Sexuality and Spinal Cord Injury

Sexuality is an essential part of all of us no matter what our age, gender, health and physical ability may be. A spinal cord injury (SCI) does not decrease a person’s sexuality and rarely does it destroy his or her interest in being sexual. Sexuality includes many areas of our lives. This section will try to answer some of the common concerns and questions that men and women have after an SCI.

 

 

 

Yes, but it will likely be different from what it was before. An SCI can change how you express your sexuality and how you act on it. For many people, the change or lack of feeling in the penis or vaginal area is a loss. This doesn’t mean you’ve lost the ability to be sexual and experience sexual pleasure. With time and practice you will discover new ways of giving and receiving pleasure.

 

 

 

Feeling sexy has a lot to do with how you feel about yourself. Feeling good about yourself will help you to start feeling sexy again. You have gone through a lot of physical and emotional changes. It takes time to get used to these changes and to start being comfortable with who you are now.

 

 

 

Many people are not interested in sex right away. This could be due to pain, fatigue, medication or feeling down. It may be helpful to talk with someone if you are worried about this.

 

 

 

Some people think about sex the first day they are injured. Others may wait months or years to experiment. Everyone is different. Being and feeling sexual again can take time.

 

 

 

Fear is normal when things change or are different from before. People may be afraid their partner will leave them, they may be afraid of a bowel or bladder accident, or they may be afraid that no one will want them as a sexual partner. If fear is stopping you from being sexual, it might help to talk to someone about your feelings.

 

 

 

There are no rules about how your body may change after an SCI. Generally, if you have changes to bowel and bladder control or sensation you will probably notice changes to genital sexual response. These changes will be different for every person and depend on many things including level of injury, whether their injury is complete or incomplete and medications. 

 

 

 

There are two different ways that men can get erections: one, from thinking about something sexual and two, through touch on the penis. 

 

Erections from thinking about something sexual (mental erections) occur when messages are sent from the brain to the spinal nerves that leave the spine around T9 to T12.

 

Blood flows into the penis and the erection occurs. Often mental erections cause some enlargement of the penis but the firmness may not be sufficient for intercourse.

 

Erections from touching the penis (reflex erections) occur when there is physical contact with the penis. The touch can be sexual or non-sexual, for example, touch from washing or from getting a catheter. In this case, messages from the nerves on the penis are sent to the lower end of the spinal cord (S2 to S4) and immediately returned to the penis. Again, blood flows into the penis creating an erection.

 

Men who have an SCI in the lower part of their spine (below T10) will likely not have reflex (or touch) erections but will likely have mental erections. Often, mental erections are either not quite firm enough or don’t last long enough for intercourse to occur. Using some method of erection enhancement will help with this problem.

 

Men who have an SCI in the upper part of their spine (above T10) will likely not have mental erections but will likely have reflex erections. After SCI, this reflex functions independently from the brain and is not completely predictable. Because of this, some men may feel uncomfortable if they get a reflex erection in a non-sexual situation. In addition, some men may find that their reflex erection does not last long enough for sexual intercourse. Again, using some form of erection enhancement will help with this situation.

 

How your erection works after your SCI depends on many things, such as your level and completeness of injury and the medications you are on. It may be helpful for you to meet with a sexual health clinician at the Glenrose Rehabilitation Hospital or Foothills Medical Centre to discuss your specific situation.

 

 

 

Many men after an SCI say that they have difficulty getting and/or maintaining an erection they are satisfied with. There are several options available that can help with these concerns.

 

 

Constrictor Bands: This is a wide elastic band designed to be placed at the base of the penis once an erection occurs. The band helps to maintain the erection by stopping the blood from flowing out of the penis. The skin of the penis may become cool and discoloured while the band is on but it will return to normal once the band is removed. It is very important the band is not kept on for more than 30 minutes, otherwise you may be at risk for skin and tissue damage. This method is most useful for men who are able to get an erection but have difficulty maintaining it.

 

 

Vacuum Devices: Vacuum devices work by placing a cylinder with an attached pump over the penis.  The pump works to create a suction causing blood to flow into the penis.  A constrictor band is then applied to help maintain the erection.

 

 

Intraurethral Medications: This method is a relatively new technology and involves the insertion of a very small suppository (via an applicator) into the urethra. The medication (Prostaglandin E1) is absorbed into the spongy tissue of the penis causing the blood vessels to open and the penis to become erect.

 

 

Intracavernosal Injections: A tiny needle is used to inject a small amount of medication directly into the spongy tissue on either side of the penis. The medication (usually Prostaglandin E1, but there are other medications available) works by causing the blood vessels to open and blood to fill the penis. This technique can be taught to your partner if hand function is a concern.

 

 

Oral Medications: There are several oral medications being explored to help with erection. Viagra is the first oral medication to be available by prescription. Others currently on the market are Levitra and Cialis. They work by enhancing the erection you have and appear to be helpful for men with an SCI.

 

 

Surgical Options: While there are surgical options available they are not commonly chosen as they require an invasive procedure which may put men with an SCI at risk for skin breakdown.  In addition, most men find that one of the methods discussed above works to meet their specific needs.

 

 

 

Discussing the topic of sex can be difficult, however, there are ways of making this task easier. Being open and honest with your partner about the changes to being sexual is important. You may need to start the discussion about sexuality with a new partner in order to raise the issue and answer some of their questions about sex. One way to do this is finding a non-sexual time to talk about some of the changes to sexuality without the pressures of being sexual. This will provide a more neutral environment and will help to make the conversation easier. 

 

You may also find it useful to practice what you want to say with a friend, a sexual health clinician, or in front of a mirror. This may help you feel more comfortable talking about sex when the time comes. If you are already in a relationship, it may be useful for you and your partner to see a sexual health clinician to discuss some of the changes to sexuality together.  The sexual health clinician can provide ways to manage some of these changes as well as answer some of your specific questions.

 

 

 

Sex will probably be different than before, but it can be as pleasurable. Your enjoyment of sex will be increased if you and your partner take some time and learn how your body has changed. This may involve talking with your partner, trying new things and planning for sex.

 

 

 

This is a time for trying new things. Take time to learn over again what feels good. You may find it helps to touch yourself, masturbate or have a partner do this for you. You can use your fingers, hands, arms, nose, lips, tongue, ears or hair to bring pleasure to yourself and your partner. Splints that you use to dress or eat with may also help with touching.  Some people try warming gels for massage, body paints or a vibrator to give pleasure to each other. Others may use mirrors, movies and books to stimulate themselves and their partners. Remember your brain is your biggest sex organ and the sensation and messages in your head are very real and can give you real pleasure.

 

 

 

Having sex now means that a little more  planning needs to take place. This may feel awkward and uncomfortable at first, but many people tell us that it starts to become something they look forward to. If you really think about it, we plan for everything else in our lives that is important, why not sex? This planning may involve setting aside time to be with your partner and planning sex around bowel and bladder schedules. 

 

 

 

 

Many men with complete and incomplete spinal cord injuries have questions and concerns about having children. 

 

There are two main areas affecting fertility after an SCI: changes in the ability to ejaculate semen and changes to the quality of the semen. Methods available to obtain sperm and advanced reproductive technologies such as in-vitro fertilization (IVF), have made it possible for many men with an SCI and their partners to become pregnant.

 

 

 

Ejaculation is controlled by a complex interaction of spinal nerves. Just as spinal cord injury affects the nerves involved with bowel, bladder and erectile function, it can also interfere with a man’s ability to ejaculate. Commonly, after an SCI, men experience an absence of ejaculation. There are a number of ways to obtain sperm that can be used to overcome this challenge to fertility. Vibrostimulation and electroejaculation are most commonly used. If there are only minor changes to ejaculation, other ways of obtaining sperm are self-stimulation and stimulation with a partner.

 

 

 

Vibrostimulation involves the placement of a vibrator on the glans (or head) of the penis.  Oftentimes stronger stimulation to the damaged nerves is needed for ejaculation to happen, so a special vibrator is used. The ejaculation usually occurs without an orgasmic sensation and an erection may or may not be present.

 

Since there is the risk for autonomic dysreflexia, the technique should first be taught by a qualified professional and tried in a medical setting where blood pressure can be monitored. If there is an increase in the blood pressure, a medication can be given to help prevent this for future attempts. Vibrostimulation seems to work best with men whose injury is complete and higher than T10.  

 

Many couples can learn to do this technique safely at home in order to get semen that can then be placed into the partner (intravaginal insemination) to attempt pregnancy. Couples may also try intrauterine insemination where, in a clinical setting, sperm is processed at a specialized lab and then put directly into the uterus using a special catheter.

 

Electroejaculation involves the use of a probe placed close to the prostate gland.  A mild electrical current is used to directly stimulate the nerves and the ejaculate is manually pushed out along the urethra. While this technique is more intrusive and requires a medical setting, it is usually successful regardless of level or completeness of injury. 

 

Men who have any genital feeling require some form of an anesthesia for this procedure.  Sperm obtained from this method is usually used for intrauterine insemination.

 

 

 

Men with an SCI tend to have changes to semen quality. Semen quality can be determined through a basic semen analysis which looks at the numbers and motility characteristics of the sperm.

 

Typically after an SCI, men have high numbers of sperm, however, the number of sperm that are moving is low. This can cause problems for men and their partners who are trying to conceive. There is no definitive reason why these changes occur, however, higher temperature of the testicles, frequent urinary tract infections, and decreased frequency of ejaculation causing changes in the seminal fluid are some possible causes.  To improve the chances of being fertile, it is suggested that men do not smoke cigarettes or marijuana, and keep themselves, especially their bladders, healthy. Certain vitamins may be recommended as well. 

 

 

 

There has been progress made in the area of male infertility which can help make up for changes to semen quality. Special laboratory techniques can be used to prepare the semen sample which can then be used for intrauterine insemination. Fertility medications along with close monitoring of the female partner’s monthly cycle can also help the chances for conception.  In addition, techniques known as in-vitro fertilization (IVF) and intracytoplasmic sperm injection (ICSI) have allowed men with very low sperm counts and/or motility to become biological parents.  Adoption and therapeutic donor insemination (TDI) are also options.  

 

 

 

 

While a man’s ability to reproduce depends on spinal nerves, a woman’s reproductive abilities are mainly controlled by hormones. Therefore, while it is common that women stop menstruating for several months after their accident, their reproductive ability does not change.

 

 

Women with a spinal cord injury who wish to get pregnant have several important things to consider. While their ability to get pregnant has not changed, their SCI may affect their health and lifestyle during pregnancy. Some of the areas to consider are:
 

• Transfers and Dressing: Women typically gain 25 to 35 pounds during pregnancy. This added weight can make dressing, bathing and transfers more difficult. In addition, this added weight may affect balance. Some women find that they need more assistance, especially during the third trimester.
 

• Lung Capacity: As pregnancy progresses, the growing fetus may put extra pressure on the diaphragm. This added stress may make breathing more difficult.  Many women find relief by frequently changing their position.
 

• Bowel and Bladder: Increased pressure from the fetus may change bowel and bladder function. For example, women may experience increased frequency of urinary tract infections and may tend to be constipated during pregnancy. Your doctor or nurse may be able to give you suggestions to help you manage these changes. 
 

• Skin Concerns: Additional weight may increase your risk of pressure sores.  Maintaining skin integrity may require special attention during pregnancy. Some women will ask a friend or partner to help them check their skin if this becomes an awkward task.

 

• Medications:  Many prescribed medications (depending on the type of drug and if it crosses the placenta to the baby’s circulatory system) and all recreational drugs can be harmful to an unborn baby. For this reason, you may wish to speak with your doctor about any drugs you are taking to determine which are safe during pregnancy.

 

 

 

A vaginal delivery is certainly possible for women with an SCI. In fact, caesarean sections should only be done for obstetrical problems or for uncontrolled autonomic dysreflexia. Women with injuries at T10 and above may not be aware of labour pains, but may feel the start of labour through signs such as abdominal or leg spasms, abdominal or back pain, autonomic dysreflexia vaginal bleeding or “waters breaking.” 

Although the risk of pre-term labour and delivery is small, it is a good idea for women with decreased uterine sensation to talk with their doctor about how to monitor for pre-term labour. 

 

 

 

Positioning your baby to breast-feed may require some planning and assistance depending on your balance and on the amount of arm and hand control that you have. If the level of SCI is T6 or above, milk production may decrease following the first six weeks related to lack of nipple sensation. In these women, nipple stimulation is necessary for continued lactation.

 

Whether you choose to breast-feed or bottle feed, your baby can still receive the nutritional and emotional requirements he or she needs. Finding a method that suits you and your baby the best is the important thing.

Pregnancy and parenting after an SCI is possible. Finding the support and information you need will help ensure that your pregnancy is safe and rewarding. It is important to find a doctor who has experience with SCI and is able to watch you closely during the entire pregnancy. 

 

Making a list of all of your questions and concerns and talking about them with your doctor will help you make decisions that meet your needs and lifestyle. 

 

There are other resources available to assist you during and after pregnancy. For example, for help with specialized adaptive equipment and/or rehabilitation support call the Canadian Paraplegic Association, Sexual Health Service or your occupational therapist

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There are a number of contraceptive options available for men and women. Which one is best for you depends on such things as hand function and physical ability, amount of sensation, blood clotting risks, personal values and partner situation. Currently available birth control methods are:
 

• barrier methods

• male or female condom (should be used with a spermicide to increase effectiveness)

• diaphragm or cervical cap (must be used with a spermicidal jelly)

• Lea contraceptive (a shallow silicone cup) (must be used with a spermicidal jelly)

• contraceptive sponge (e.g. Protectaid)

• IUD (intrauterine device)

• vaginal spermicides (available in foams, gels, creams, suppositories and in sponges)

• hormonal methods

• birth control pills

• Depo Provera (hormone injection every 12 weeks)

• Norplant (surgical implants)

• emergency contraceptive pill or “Morning After Pill” (taken within 72 hours of having unprotected intercourse).  This is not considered a birth control method.

 

Women who are at risk for blood clots and who wish to use a hormonal method of birth control may wish to consider a progesterone only medication such as
 

• Depo-Provera or Norplant

• sterilization

• vasectomy (male sterilization)

• tubal ligation (female sterilization).

 

Due to the number of birth control methods available, it is important to seek information from your doctor, sexual health clinician and/or planned parenthood clinic and then make a choice based on your individual needs.

 

 

 

Sometimes after an SCI there are changes to a man’s ability to ejaculate and vaginal lubrication in women. However, a decrease or absence of sexual fluids in one partner does not mean transmission of an STI (sexually transmitted infection) cannot take place.

STI’s can be passed from woman to man and vice versa, as well as from man to man or woman to woman. If a person is infected, he or she can pass the STI through body fluids or sometimes through direct contact with infected skin (e.g., herpes and genital warts). 

 

 

 

Most of the above birth control options offer no protection against STI’s. Latex condoms, especially those treated with a spermicide, do help to protect against STI’s if they are used according to directions and if a condom is used every time you have sex, including oral and anal sex. For individuals with latex sensitivities, the female condom and certain male condoms are available in polyurethane. Natural sheep gut condoms are not effective against STI’s.

 

There are ways to give and receive sexual pleasure which do not involve oral, anal or vaginal sex. For example, hugging, kissing, massage, fantasizing and touching offer sexual pleasure as well as protection from STI’s. More information on STI’s is available through your health care provider or Sexual Health Service.

 

 

Summary

Sexuality is an important area for many people after an SCI. This section has tried to look at some of the common sexual health concerns that men and women have after an SCI.

It is important to note that sexuality is a unique and individual experience and talking with a Sexual Health Clinician or a member of your rehab team may help to answer some of your specific questions. Taking the time to explore and understand the changes from your spinal cord injury is an important first step. Remember a spinal cord injury may affect some aspects of how you express sexuality, but it does not mean that the sexual part of your life has to be any less pleasurable or fun.
 

If you have any questions or concerns about sexuality and would like to speak to a Sexual Health Clinician please call Sexual Health Service at the Glenrose Rehabilitation Hospital 735-7999 ext. 2284 (voice mailbox) or request a referral by your team. In Calgary call the Regional Fertility Program located at the Foothills Hospital 

403-284-5444.