K. Charvier

Perceived Physiological and Orgasmic Sensations at Ejaculation in Spinal Cord Injured Men

INTRODUCTION With the advances in penile vibrator stimulation (PVS), most spinal cord injured (SCI) men can self-ejaculate. Oral midodrine may further increase ejaculation success, while maintaining autonomy. Since most SCI men attempt ejaculation for sexual rather than reproductive purposes, self-ejaculation should be emphasized and sensations explored. AIMS Explore (i) self-ejaculation success rate in SCI men; (ii) vascular parameters indicative of autonomic dysreflexia (AD) during sexual stimulation and ejaculation; and (iii) sensations associated with ejaculation. METHODS Ejaculation was assessed on 81 SCI men with complete ASIA A (49%) and incomplete B to D lesions (51%), subdivided into tetraplegics (C2-T2), paraplegics sensitive to AD (T3-T6), paraplegics not sensitive to AD (T7-T10), paraplegics with lesions to the emission pathway (T11-L2), and paraplegics with lesions interrupting the emission-ejaculation pathways (L3-below). Natural stimulation was attempted first followed, if negative, by PVS followed, if again negative, by PVS combined with oral midodrine (5-25 mg). MAIN OUTCOME MEASURES Ejaculation success, systolic and diastolic blood pressure, and perceived physiological and orgasmic sensations. RESULTS Overall 91% reached ejaculation, 30% with natural stimulation, 49% with PVS and 12% with midodrine plus PVS. Midodrine salvaged up to 27% depending upon the lesion. Physiological and orgasmic sensations were perceived significantly more at ejaculation than sexual stimulation. Tetraplegics did not differ from paraplegics sensitive to AD on perceived cardiovascular and muscular sensations, but perceived significantly more autonomic sensations, and generally more physiological sensations than lower lesions unsensitive to AD. CONCLUSION Most SCI men can self-ejaculate and perceive physiological and orgasmic sensations. The climactic experience of ejaculation seems related to AD, few sensations being reported when AD is not reached, pleasurable climactic sensations being reported when mild to moderate AD is reached, and unpleasant or painful sensations reported with severe AD. Sexual rehabilitation should emphasize self-ejaculation and self-exploration and consider cognitive reframing to maximize sexual perceptions.

Sexual function in spinal cord injury men. I. Assessing sexual capability

Precise diagnoses are seldom made upon complaints of sexual dysfunction by spinal cord injured men. The dysfunction is inevitably attributed to the neurological condition and available treatments are offered with little knowledge of the individual residual capacity or other contributing factors. Current practice emphasizes these treatment approaches, but the high rejection rate associated with the most widely used technique of intracavernous injections suggests that remaining sexual function should also be investigated. This study explores remaining function using physiological recording techniques and classifying the subjects according to the innervation of the reproductive system. The results show that, with objective measurements and proper classification of the subjects, 100% of individuals with high lesions maintain penile responses to reflexogenic stimulation and up to 90% of those with lower lesions maintain penile responses to psychogenic stimulation. These latter subjects also show naturally occurring emissions in 100% of the cases when they suffer from lesions to the conus terminalis and when they use psychogenic stimulation as a means of inducing erection and emission. Results from subjective reports reveal that spinal cord injured men underestimate their sexual capacity, while diagnoses based on clinical findings are better predictors.

Blood pressure changes during sexual stimulation, ejaculation and midodrine treatment in men with spinal cord injury

Associate Editor

Posttraumatic erectile potential of spinal cord injured men: How physiologic recordings supplement subjective reports

OBJECTIVE To investigate by means of a neurophysiologic model the remaining erectile function in spinal cord injured men. DESIGN A nonrandomized control trial. SETTING A Referred Care Center. SUBJECTS Forty-seven spinal cord injured men and 7 noninjured controls. INTERVENTION The subject penile responses were recorded by a penile strain gauge during two sessions--one to obtain baseline responses, and one with reflexogenic stimulation (masturbation) and psychogenic stimulation (film). MEASURES Average tumescence, maximal tumescence, percentage rigidity, and duration of tumescence and rigidity. RESULTS Significant results were found for subjects with lower lesions using psychogenic stimulation as their optimal mode compared with reflexogenic stimulation as an alternate mode, and for subjects with higher lesions using reflexogenic stimulation as their optimal mode, compared with psychogenic stimulation as an alternate mode. The responses with optimal stimulation modes were comparable to those achieved by controls. CONCLUSION The findings validate the neurophysiologic model of posttraumatic erectile potential as a function of the lesion type and stimulation source. The results were comparable to those of noninjured subjects; the potential for normal function is present and may be amenable to sexual rehabilitation or use in conjunction with new oral drug treatments for impotence.

Assessing and conceptualizing orgasm after a spinal cord injury

Study Type – Aetiology (individual cohort)

The Control of Male Sexual Responses

Male sexual responses are reflexes mediated by the spinal cord and modulated by neural circuitries involving both the peripheral and central nervous system. While the brain interact with the reflexes to allow perception of sexual sensations and to exert excitatory or inhibitory influences, penile reflexes can occur despite complete transections of the spinal cord, as demonstrated by the reviewed animal studies on spinalization and human studies on spinal cord injury. Neurophysiological and neuropharmacological substrates of the male sexual responses will be discussed in this review, starting with the spinal mediation of erection and its underlying mechanism with nitric oxide (NO), followed by the description of the ejaculation process, its neural mediation and its coordination by the spinal generator of ejaculation (SGE), followed by the occurrence of climax as a multisegmental sympathetic reflex discharge. Brain modulation of these reflexes will be discussed through neurophysiological evidence involving structures such as the medial preoptic area of hypothalamus (MPOA), the paraventricular nucleus (PVN), the periaqueductal gray (PAG), and the nucleus para-gigantocellularis (nPGI), and through neuropharmacological evidence involving neurotransmitters such as serotonin (5-HT), dopamine and oxytocin. The pharmacological developments based on these mechanisms to treat male sexual dysfunctions will complete this review, including phosphodiesterase (PDE-5) inhibitors and intracavernous injections (ICI) for the treatment of erectile dysfunctions (ED), selective serotonin reuptake inhibitor (SSRI) for the treatment of premature ejaculation, and cholinesterase inhibitors as well as alpha adrenergic drugs for the treatment of anejaculation and retrograde ejaculation. Evidence from spinal cord injured studies will be highlighted upon each step.

Clinical approach to erectile dysfunction in spinal cord injured men. A review of clinical and experimental data.

Despite the many developments in the area of sexual dysfunction, rehabilitation settings seldom investigate the remaining sexual function following spinal cord injury, or offer differential diagnoses of sexual dysfunction in spinal cord injured men. This article attempts to show how sexual rehabilitation should begin with a thorough assessment of the sexual function of paraplegic and tetraplegic men. Assessment includes a basic neurological examination of the perineal area and an extended clinical interview on sexual function and visceral function. The interpretation of patient evaluation is discussed in terms of a classification system adapted to sexual purposes and in terms of the differential diagnoses between sexual dysfunctions of organic, and those of predominantly psychogenic origin in the spinal cord injured patient. The organic or psychogenic contribution is discussed in terms of sophisticated procedures, where assessment of nocturnal penile tumescence (NPT) is critically evaluated and where alternatives such as urodynamic findings and skin potentials are discussed. Treatment strategies, such as intracavernous injections and cognitive-behavioural strategies adapted to different lesion types, are discussed.

Sympathetic skin responses and psychogenic erections in spinal cord injured men

Sympathetic skin responses (SSR) are a simple procedure to investigate sympathetic activity. More specifically, SSR elicited from median nerve stimulation and recorded from the feet and genitals assess sympathetic activity resulting from thoracic-lumbar (TL) innervation. Since TL innervation is also involved in the mediation of psychogenic erection in spinal cord injured men, this study investigated the relationship between SSR and psychogenic erection in spinal cord injured subjects. The results support a general association between SSR and psychogenic erection and show that subjects who maintain SSR responses in the feet and genitals generally maintain psychogenic erections as well. Inconsistent cases are discussed from a theoretical and clinical perspective and overall results are discussed in terms of their clinical application in the evaluation of sexual function in spinal cord injured men.

Sexual Rehabilitation for Men with Spinal Cord Injury: Preliminary Report on a Behavioral Strategy

Training of the perineal muscles was attempted in our centers on the basis of our previous findings indicating that when the appropriate source of stimulation is used, subjects exhibit peaks of activity suggesting a rehabilitation potential. Muscular training was considered because pressure stimulation of the glans penis triggers contractions of perineal muscles which propel the blood throughout the penis to ensure optimal tumescence. The technique was combined with biofeedback and home exercises and was tested on 10 patients initially presenting erectile difficulty but maintaining perineal innervation. The results showed significant improvements in average and maximal tumescence and maintenance of these improvements. The results are discussed in terms of their clinical application to a cognitive-behavioral approach to sexual dysfunction in spinal cord-injured men.

Using Sympathetic Skin Responses in Individuals With Spinal Cord Injury as a Quantitative Evaluation of Motor Imagery Abilities

Background Motor imagery (MI) ability should be evaluated in selected individuals with spinal cord injury (SCI) who can benefit from MI training in their rehabilitation program. Electrodermal activity seems to be a reliable indicator for assessing MI ability. However, individuals with SCI have a variety of autonomic dysfunctions. Objective This study aimed to investigate electrodermal responses (EDRs) elicited by MI. Design A cost-utility analysis of EDR above and below the lesion level in individuals with complete or incomplete SCI (n=30) versus a control group of individuals who were healthy (n=10) was used. Method The EDR was recorded above and below the lesion level during MI of a drinking action. Duration, latency, and amplitude of EDR were the outcome measures. Results Hand and foot EDR in the control group occurred with the same pattern and similar latencies, suggesting a common efferent sympathetic pathway to sweat glands of the hand and foot mediating a sympathetic skin response. Individuals with SCI elicited responses above the lesion level. The EDR amplitude was correlated to the lesion level and autonomic dysreflexia history. No foot response was recorded in individuals with complete cervical and thoracic motor lesions. Foot response with a lower amplitude and higher latency occurred in participants with incomplete motor lesion, suggesting a link between the descending motor pathway and sympathetic function. Limitations The small sample of individuals with incomplete SCI limits the generalization of the results obtained at the foot site. Conclusions Electrodermal response above the lesion level may be a reliable index for assessing MI ability in individuals with SCI. It is a noninvasive, user-friendly method for clinicians to consider before enrolling individuals in MI training.