 1 in 3 men experience ED. Following SCI, the likelihood rises to 50% to 95%.
- Many men with SCI still have some erectile function, but their erections are often not firm enough, or do not last long enough, for them to engage in sexual intercourse.
- This may affect their relationships, reduce intimacy with partners, lower self-esteem, or cause depression. ED affects the quality of life for men with SCI.
This section of the Spinal Cord Connections website is designed to promote discussion of erectile dysfunction after spinal cord injury. Although there are ways other than intercourse to have a fulfilling sex life, a number of treatments for ED are available if it is a concern for you.
Treatments are briefly defined here, with a description of how they work and a list of some of the potential risks and side effects. Talk to your doctor before you try any of these treatments.
For information on ejaculation and fertility issues, see Sexuality: The Male SCI.
Erectile Dysfunction: What is it?
Erectile dysfunction occurs when not enough blood enters and remains in the penis to sustain an erection for sexual intercourse. For males with SCI, this is caused by the injury to the nervous system.
What happens during a normal erection?
When a man is sexually stimulated, the arteries in the penis relax and widen, allowing an increase in blood flow to the shaft of the penis. As the blood volume increases, small veins contract, restricting blood flow and maintaining the erection.
What happens after a spinal cord injury?
Most men have some erectile function after SCI. Depending on their level of injury and the degree of completeness, they experience one or two types of erections:
- Reflexogenic erections result from direct physical stimulation (touching) or indirect stimulation (full bladder), and normally occur in men with a complete injury above the T12 level of the spinal cord.
- Psychogenic erections result from mental stimulation (fantasies), and normally occur in men with a complete injury at or below the T12 level.
Men with incomplete spinal cord injuries can have both types of erections.
Deciding on treatment
The type of SCI you have influences the degree of erectile dysfunction you experience and which treatments will work best for you. A variety of treatments is now available. These include:
- Viagra
- intracavernous injections
- vacuum erection devices
- urethral suppositories
- penile implants
When choosing a treatment, keep in mind these questions:
- What is the success rate of the treatment?
- Is it safe? Are there any side effects?
- Will I need surgery? Can it be reversed?
- Is it easy to use? Will I be able to make it work?
- Can I afford it? Is it easy to get where I live?
Some side effects occur from improper use of a treatment. Some treatments may not be right for you, depending on the type of SCI you have. Understanding the basic anatomy of the penis will help you understand how each treatment works.
Viagra™
What is it?
Viagra (sildenafil) is a blue tablet that you swallow 30 to 60 minutes before having intercourse. You must take the pill each time before intercourse. For the pill to have the best results, the penis requires physical stimulation along with sexual foreplay or erotic stimulation. If you eat fatty foods or drink alcohol before taking this medication, it may not work as well.
The erection may last up to four hours. Viagra should be taken no more than once a day. The success rate of having an erection with this drug is about 80%.
How does it work?
During sexual stimulation, your body produces a compound that relaxes the muscles of the penis. As the muscles relax, blood enters the penis. Viagra works by holding back an enzyme that causes this compound to break down. This allows the muscles in the penis to stay relaxed—causing the blood to continually flow into the penis and create an erection.
What are some of the potential side effects?
- Abdominal pain or stomach upset
- Changes in your vision—a blue haze
- Low blood pressure
- Facial flushing
- Runny nose
- Headache
Who should not use this treatment?
People who take nitrates (such as nitrospray or the nitro patch) and/or people with unstable heart conditions.
Intracavernous injection
What is it?
Intracavernous injection is a medication that is taken through a needle. The drugs commonly injected are:
- papaverine
- prostaglandin E1
- Caverject (alprostadil)
- Phentolamine
How well each medical works varies from person to person and depends on the type of spinal cord injury you have.
For you to get an erection, you or your partner must inject the medication (with a needle) into the side of the penis 20 minutes before intercourse. The injection must be done before each sexual encounter. The erection lasts two to four hours.
This treatment should be used no more than once a day. The success rate of having an erection with this treatment is about 80%.
How does it work?
The drug used for this treatment causes the blood vessels in the penis to relax. This increases the blood flow to the penis, creating an erection. In the case of the combination drug, papaverine acts as the muscle relaxant and phentolamine causes the arteries in the penis to relax, which together creates an erection.
What are some potential side effects?
- Bruising
- Scarring at the injection site
- Pain at the injection site
- The penis may erect on a slight curve
- Priapism, which is a prolonged erection lasting six hours or more, may occur. This requires immediate medical attention.
Who should not use this treatment?
People with any of the following:
- unstable heart disease
- sickle cell anemia
- low blood pressure
- symptoms of a stroke and/or varicose veins
Vacuum erection device
What is it?
The vacuum erection device—or Rocket—consists of a clear plastic tube, a hand or battery pump and a rubber ring. This treatment for ED may be used many times a day. The erection occurs within minutes of use and lasts for about 30 minutes. The success rate of having an erection with this device is about 50%.
How does it work?
- Place a plastic tube over the entire length of the penis using lots of lubrication to create a tight seal.
- Then use the pump to remove air from the tube, which creates a vacuum that draws blood into the penis.
- Once the penis is erect, push the rubber ring off of the open end of the tube onto the base of the penis. The rubber ring keeps the penis erect after the tube is removed.
- When the rubber ring is removed, the penis goes back to its soft state. You must remove the rubber ring after intercourse.
What are some potential side effects?
- Small purplish spots on the skin
- Mild sweating due to excess fluid
- Abrasions
- A cold penis
- A bent penis
Who should not use this treatment?
People with any of the following:
- sickle cell anemia
- leukemia
- blood clotting problems
Urethral suppository
What is it?
MUSE (Medicated Urethral System of Erection) is a urethral suppository. It is a pellet the size of a grain of rice that you put into the tip of the penis (urethra) 5 to 10 minutes before intercourse. You must use this medication each time before intercourse.
The erection may last up to 60 minutes. This drug should be taken no more than twice a day. The success rate of having an erection with this treatment is about 50%.
How does it work?
- To use MUSE, insert the suppository after urination, using an applicator. The small amount of urine that remains in the penis will allow the pellet to dissolve and pass through the penile tissue to the bloodstream, where it can work.
- The medicated pellet is a gel-form of alprostadil, a synthetic form of a substance found in semen. This compound causes the arteries in the penis to dilate and the muscles to relax.
- This allows blood to rush into the penis and cause an erection.
- Put a rubber ring over the base of the penis to maintain the erection. You must remove the rubber ring after intercourse.
What are some potential side effects?
- Penile pain
- Urethral discomfort
- Bleeding from the urethra
- Low blood pressure
Who should not use this treatment?
People with any of the following:
- abnormal penile anatomy
- blood-related illness or disease
- a known allergy to alprostadil
Penile implant
What is it?
Penile implant requires that a surgeon put a device into the penis through a small cut that is made in the skin between the testicles. Penile implants can be rigid, semi-rigid or inflatable. The surgery is used only as a last resort.
Removal or reimplantation of a second device may reduce the change of further success with other treatments. The success rate of having an erection after the surgery is more than 90%.
How does it work?
- The rigid penile implant is a metal rod that causes the penis to stay erect all the time.
- The semi-rigid implant is a flexible rod that allows the penis to be bent into the desired position for intercourse.
- The inflatable implant is two plastic tubes with a pump and reservoir attachment. The penis becomes erect by squeezing the pump into the scrotum, which transfers fluid from the reservoir to the tubes. This causes the tubes to expand and form an erection. Afterwards, when a valve is opened, the penis deflates to its soft state.
What are some potential side effects?
- The implant may break
- An infection may occur
- The implant may wear away or pierce through the skin
- Recovery after surgery may take up to 3 weeks
Who should not use this treatment?
People with an indwelling catheter in the bladder, or people who have success with other treatments for erectile dysfunction.