Sean M. Ferrell

AN ANALYSIS OF 653 TRIALS OF PENILE VIBRATORY STIMULATION IN MEN WITH SPINAL CORD INJURY

PURPOSE We evaluated ejaculatory response and semen quality in 653 trials of penile vibratory stimulation in 211 men with spinal cord injury, and compared results with low versus high amplitude vibratory stimulation. MATERIALS AND METHODS Low and/or high amplitude penile vibratory stimulation was performed 1 to 27 times in each patient, and antegrade and retrograde specimens of those who ejaculated were analyzed. RESULTS Significantly more patients ejaculated using high (54.5%) versus low (39.9%) amplitude stimulation. Using either amplitude the ejaculatory success rate was highest in men with injuries at C3 to C7, followed by T1 to T5, T6 to T10 and T11 to L3. While high amplitude stimulation increased the ejaculatory success rate in each group, the highest rate occurred in men with injuries at C3 to C7 (65.6%). Ejaculation was reliable, since most men who ejaculated did so during 100% of the trials and within 2 minutes of stimulation onset. Symptoms of autonomic dysreflexia were safely managed with nifedipine. All patients who ejaculated produced antegrade specimens. With the exception of ejaculate volume, which was significantly higher with high versus low amplitude stimulation, semen parameters were similar using both vibrator amplitudes. CONCLUSIONS Ejaculatory success is better while semen quality is similar using high versus low amplitude penile vibratory stimulation in men with spinal cord injury. This method may be considered first line treatment for anejaculation in men with spinal cord injury due to its safety, relative effectiveness, and relatively low investment of time and money.

SPERM MOTILITY FROM THE VAS DEFERENS OF SPINAL CORD INJURED MEN IS HIGHER THAN FROM THE EJACULATE

PURPOSE Recent evidence suggests that the seminal plasma of spinal cord injured men contributes to their distinctive semen profile of normal sperm concentration but low sperm motility and viability. This finding indicates that sperm in these men may be normal before exposure to the seminal and prostatic fluids. To investigate this question we compared vas aspirated to ejaculated sperm in 12 men with spinal cord injury and 14 healthy, age matched controls. MATERIALS AND METHODS Ejaculate was collected by penile vibratory stimulation or electroejaculation in spinal cord injured men and by masturbation in controls. Sperm was aspirated via microsurgery from 1 hemisectioned vas deferens in spinal cord injured men and during routine elective vasectomy in controls. Ejaculated and aspirated specimens were compared. RESULTS In men with spinal cord injury mean vas aspirated sperm motility and viability plus or minus standard error of mean were significantly higher than mean ejaculated sperm motility and viability (54.4% +/- 5.0% and 74.1% +/- 5.3% versus 14.1% +/- 2.6% and 26.1% +/- 4.9%, respectively). In controls mean vas aspirated sperm motility and viability were not significantly different from mean ejaculated sperm motility and viability (77.5% +/- 5.2% and 88.9% +/- 2.5% versus 74.3% +/- 5.2% and 85.0% +/- 3.5%, respectively). CONCLUSIONS In spinal cord injured men sperm motility and viability were significantly higher before contact with seminal fluids. Although aspirated sperm from men with spinal cord injury generally had lower motility and viability than that of controls, implying that epididymal or testicular factors may also have a part, the greatest decrease was observed in the ejaculate. Further study of infertility in these men should focus on prostatic and seminal vesicle factors.

SERUM AND SEMEN PROSTATE SPECIFIC ANTIGEN CONCENTRATIONS ARE DIFFERENT IN YOUNG SPINAL CORD INJURED MEN COMPARED TO NORMAL CONTROLS

PURPOSE Recent investigations have indicated that factors within the seminal plasma may contribute to the condition of low sperm motility in men with spinal cord injury. To determine whether the prostate gland functions normally in these men we chose prostate specific antigen (PSA) as a marker of prostatic function, and compared serum and semen concentrations in spinal cord injured and healthy noninjured men. MATERIALS AND METHODS The study included 21 spinal cord injured men (mean age 33.3+/-1.2 years) and 22 noninjured normal men (mean age 30.3+/-1.5 years). Blood was obtained from subjects following at least 24 hours of abstinence from ejaculation and serum PSA was determined by modified enzyme immunoassay. Antegrade ejaculates from all subjects were frozen to -80 C, exactly 15 minutes after collection. Seminal plasma PSA was determined using Hybritech Tandem MP assay. RESULTS Mean serum PSA concentration was 1.20+/-0.19 ng./ml. in spinal cord injured and 0.69+/-0.07 ng./ml. in noninjured men (p<0.02). Mean seminal plasma PSA concentration was 0.59+/-0.11 mg./ml. in spinal cord injured and 1.29+/-0.15 mg./ml. in noninjured men (p<0.001). CONCLUSIONS Our findings of elevated serum and decreased seminal plasma PSA concentrations indicate that prostatic secretory dysfunction is present in men with spinal cord injury.

Semen quality in spinal cord injured men: Does it progressively decline postinjury?☆☆☆

OBJECTIVE To determine if semen quality of men with spinal cord injury (SCI) undergoes a progressive decline as a function of years postinjury. DESIGN A retrospective analysis of cross-sectional data. SETTING University-based research center. SUBJECTS Semen quality was examined in 638 specimens from 125 men with SCI. INTERVENTION Penile vibratory stimulation, electroejaculation, and masturbation were used as semen retrieval methods. Routine semen analysis was performed to evaluate semen quality. MAIN OUTCOME MEASURES Sperm concentration, total sperm count, and percent sperm motility were examined at 2-year intervals from men whose injuries had occurred 6 weeks to 26 years earlier. RESULTS No difference in any semen parameter was found as a function of time postinjury. CONCLUSIONS Semen quality in men with SCI does not progressively decline after the SCI. Men with SCI who are considering biologic fatherhood should be advised that the number of years after injury need not be a determinant in deciding when to start a family.

SEMEN RETRIEVAL IN MEN WITH SPINAL CORD INJURY IS IMPROVED BY INTERRUPTING CURRENT DELIVERY DURING ELECTROEJACULATION

PURPOSE Based on the findings of a previous study of pressure differentials in the external and internal urinary sphincters during electroejaculation we determined whether semen retrieval in men with spinal cord injury would be improved by interrupting current delivery during electroejaculation. MATERIALS AND METHODS We tested continuous versus interrupted current delivery in the same group of 12 men with spinal cord injury. Patients underwent a mean of 4 randomly assigned continuous or interrupted trials 4 to 8 weeks apart. Antegrade and retrograde semen parameters were analyzed per trial. Multiple trials of each method per patient were averaged and semen parameters by the continuous and interrupted methods were compared. RESULTS Interrupted delivery resulted in significantly greater mean antegrade volume versus continuous delivery (2 versus 0.9 cc). In this antegrade fraction mean total sperm count and mean total motile sperm was higher for interrupted (130 million and 35 million) versus continuous (79 million and 26 million, respectively) delivery. The mean retrograde total sperm count was 4-fold higher for continuous (120 million) versus interrupted (29 million) delivery. In the total ejaculate of the combined antegrade and retrograde fractions the mean total sperm count and mean total motile sperm were not significantly different for the 2 methods. CONCLUSIONS Each method resulted in a similar mean total sperm count and total motile sperm in the total ejaculate but a higher proportion of sperm was found in the antegrade fraction using the interrupted method. We recommend interrupted current delivery as the technique of choice when electroejaculation is performed to obtain sperm for fertilization.

Reflexes and somatic responses as predictors of ejaculation by penile vibratory stimulation in men with spinal cord injury

Study design: Retrospective chart review.Objective: To identify factors in addition to level of injury (LOI) that may predict ejaculation by penile vibratory stimulation (PVS) in spinal cord injured males.Setting: Major urban medical school and teaching hospital.Materials and methods: Presence of a bulbocavernosus response (BCR) and a hip flexor response (HR) before PVS (n=123 patients), and somatic responses during PVS (n=204 trials performed on a subset of 44 patients) were evaluated for their frequency of occurrence on trials with and without ejaculation.Results: Overall ejaculation success rates for cervical, T1–T6, and T7–T12 LOI were 71%, 73%, and 35%, respectively. Eighty per cent of patients who were positive for both BCR and HR ejaculated with PVS, while only 8% of patients who were negative for both BCR and HR ejaculated with PVS. For cervical injuries, BCR and HR were no more predictive of ejaculation by PVS than LOI alone. T1–T6 patients were more likely to ejaculate when at least one reflex was present. T7–T12 patients with no BCR were unlikely to ejaculate by PVS. Except for abdominal contractions, somatic responses were not present in the majority of PVS trials. When they were present, however, they occurred in a high percentage of ejaculation trials: withdrawal response (hip flexion, knee flexion and thigh adduction) (90%), piloerection (84%), extremity spasms (83%), thigh abduction (80%), and thigh adduction (72%).Conclusion: We recommend that patients with cervical injuries initially undergo PVS. Patients with T1–T6 LOI with at least one reflex present, and patients with T7–T12 LOI with both reflexes, or only BCR present, may undergo PVS. Certain somatic/autonomic responses, when seen, may help in deciding whether to continue with a given trial, or give a repeat trial, of PVS.Sponsorship: The Miami Project to Cure Paralysis and the State of Florida Specific Appropriations.Spinal Cord (2001) 39, 514–519.

Sensitivity of 24-h EMG duration and intensity in the human vastus lateralis muscle to threshold changes.

Few studies have quantified lower limb muscle activity over 24 h using electromyographic signals (EMG). None have described the changes in EMG duration and intensity when data are analyzed with different thresholds. Continuous bilateral EMG recordings were made from vastus lateralis (VL) in 10 subjects (20-48 yr) for 24 h. Before and after this recording, voluntary quadriceps forces and VL EMG at 25%, 50%, 75%, and 100% of the maximal voluntary contraction (MVC), percentage voluntary activation (twitch interpolation), and compound action potentials (M-waves) were recorded. Offline, the 24-h EMG integrals (IEMG, 10-ms time constant) were normalized to the MVC IEMG. Total EMG duration and mean IEMG ranged from 1-3 h and 3.2-12.1% MVC, respectively, when the data were analyzed using the baseline (+3 SD) as threshold. When analysis was done with progressively higher thresholds, from baseline up to 4% MVC, the total EMG duration declined curvilinearly. In some cases the decline in duration was 50-60% for a 1% MVC threshold increment. The mean 24-h IEMG increased by 1.5-2% MVC for each 1% MVC threshold increment. Hence, a small change in the analysis threshold may result in large changes in 24-h EMG duration but moderate changes in mean IEMG. Our findings suggest that VL was active for a short amount of time and at low intensities over 24 h.