Anorgasmia in Anterior Spinal Cord Syndrome J Neurol Neurosurg Psychiatry: First Published As 10.1136/Jnnp.56.5.548 on 1 May 1993

54858ournal ofNeurology, Neurosurgery, and Psychiatry 1993;56:548-551

Anorgasmia in anterior spinal cord syndrome J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.5.548 on 1 May 1993. Downloaded from

Aleksandar Beric, J Keith Light

Abstract 16 month period. Three male and two female Three male and two female patients with patients had dissociated sensory loss in the anorgasmia and dissociated sensory loss lumbosacral segments without a peripheral due to an anterior spinal cord syndrome nerve or lumbosacral cord lesion. Their ages are described. Clinical, neurophysiologi- ranged from 20 to 56 years. cal and quantitative sensory evaluation The patients' sexual functions were revealed preservation of the large fibre assessed clinically with special emphasis on dorsal column functions from the the presence or absence of orgasm. Clinical lumbosacral segments with concomitant sensory examination was performed followed severe dysfunction or absence of the by quantitative sensory evaluation of vibrato- small fibre neospinothalamic mediated ry perception, temperature and thermal pain functions. These findings indicate a role in the lumbosacral segments. All the patients for the spinothalamic system in orgasm. were tested in a sound-proof, temperature controlled (22°C) room with the patient (7 Neurol Neurosurg Psychiatry 1993;56:548-551) supine to provide optimal relaxation and con- centration during the test procedures. Vibratory threshold measurements were Patients with paraplegia and tetraplegia may obtained with a vibrameter (Somedic AB have transitory or permanent sexual dysfunc- Stockholm) designed according to Goldberg tion.'-3 This dysfunction is more common and Lindblom."3 The probe was placed over with more severe lesions.4 Reproductive func- the first metatarsal bone or over the anterior tions may not be significantly altered in surface of the tibia. The vibratory threshold females.5 Males commonly have absent ejacu- was determined according to the methods of lation and/or impaired spermatogenesis limits. Three successive measurements of depending on the level of lesion.6 A lesion threshold were averaged for each test site. above T10 which does not interfere with Temperature perception and cold and heat either the sympathetic or the parasympathetic pain perception were tested with a Marstock functions, usually results in less severe sexual thermal stimulator (Somedic AB) based on dysfunction than lumbosacral lesions. Both the technique by Fruhstorfer et al.'4 The sexes may develop anorgasmia, irrespective of thermode stimulating surface, consisting of the level of the spinal lesion. The surgical 36 Peltier elements, was either warmed or literature has documented that anteriolateral cooled depending on the direction of the http://jnnp.bmj.com/ cordotomy, especially bilateral, results in applied current. A thermocouple attached to sexual dysfunction, including anorgasmia.'-"0 the thermode measured the change in skin These reports are conflicting as the sexual temperature. The thermode was placed dysfunction has not been systematically laterally over the dorsum of the feet, and analysed and the pre-existing abnormalities thresholds for warm, cool, cold pain and heat for which the cordotomy was performed may pain recorded. In addition to the standard

have influenced the results. The bladder and stimulation sites, temperature and thermal on September 28, 2021 by guest. Protected copyright. bowel pathways travel along the anterolateral pain perception were assessed over the S3 tracts.""12 The precise role that the antero- and S4 dermatomes in the gluteal fold. lateral system plays in sexual function, Neurophysiological assessment included including orgasm, is unclear. There are no recording lumbosacral and cortical somato- New York University reports on the sacral sensory finding in sensory evoked potentials according to a tech- Medical Center, patients with anorgasmia. The function of the nique described previously.'5 Cortical SEPs Hospital for Joint large fibre system and dorsal columns has were recorded using silver-silver chloride Diseases, New York not in Department of likewise been precisely assessed these electrodes placed over the modified Cz point Neurology patients. (1.5 cm behind Cz), C3' and C4' points (1 to A Beric We interviewed all patients seen during 1-5 cm behind C3 and C4) referenced to Fz Baylor College of 1990-91 at the Division of Restorative (International 10/20 system). Electrode Medicine, Houston, Neurology and Human Neurobiology, Baylor impedance was kept below 5 KOhm. A 0 5 Texas, USA College of Medicine, who had dissociated ms rectangular pulse was delivered to the tib- J K Light as Correspondence to: sensory loss in the lumbosacral segments ial nerve at the popliteal fossa by a 2 cm Dr Beric, Department of established with quantitative sensory assess- diameter disc cathode and 5 cm square lead Neurology, Hospital for Joint Diseases, 301 East ment. plate anode positioned over the patella. Two 17th Street, New York, intensities of stimulus strength were used, NY 10003, USA one to produce a maximal H response, and Received 20 January 1992 and in final revised form Material and methods the other to produce a maximal M response 5 October 1992. Ninety six patients were assessed clinically of the soleus muscle. Pseudo-random stimu- Accepted 13 October 1992 and by quantitative sensory testing during a lation was used with stimuli delivered during Anorgasmia in anterior spinal cord syndrome 549

the phase of the ECG by delaying Patient 2, a 24 year old white male,

quiescent J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.5.548 on 1 May 1993. Downloaded from the trigger 300-500 ms after the QRS com- sustained a C7 spinal cord injury following a plex. At least two repeatable averages of 128 car accident in August 1984. He was left responses were obtained with an analysis time tetraplegic. During the following months, of 200 ms. The Viking I system (Nicolet however, he regained some sensation and Biomedical) was used for amplification, aver- motor function in the lower extremities but aging and analysis. Analog filters were 5 Hz still complained of spasticity and required to 1 kHz. Lumbosacral somatosensory braces and crutches to walk. Clinical exami- evoked potentials (LSEPs) were recorded nation revealed increased deep tendon reflex- simultaneously by Beckman surface elec- es in both the upper and lower extremities trodes placed at T12, L2, IA, and S1 spinous with bilateral Hoffman sign, unsustained processes referenced to an electrode at T6. clonus at the knee and ankle level and a Pairs of Beckman electrodes were placed over Babinski sign bilaterally. Although the patient the soleus muscles to monitor H and M has a normal libido and erection, he denies responses. Analog filters for H and M ejaculations and orgasms since his injury. responses, as well as for LSEPs were from Patient 3, a 57 year old male, was injured 10 Hz to 3 kHz. in December 1985 in a tractor accident caus- In addition, pudendal cortical SEP was ing a complete C6 tetraplegia. Clinical exami- recorded in one patient. Pudendal SEP was nation showed exaggerated deep tendon recorded with surface cup electrodes placed reflexes bilaterally in the lower extremities at Cz' (1-5 cm posterior to Cz according to with increased tone and occasional flexor and the 10-20 International EEG system) refer- extensor spasms. A sustained right ankle enced to Fz electrode. The stimulus was a 0-2 clonus was present with bilateral Babinski ms rectangular pulse delivered to the clitorial sign. The patient is able to obtain a reflex nerve by the bipolar bar electrode (Teca Inc). erection which is short-lasting and unsatisfac- The stimulus intensity was adjusted to be tory for sexual intercourse. He has not had sufficient to elicit a clinical bulbocavernosus ejaculation or orgasms since injury. reflex. The amplification and averaging was Patient 4, a 20 year old male, sustained a accomplished with DISA 1500 System. C5-6 SCI in October 1989 during a football Bandwidth was 10 Hz to 1 kHz with an game resulting in initial complete paralysis analysis time of 100 ms. Two reproducible below the lesion. Sensory and motor func- averages of 128 stimuli were obtained and tions later improved in the proximal arm and analysed for latency and amplitude. shoulder. The patient also regained some, Video cystometry was performed on all five although different, sensation related to patients. A number 10 French double lumen urgency to urinate. He also complains of a Porges catheter was introduced trans- burning pain in the buttocks and has occa- urethrally into the bladder. One channel was sional spasms in the lower extremities, usually connected to a Statham transducer and the triggered by volitional efforts to move his other to an infusion pump. The bladder was legs. Clinical examination revealed absent filled at the rate of 60cc per minute to a vol- voluntary control in the lower extremities ume of 700cc with the patient in the left with symmetrical deep tendon reflexes and a

oblique or supine position. The urodynamic bilateral Babinski sign. The patient denies http://jnnp.bmj.com/ results were recorded on a Dantec 5500 uro- ejaculation and orgasm, although he is able to graph. The results were interpreted according obtain erections sufficient for sexual inter- to International Continence Society guide- course. lines. Patient 5, a 44 year old female with a chief complaint of constant burning pain in the thoracolumbar back, buttocks, feet and Results ankles, was diagnosed in 1980 with arterio- All five patients complained of anorgasmia venous malformation (AVM) involving the on September 28, 2021 by guest. Protected copyright. regardless of the aetiology of their dissociated T7 to T9 radicular arteries. She had two sensory loss. embolisation procedures in 1980. Between Patient 1, a 29 year old female suffered 1981-83 she noticed increasing weakness of multiple stab wounds to the chest and back in her legs. Clinical examination showed that March 1989 and developed hypotensive the deep tendon reflexes were symmetrical in episodes during surgery with clamping of the the upper and lower extremities with the aorta. Post operatively she became deeply Babinski sign present bilaterally. The patient paraparetic with absence of temperature has a normal libido and a history of anorgas- perception in the lower trunk and lower mia since 1981. extremities. Clinical examination revealed All 5 patients showed absent pin prick and mild hypertonia in the lower extremities with temperature sensation below the spinal symmetrical deep tendon reflexes. Clonus lesion. Quantitative sensory evaluation con- was absent but the Babinski sign was present firmed absent temperature perception in four bilaterally. Pudendal SEP revealed a normal patients. Patient 3, however, retained some W waveform with a normal P1 latency of 31 perception of cold, albeit altered. Thermal ms. The sensory threshold to electrical stimu- pain was also absent in patients 2, 3 and 4, lation of the clitorial nerve was normal. The while in patients 1 and 5 some heat pain per- patient has been unable to obtain an orgasm ception was retained, but with a significantly since injury despite normal libido, sexual higher level than normal. LSEPs were normal activity with partner and sexual counselling. in all patients suggesting that the peripheral 550 Benic, Light

sensory neuron and lumbosacral cord were bilitation, but the question of underlying intact. Patients were at least 18 months after neurogenic dysfunction has been neglected. J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.5.548 on 1 May 1993. Downloaded from the onset of dysfunction and they were not As pointed out by Brindley,20 anorgasmia has taking any antidepressant or neuroleptic not been discussed in relation to the anatomy medication. They were all sexually active of the spinal cord lesion, for example, anteri- before injury and able to obtain orgasm. or, posterior, or lateral, which is a major part Patients 1 and 2 reported anorgasmia as one of our study. of their major complaints. All the patients The question of anorgasmia is a difficult went through several levels of rehabilitation and sensitive issue. Orgasm is a subjective programmes, including sexual counselling, sensation, and we have relied on patients' and were considered fully rehabilitated in reports regarding its presence or absence. accordance with the level of their disability. Due to the fact that all patients were and are Only Patient 4 was considered severely sexually active and have had orgasm in the disabled. past, we accepted their reports of anorgasmia as reliable. In addition, none of the patients were in litigation or were considered un- Discussion reliable during their extensive assessments. Sexual dysfunction, including anorgasmia A precise assessment would help in the may be a complication of treatment with understanding, classification and prognosis of medication such as neuroleptics and anti- the anorgasmia. This study suggests that depressants.16-18 Decrease in dose or discon- anorgasmia in patients with dissociated sen- tinuation of the offending medication usually sory loss and severe or complete dysfunction resolves the anorgasmia. Trauma to the of the spinothalamic system, is long lasting nervous system may also result in transitory and possibly permanent. Only patients with sexual dysfunction. This, however, may be an intact sacral spinal cord were studied to permanent in patients with spinal cord injury, evaluate possible spinal cord pathways especially those with complete lesions. As our involved with orgasm. It is possible that some patients were able to obtain orgasm before descending facilitation is necessary as only injury and were not taking any medication 5-10% of patients with spinal cord injury are that could induce anorgasmia, it can be able to obtain ejaculation, regardless of the concluded that their sexual dysfunction is the degree of incompleteness. Other stimuli such direct result of the trauma. Sexual dysfunc- as vibration, electrical stimulation or intrathe- tion following spinal cord injury has been cal physostigimin may also trigger ejaculation studied in detail by several investigators,'-6 in patients with spiral cord injury who other- 19-22 where it has been shown that the ability wise would be unable to ejaculate. All of our to obtain an erection is related to the intact- patients had dissociated sensory loss with ness of the sacral segments,2223 whereas the preserved dorsal column modalities of sacral male reproductive function, especially sper- sensation, making it unlikely that ejaculation matogenesis, is related to the lower lumbar would be unnoticed. A dissociation between segments.6 It has been suggested, especially in ejaculation and orgasm is possible25 26 but rare females, that in the presence of anorgasmia in the non-spinal cord injury population.

other erogenic zones can be developed as a Interestingly, non-ejaculatory orgasm in http://jnnp.bmj.com/ replacement for the major genital zone.2 males is also possible,25 further complicating However, anorgasmia continues to be a sig- the issue. It is necessary to have preserved nificant problem in both sexes, especially with ascending functions allowing impulses from high tetraplegia. There are, however, other the lumbosacral cord to reach the brain for causes of anorgasmia in patients with spinal orgasm to occur, regardless of the mechanism cord injury unrelated to the neurogenic of orgasm. As we did not assess whether injury. These include depression, difficulty strong peripheral stimulation would elicit with positioning and fear of urinary inconti- ejaculation in our patients or if they were able on September 28, 2021 by guest. Protected copyright. nence during intercourse as a result of the to achieve orgasm at that time, we postulate associated neurogenic bladder. Libido may that descending facilitation through the also be decreased for the same reasons. These anterolateral quadrant was probably involved important factors are unlikely to play a role in in addition to the presence of ascending our patients as they all had normal libido and spinothalamic dysfunction. We cannot specify had graduated from a sexual rehabilitation if any anterolateral spinal tract, other than the programme. In addition, their partners had neospinothalamic system, is important for been educated about urinary incontinence orgasm. Based on good motor control and and the necessity of performing clean muscle strength in patient 1 and the uni- catheterisation before intercourse. This is in lateral good motor control in patient 2, the contrast to stroke patients where a decrease in descending motor system, or pathways travel- libido and sexual function may be the result ling along them are unlikely to be relevant. of fear of inducing hypertension and thus the Bladder function itself does not appear to add possibility of restroke.24 It is therefore reason- to the understanding of the sexual dysfunc- able to conclude that anorgasmia in our tion because it is multifactorial (influence of patients was the result of neurological dys- sphincterotomy, recurrent infections, etc.) function only. The topic of sexual dysfunc- and in our patients was either normal or tion in neurological disease has been abnormal, being either hyperreflexic or even addressed from many aspects including areflexic in one patient. As the patients did psychosocial, psychiatric, disability and reha- not have any local lumbosacral dysfunction, Anorgasmia in anterior spinal cord syndrome 551

Supported in part by The Vivian L Smith Foundation for

their reflex functions were preserved, includ- J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.56.5.548 on 1 May 1993. Downloaded from ing presumably the ejaculation reflex in males Restorative Neurology, Houston, Texas. 1 Bors E, Comarr E. Neurological disturbances of sexual as well as lubrication in females. function with special reference to 529 patients with The five patients described with anorgas- spinal cord injury. Urol Surv 1960;10: 191-222. absence of 2 Guttmann L. The married life of paraplegics and mia all had severe or complete tetraplegics. Paraplegia 1964;2: 182-8. small fibre spinothalamic functions but pre- 3 Munro D, Home HW Jr, Paull DPP. The effect of injury column to the spinal cord and cauda equina on the sexual served larger fibre mediated-dorsal potency of men. NEJM 1948;239:903-1 1. functions. This finding implies that, at least 4 Siosteen A, Lundqvist C, Blomstrand C, Sullivan L, tests assessing Sullivan M. 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Physiology of erection and management of http://jnnp.bmj.com/ male with anorgasmia due to paraplegic infertility. In: Hargreave TB, ed. Male inferti- would patients ity. Berlin: Springer-Verlag, 1983:509-61. anterior spinal cord syndrome have if ejacula- 21 Kennedy S, Over R. Psychophysiological assessment of could be by strong peripheral male sexual arousal following spinal cord injury. Arch tion obtained Sex Behav 1990;19:15-27. stimulation? There is controversy as to 22 Yalla SV. Sexual dysfunction in the paraplegic and quadri- with spinal cord injury plegic. In: Bennett AH, ed. Management of male whether patients Impotence, international perspectives in urology, vol 5. experience true orgasm or only feel some Baltimore: Williams and Wilkins, 1982:181-91. different but pleasurable sensation. Our 23 Brindley GS, Sauerwein D, Hendry WF. Hypogastric plexus stimulators for obtaining semen from paraplegic on September 28, 2021 by guest. 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Standardized evaluation of erectile dysfunction in 95 We are indebted to the personnel of the Division of consecutive patients. J Urol 1989;141:857-62. Restorative Neurology and Human Neurobiology, Baylor 29 Ertekin C, Ertekin N, Almis S. Autonomic sympathetic College of Medicine, Houston, Texas, for excellent technical nerve involvement in diabetic impotence. Neurourol assistance. Urodynamics 1989;8:589-98.