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and : Sexuality in Men with SCI

Stacy Elliott Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 Ejaculation and orgasm are two entities of sexual satisfaction in men after injury (SCI). The scientific literature focuses on potentiating and on the retrieval procedures for purposes, but little has been written about the pleasurable aspects of ejaculation and the potential for orgasm in men after SCI. Men with SCI who have lower motor neuron or incomplete injuries appear to have an increased chance of ejaculating through sexual practices, whereas men who have injuries above neurologi- cal level T10 respond best to vibrostimulation. Orgasm after SCI is a local, learned spinal reflex that is interpreted via cerebral centers. In general, intense genital stimulation may be needed to elicit the subjective experience of orgasm, but extragenital stimulation or cerebral input alone can lead to orgasmic release for some men after SCI. Sexual rehabilitation includes three principles: maximization of the innate physiological potential, to limitations, and promotion of a positive outlook for sexual potential via experimen- tation. Key words: ejaculation, erection, orgasm,

any articles on male sexuality after partner.3,4 More recently, client-oriented spinal cord injury (SCI) focus ei- writings5 promote positive sexuality and Mther on erection dysfunction or on for the person with SCI. A focus on fertility problems. However, little attention the enhancement of the remaining capacities is paid specifically to the psychophysiologi- instead of preoccupation with the lost capaci- cal aspects of sexual pleasure attainable after ties, as well as receptivity to the sexual power SCI, including the ability to ejaculate and the of emotional intimacy, may result in a more subjective experience of orgasm. After SCI, rewarding sexual life after injury. many men initially focus on the ability to Current literature on erection function in achieve an erection adequate for sexual inter- men with SCI is not centered on the attain- course, even if they cannot feel the erection ment and reliability of natural after or the pelvic arousal per se. Earlier research- SCI but on methods of erection enhance- ers1,2 emphasized the vicarious pursuit of ment. Literature on ejaculation tends to focus pleasure after SCI, claiming the loss of this “genitopelvic”1(p90) awareness resulted in a focus on the “cerebrocognitional aspect”1(p91) Stacy Elliott, MD, is Clinical Professor, UBC Depart- of sexual ability, with satisfaction mainly ment of , Division of ; Sexual Medicine Consultant to the Sexual Medicine resulting from a “boost of self-esteem and Clinic, BC Center for Sexual Medicine; Sexual Reha- pride of accomplishment at being able to bilitation Consultant to Sexual Health Department, GF satisfy the partner.”1(p91) Strong Rehabilitation Center; and Co-Director, However, later articles emphasized that Vancouver Sperm Retrieval Clinic, BC Center for the sexual pleasure of the person with tet- Sexual Medicine, British Columbia, Canada. raplegia or paraplegia need not be limited to Top Spinal Cord Inj Rehabil 2002;8(1):1–15 the satisfaction gained by gratification of a © 2002 Thomas Land Publishers, Inc.

1 2TOPICS IN SPINAL CORD INJURY REHABILITATION/SUMMER 2002

on sperm retrieval methodology. Erection This article will concentrate on aspects of dysfunction treatments and sperm retrieval genital sexual functioning and pleasure in for fertility are both very important in the men after SCI, including the potential for sexual rehabilitation of men after SCI, but ejaculation and orgasm and how these inter- sexual pleasure is also of great significance. relate with erectile capacity. The neuro-

There is a paucity of information on orgas- of erection has become well elu- Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 mic sensations accompanying ejaculation cidated over the last few years, and during sperm retrieval in a clinical setting, let ejaculation physiology is not far behind. alone sensations accompanying ejaculation However, there is little comparable under- at home in a more conducive, private setting. standing of orgasm or even how orgasm is Clinicians have been told of orgasmic expe- defined, especially after SCI. This article is riences that are unaccompanied by ejacula- an overview of the current literature com- tion.6 No formal surveys have looked at such bined with my clinical experience, observa- occurrences, but these anecdotal reports are tions, and theories about the mechanism and crucial in the clinician’s learning, under- sexual interpretations of erection, ejacula- standing, and knowledge of sexual physiol- tion, and orgasmic function after SCI. Other ogy after SCI and they ultimately direct new articles in this issue provide more specific research. For the patient, the Internet is prob- information on erection dysfunction and its ably the biggest source of such information. management, sperm retrieval, and fertility. The use of chat lines or question and answer sites to share experiences is a valuable Sexual Functioning After SCI method of learning how to obtain better arousal and release. Clearly, the area of natu- The 1960 article by Bors and Comarr7 is ral arousal, release, and sexual pleasure for one of the original, and most frequently cited, both men and women after SCI needs further self-report studies on the sexual capacity of directed, scientific research. men after SCI. Their objective was to quan- The scientific literature has focused prima- tify sexual responses according to level of rily on self-reports and, therefore, on subjective injury and completeness of SCI but not to definitions of erection, ejaculation, and orgas- provide information about sexual pleasure or mic capacity. An erection that is defined as overall sexual satisfaction. The issues of adequate for vaginal penetration in a study sexual and fertility rehabilitation were not as protocol may be quite different from an erec- openly approached in the hospital setting tion that is rigid and reliable enough for satisfy- then as they are today. Without the erection ing coital and/or noncoital sexual activities. For enhancement techniques and fertility options most men, ejaculation is considered to have that are available now, sexual and paternity occurred if there is visible confirmation of expectations were understandably down- ejaculate, yet orgasmic capacity can be variably played by health professionals. Erection en- interpreted and may not be related to ejacula- hancement consisted mainly of penile pros- tion at all. Furthermore, it is only by going thesis until intracavernosal injection became beyond conventional scientific thinking about available in the early 1980s. Fertility was sexual physiology that some men with SCI limited to those men who could ejaculate have experienced their full sexual potential. with sexual activity and whose sperm quality Ejaculation and Orgasm 3

was adequate for conception; this was about 5% of men in the original study.7 It must be Ejaculation consists of two stages – remembered that bladder care was less so- seminal emission and propulsatile phisticated at that time, the level and extent ejaculation – and is mediated through of the spinal injuries were not as well de- the T10-S4 segments of the spinal cord. fined, and surgical procedures and medica- Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 tions used for bladder management may ac- tually have interfered with sexual function and fertility potential. of vibrostimulation, ejaculation is more Since the original report, other researchers likely to occur, especially in patients whose have investigated the ranges of sexual capac- injury is above the T10 neurological level. ity. The reported frequency of erections in The is capable of specific frequen- men with SCI ranges from 54% to 95%, and cies and amplitudes not easily duplicated by frequency of ejaculation ranges from 3% to sexual techniques. However, for some men, 20%.7–9 A data summary10 in 1977 showed the reverse is true; they can ejaculate to erection capacity as 93% reflexogenic in specific but not to patients with complete upper motor neuron vibrostimulation. (UMN) lesions, 98% reflexogenic in patients Recent self-report studies of men with SCI with incomplete UMN lesions, 26% psy- state that 42%–47% experience orgasm of a chogenic in patients with complete lower similar, weaker, or different quality than motor neuron (LMN) lesions, and 83% psy- preinjury.13,14 Although awareness of genital chogenic in patients with incomplete LMN orgasm (the ability to feel genitally centered lesions. Bors and Comarr7 indicated that men orgasmic release) is assumed to depend on with incomplete injuries and UMN injuries intact genital afferents (upgoing lateral had a better prognosis for erection as com- spinothalamic tracts) to the brain and intact pared to complete and LMN injuries, but it efferents (downgoing corticospinal tracts) must be remembered that self-reports do not from the brain,4 38% of men with complete always accurately reflect the full physiologi- SCI reported they retained the ability to cal response to erotic stimulation. For ex- achieve orgasm.13 ample, in male patients with SCI who felt they could not get erections, penile tumes- Neurology of Ejaculation and Orgasm cence was nevertheless demonstrated when they were exposed to erotic stimulation via Ejaculation consists of two stages—semi- film, text, and fantasy.11 nal emission and propulsatile ejaculation— Ejaculation during sexual activity is gen- and is mediated through the T10-S4 seg- erally reported in less than 10% of men with ments of the spinal cord. Ejaculation is a complete SCI and in 32% with incomplete spinal reflex. Like erection, this reflex is SCI. Men with LMN lesions and more caudal under tonic inhibition from the supraspinal lesions more commonly report ejaculation centers.15 Usually, genital stimulation in capacity.12 The ability to have orgasm combination with central arousal acts as an through sexual activity is poorly defined in afferent that removes this inhibition, allow- most studies.12 Fortunately, with the advent ing the natural efferent components to un- 4TOPICS IN SPINAL CORD INJURY REHABILITATION/SUMMER 2002

fold. Excitatory supraspinal afferents alone causes spasmodic contractions of the semi- can induce ejaculation as evidenced by noc- nal vesicles, , and , which turnal emissions. Alternately, if supraspinal propels the seminal bolus distally. Intermit- control is lost because of complete SCI, the tent relaxation of the external sphincter coor- tonic inhibition is removed, allowing the dinates with the three to seven rhythmic

undamaged sacral reflex to be triggered by contractions (approximately 0.8 seconds Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 the appropriate genital afferents, which re- apart) of the bulbospongiosus, ischiocaver- sults in ejaculation. nosus, , and related muscles inner- Stage 1 or seminal emission is arousal vated by the pudendal carrying the related and is under some voluntary control somatic fibers.16 in the able-bodied man. This phase involves It has been proposed that a neural “coordi- the sympathetic outflow from the presacral nation center” for ejaculation exists in the and hypogastric (T10-L2) promoting T12–L1 region.17 Afferent signals from S2-4 sperm transport from the storage site in the ascending to the “center” stimulate sympa- tail of the to the more distal thetic outflow, triggering the initial stages of genital ducts. of seminal fluid deposition and emission, and the and contraction of the semi- precisely direct the activation of the descend- nal vesicles cause the spermatozoa and semi- ing efferent parasympathetic and somatic nal fluid to mix with the prostatic secretions outflow through the sacral cord to the puden- to form the seminal bolus. The seminal bolus dal nerve. The latter results in clonic contrac- is then deposited into the prostatic urethra via tions of the periurethral musculature and the ejaculatory ducts. Sympathetic input via antegrade ejaculation. the hypogastric nerve (L1,2) causes a closure Because propulsatile ejaculation immedi- of the bladder neck by stimulation of alpha- ately follows seminal emission, it is thought adrenergic receptors that, in turn, prevents that an acute rise in intraprostatic pressure the seminal bolus from entering the bladder from the presence of the seminal bolus in the (). In addition, the ex- ejaculatory ducts and prostatic urethra may ternal sphincter also remains closed during assist in triggering the switch from the sym- the seminal bolus deposition, increasing the pathetic to the parasympathetic nervous sys- prostatic pressure and instigating a feeling of tem. It is still not clear if the somatic or impending release, called ejaculatory inevi- is responsible for tability. Cerebral control of impending the orgasmic sensations; they may both pro- ejaculation is minimal at this point.16 In- vide input. Furthermore, it is still not clear, creased prostatic pressure and the general even in neurologically intact men, in what of the pelvic organs corre- phase orgasm actually occurs. spond with conscious pleasurable feelings of Men with alterations to one or the other of tension in the genital area. their ejaculation phases help our understand- Stage 2 or propulsatile ejaculation is the ing of orgasmic sensations. For example, process of expulsion of the ejaculatory fluid men who have their prostate removed by out the urethral meatus where it appears as an radical prostatectomy and who no longer antegrade ejaculate. The pelvic nerve carry- have antegrade ejaculation still feel pleasure ing parasympathetic fibers from S2-S4 during the phase of seminal emission and Ejaculation and Orgasm 5

experience orgasm, although it may be al- ous and sometimes unexpected ejaculation tered in intensity or duration.18 Men in whom capacity. Physiological factors, such as cur- there is technically no seminal emission due rent medical status, presence of bladder in- to interruption of their sympathetic chain (as fections or pressure sores, and medications, in retroperitoneal node dissection for may alter or attenuate ejaculation in men testicular cancer) still have the second phase with SCI. Psychological influences on Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 triggered and experience orgasm despite not sexual functioning (even in complete SCI) having an increased prostatic pressure from tend to be unrecognized and/or underesti- the seminal bolus deposition.19 Men with mated. Both of these factors influence the altered somatic innervation, such as may be reliability of ejaculation with sexual activity seen in multiple sclerosis, may have poor from one sexual attempt to the next, espe- motor contraction of their and cially compared to preinjury. Compared with take longer to reach what is usually a blunted, literature on the capacity for ejaculation and less intense orgasm; ejaculate appears by assisted fertility after SCI, there has been gravity after orgasm has occurred, regardless little written about the quality and predict- of the erectile ability.20 ability of ejaculation during sexual activity, Many men with SCI are anejaculatory, let alone sexual satisfaction and orgasm. with neither seminal emission nor pro-pulsa- Usually, obvious pulsatile antegrade tile ejaculation; other men with SCI have ejaculation is triggered by vibrostimulation, variable capacities for ejaculation and or- because the sacral reflex is evoked. How- gasm, depending on the completeness and ever, sometimes retrograde ejaculation oc- level of injury.21 However, it is my observa- curs as evidenced when typical ejaculatory tion that the sexual experiences of many men signs are present with no or small amounts of with SCI do not neatly fit the predictions antegrade ejaculate. Unlike vibrostim- stemming from current knowledge of neurol- ulation, electroejaculation is thought to ogy; thus, there may be additional factors evoke only seminal emission. The besides hard-wiring that modulate the out- flows from the urethra, and often more can be come of each individual’s capacity or inter- expressed by milking the urethra and penile pretation of sexual pleasure. bulb. More samples appear to go retrograde with electroejaculation than with Changes to Ejaculation and Orgasm vibrostimulation. Our standard protocol is to After SCI hold a balloon Foley catheter against the bladder neck during electroejaculation pro- Because ejaculation is a highly complex cedures; semen is then directed antegrade process requiring the sequential coordina- around the catheter and is collected. tion of the sympathetic, parasympathetic, The vast majority of patients who undergo and somatic nervous systems, the exact alter- monitored sperm retrieval have no feeling of ation in ejaculatory function after SCI can be pelvic arousal or accompanying orgasm with unpredictable. There can be combinations of ejaculation. Even if they do not experience interrupted seminal emission, inadequate orgasmic release, just seeing the ejaculate— closure of the bladder neck, and poor possibly for the first time since their injury— propulsatile ejaculation, all leading to vari- is important to their manhood and sexual 6TOPICS IN SPINAL CORD INJURY REHABILITATION/SUMMER 2002

sense of self. The process of obtaining an Clinical questioning reveals that, regardless ejaculate is not a sexual experience in the of erection status, some men identify their clinical setting. Many men feel unwell before seminal emission phase as “orgasm,” which ejaculation with discomforting spasm or im- is followed by a lesser release phenomenon pending autonomic dysreflexia. Men with (also pleasurable) as the fluids are ejaculated higher lesions often get dysreflexic at ejacu- with force to the external meatus during Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 lation. These are not pleasant experiences. propulsatile ejaculation. These can Despite this, it is my observation that ap- be “drawn out” or extended in duration and proximately 5%–10% of these men experi- intensity, or even in multiplicity, by the vol- ence new pleasurable sensations at ejacula- untary component of the seminal emission tion that they have not felt before through phase: once started, propulsatile ejaculation anejaculatory sexual activity. If this experi- is under poor voluntary control. For other ence occurs with vibrostimulation, some men, orgasm is the brain’s cognitive inter- men can then capitalize on this by learning to pretation of the pulsatile contractions of ejaculate at home under sexual, but safe, smooth and skeletal muscle during the sec- conditions (the risk of autonomic dysreflexia ond phase. The lay press has recently popu- with such sexual activity can be tempered by larized exercises specific to pelvic floor precautionary positioning and the use of pro- awareness and strengthening as the basis for phylactic antihypertensives). This is espe- improved or multiorgasmic sensations in cially true for men with incomplete lesions; men.24 Other men are not able to articulate vibrostimulation with the additional cognitive whether their orgasmic sensation takes place arousal available in a private setting (or more primarily in the first or the second phase: one accurately, the removal of remaining inhibi- phase blends into the other with varying tory control that still prevails in a clinical intensity. Each man has his own descriptive setting) contributes to improved outcome. definition of the final constellation of events Orgasmic capacity after SCI is poorly un- that constitutes orgasm. derstood. Part of the problem in discussing Once the second phase is completed, a orgasmic capacity and satisfaction is that ensues. Repeat orgasms there is no clear definition of what constitutes rarely occur without an interim recovery pe- “orgasm.” Neurologically intact patients at riod called the refractory period.23 The dura- the Sexual Medicine Clinic, BC Center for tion of this refractory period is widely influ- Sexual Medicine, describe orgasm in various enced by age and sexual experience. Some ways based on their sexual experience. Even men (usually young) are capable of more than though it is possible to have orgasm without one ejaculation within a relatively short period erection,22 these men feel that their orgasmic of time. They describe orgasm with each such reliability is improved with an erection and experience and may not experience penile strive to attain erection before allowing detumescence between orgasms. Typically, themselves to actively pursue orgasm. Other orgasm delays the refractory period. Men with men, especially those with generalized erec- often ejaculate prior to tion dysfunction secondary to medical or partner sexual activity as a way to increase surgical causes, have already discovered that their ejaculatory latency with intercourse. As erection is not required to reach orgasm.23 men age, the refractory period lengthens, pe- Ejaculation and Orgasm 7

nal emission and projectile ejaculation 27 or, As men age, the refractory period alternately, as the “pleasurable and localized lengthens, penile detumescence is more (genital) sensations at the time of seminal immediate after orgasm, and the emission”28 alone. Another description is capacity for multiple orgasm is limited that orgasm is thought to be the conscious

to an experienced few. of the contraction of both the Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 smooth muscles of the internal sexual organs and the striated pelvic muscles.29 Orgasm has also been described as a spinal cord reflex that is triggered by appropriate cerebral and nile detumescence is more immediate after sensory stimulus and that therefore can be orgasm, and the capacity for multiple orgasm inhibited by supraspinal suppression (con- is limited to an experienced few. scious or subconscious).30 As is well known The fact that orgasmic experiences can in the field of therapy for female occur with or without an erection, without and male-inhibited ejaculation, ejaculate being produced, and even without the provision of effective, excitatory physi- structures (i.e., a prostate after cancer,23 a cal stimulus of sufficient intensity and dura- after amputation for sex reassignment tion, as well as the temporary removal of the surgery25) indicates the resilience of the or- normal tonic inhibitory cortical control on gasmic capacity. It also supports the theory the spinal reflexes, is necessary for orgasm to that orgasm is a reflex with cerebral influ- be triggered. This supports the traditional ence and can therefore be learned and prac- view that orgasm is a pelvic reflex response ticed. Low states and medications and a learned reflex. that either influence reflex capacity (such as In our neurologically intact population, antispasmodics26) or delay orgasm (such as the intensity of pleasurable sensations seems some antidepressants) can influence the abil- to be dependant on psychophysiological fac- ity to reach orgasm and/or the intensity of tors such as length of , duration of orgasm. SCI is one of the biggest challenges arousal, strength and tone of the pelvic floor to this orgasmic resilience. muscles, and intensity of cerebral afferents How has orgasm been defined in the scien- (sensory input from fantasy, memory, visual, tific literature? Researchers working in the olfactory, tactile, and taste afferents). The scientific study of orgasm can monitor spe- majority of able-bodied men experience or- cific physiological responses of increased gasm resulting from stimulus on the penis heart rate, pressure, and pelvic floor (hand, oral, vibratory, intercourse). How- contractions and correlate this to subjective ever, some men can experience orgasm from awareness. Literature on the neurophysiol- stimulation to nonpenile sites, such as the ogy of ejaculation uses the words “sexual , , prostate, , or, rarely, climax” or “orgasm” interchangeably with by psychogenic (fantasy, memory, other “ejaculation,” but they are two different phe- cognitive sensory triggers) input alone. As nomena. Orgasm has also been described as a mentioned before, the capacity for orgasm is “combination of pleasurable physical and psy- rarely lost despite significant medical or sur- chological sensations” that occurs during semi- gical alterations. However, the genital orgas- 8TOPICS IN SPINAL CORD INJURY REHABILITATION/SUMMER 2002

mic capacity of men after SCI is often lost or sion.31 If the reflex response remains after significantly altered, and therefore the SCI, and the autonomic nervous system (or “sexual pay-off” for men diminishes until some yet unidentified hormonal or alternate they learn new pathways of arousal or adapt neural transmission such as the vagus to their limitations. Men with SCI report nerve32) is still intact, then orgasm could becoming orgasmic from either intense geni- potentially be experienced. Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 tal stimulation or from learning to become The traditional view of orgasm is sup- highly receptive to and aroused by ported by recent evidence that women with nongenital stimulation. The example of complete SCI at T6 or above describe orgas- “eargasms” discussed by patients is one such mic experiences indistinguishable from their mechanism. Other men with SCI learn alter- able-bodied counterparts.33 The same re- nate sexual inputs they may not have been searcher proposes that the preserved orgas- attuned to before their injury. These include mic sensory experience is partially derived previously unrecognized erogenous zones or from afferent autonomic innervation, which a new attention to emotional or spiritual remains even in the presence of complete connections. The combination of these new SCI.34 In this group of women, only 17% of inputs with stimulation of sensate areas of the women with complete LMN dysfunction af- body can result in what is recognizable as an fecting the S2-S5 spinal segments were able orgasm post injury. Intriguing accounts of to achieve orgasm, as compared with 59% of spiritual focusing during sexual activity that women with other levels and degrees of SCI, may not even involve the genitalia have also which suggests that orgasm is related to a triggered orgasm in some patients with SCI. preserved reflex. Although these orgasmic experiences are In terms of changes in after different in nature and location, they can be SCI, there are so many factors that can influ- just as sexually gratifying and meaningful, if ence drive (depression, medical condition, not more, as the recognizable genitally based lack of partner, disinterested partner, fear of orgasms that were experienced before injury. incontinence, etc.) that it is difficult to say However, it takes tremendous motivation whether the biological component of drive and support to learn or to appreciate these remains intact or is altered. It is my experi- new pathways. ence that drive is initially lowered with the Prior to injury, experience probably difficulties or preoccupation of adjusting to a makes orgasm more reliable through neural new body, but within a year or two the drive memory or “grooving,” which fosters confi- often returns to preinjury level. The chal- dence. How this translates to critical amounts lenge for these men with SCI is to learn to of required at the spinal interpret and incorporate new sexual poten- cord level is still unclear. There may be many tial that was previously not focused on. There factors, such as the integrity of the serotoner- is no evidence to suggest that there is any gic neurons in the spinal cord. For example, difference in the actual capacity to be men- ejaculation reflexes, which were absent in tally aroused pre- and post-SCI unless there cord-transected paraplegic rats, were re- is concomitant brain injury. It is likely that stored with intraspinal transplants of sero- changes to overall are secondary to tonergic neurons below the level of the le- sexual function capacity and psychological Ejaculation and Orgasm 9

factors rather than to hormonal or organic variably have positive bulbocavernosis re- brain influences. flex), some men with incomplete lesions below T10 respond if there is enough nerve Predictors of Ejaculation recruitment.40 In the latter case, sympathomi- metic drugs (i.e., pseudoephedrine) may help 35,36 My experience with vibrostimulation if there is no risk for autonomic dysreflexia. Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 for sperm retrieval consistently demon- Arousal of the sympathetic nervous system is strates several characteristic signs of ejacula- considered facilitatory for in tion consistent with findings of others in the certain patient subgroups41; this may be the field16,37–39: episodic abdominal and leg con- case in men with SCI. Sometimes, men with tractions, generalized piloerection, scrotal incomplete lesions are not able to ejaculate in wall retraction, and, usually, development of the clinical setting but can at home in a a rigid erection (ejaculation can occur with a private sexual setting with the appropriate flaccid or semi-erect penis). Ejaculation is vibrator. Failure at the clinic is likely due to imminent when the abdominal or leg spasms remaining tonic inhibitory control over the become more tonic and strong in nature ejaculatory reflex. (even to the point of discomfort or chest wall Ejaculation can invoke negative conse- tightening). Erection rigidity peaks, the glans quences for men with SCI. Men whose injury becomes acutely filled (if not so already), is T6 or higher are at risk for autonomic urethral spasms occur, the already elevated dysreflexia with the stimulation required to blood pressure acutely rises, and the pulse reach ejaculation. Symptoms typically cor- rate drops at ejaculation. Sometimes ejacula- relate with blood pressure, but there are ex- tion is elusive despite these impending signs. ceptions. We have recorded a pressure of To assist in triggering the reflex, one might 220/113 in a premedicated patient with tet- extend the legs, abduct the thighs, lie flat raplegia who was asymptomatic at ejacula- versus upright (the latter is better for control tion. This risk for dysreflexia during proce- of autonomic dysreflexia), have either a full dures can be lessened by the use of or an empty bladder, and use erection en- prophylactic antihypertensive drugs to blunt hancement such as or the high blood pressure response, reduction intracavernosal injection. The vibrator in the duration of vibratory stimulus (usually placement and applied pressure is also im- by applying a more aggressive amplitude or portant: I and others20,21 have noted indi- manual pressure), and removal of the vibra- vidual signature or trigger spots on the dorsal tor at the point of impending ejaculation glans or frenulum that reliability evoke versus during ejaculation. Sometimes, the ejaculation in some men. Occasionally two tendency to become dysreflexic attenuates vibrators may be needed to be applied at once with frequent, repeated vibrostimulation to elicit ejaculation, but, due to the intensity over months or years. Loss of spasticity from of the stimulus, these trials need to be done 1–48 hours is another side effect of ejacula- under supervision of experienced clinicians tion and can be seen with both vibrostimulation only. Although it is well known that men and electroejaculation.42,43 Loss of spasticity with UMN lesions above T10 respond the may be symptomatically helpful for the patient best to vibrostimulation (these men will in- or could hinder him, depending on the patient’s 10 TOPICS IN SPINAL CORD INJURY REHABILITATION/SUMMER 2002

dependence on spasm for mobility and trans- preserved lower thoracic “coordination cen- fers. Some men experience unwanted effects ter” that can send information to stimulate a on bladder management or bowel continence local cord “orgasmic” reflex. Because the after sperm retrieval procedures, especially chances of this are so small, patients in the electroejaculation. Mobility, bladder, and Vancouver Sperm Retrieval Clinic, BC Cen- bowel issues can all influence the man’s capac- ter for Sexual Medicine, are told not to expect Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 ity to be sexual. Other effects of sperm retrieval orgasmic sensations if they have not had procedures are described elsewhere.27,28,38,39 them before with sexual activity. Lower ex- pectations may actually enhance the chance Predictors of Orgasm of orgasmic sensation, if there is to be any, because self-consciousness about sexual ex- Compared to men with complete lesions, periences in a clinical setting induces cortical men with incomplete lesions who had not inhibition. However, if such sensual or or- experienced orgasmic sensations with less gasmic experiences do occur, they are genitally stimulating sexual practices had a framed in a positive light and are followed by greater chance of recognizing orgasmic sen- discussions of how this may be incorporated sations the first time while undergoing in a personal setting with sexual activity. vibrostimulation. The unexpected potential for orgasm that is recognized in a clinical and Erection, Ejaculation, and Orgasm After sexually inhibiting setting can usually be SCI: How Do They Intermingle? enhanced by practice with the vibrator at home in a more conducive, private environ- Ejaculation is a separate neurological pro- ment. In my experience, men with high com- cess from erection and/or orgasm, although plete lesions rarely report orgasmic experi- there may be spinal, autonomic, and somatic ences from vibrostimulation-induced pathways that are shared. Erection is prima- ejaculation. Men who are technically incom- rily a parasympathetic event, but the thora- plete at any level occasionally feel pleasur- columbar sympathetic pathways are in- able or orgasmic sensations with vibro- volved. Under normal circumstances, the stimulation and sometimes even with psychogenic and reflex arcs act synergisti- electroejaculation, even if there is concomi- cally to dictate the final erectile response via tant discomfort. It has yet to be proven a common parasympathetic pathway.44 The whether men in this latter group have some sympathetic nervous system is responsible for detumescence. After a complete UMN SCI, reflexogenic erections are usually pos- sible because the sacral pathways are left Men who are technically incomplete at intact. However, sympathetic pathways any level occasionally feel pleasurable stemming from T10-L1 (thoracolumbar) or orgasmic sensations with have the capacity to maintain the erection vibrostimulation and sometimes even independently if the sacral parasympathetic with electroejaculation, even if there is pathways are unavailable.44 This is the expla- concomitant discomfort. nation behind the psychogenic erectile ca- pacity in men with LMN lesions affecting the Ejaculation and Orgasm 11

sacral reflexes who have lost their reflex area of their zone of injury, their nipples, erection. , or neck. Even visceral (and likely The scientific literature on men with SCI autonomic) inputs may contribute to this corresponds to the experiences of women potential. It is this elevation of awareness that with SCI to a certain degree. Using the male is the basis of using the senses as primary analogy of pelvic arousal, it was felt that afferents (“sexual software” or the spiritual Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 women with UMN lesions above the sacral sciences50) that has expanded the pleasurable area were capable of reflex lubrication in the or even orgasmic scope for some men with same way men were capable of reflex erec- SCI whose “neurological hardware” has tion and that women with sacral lesions were been permanently disrupted.51 dependant on psychogenic lubrication as What is the relationship between erection men were with psychogenic erections. Fur- and ejaculation in UMN and LMN injuries? thermore, there is some evidence that women Men with complete UMN injuries usually with SCI and UMN dysfunction that affects retain their reflex erection (it may be en- the sacral spinal segments had preservation hanced) due to the loss of supraspinal inhibi- of their reflex genital vasocongestion.45,46 In tory control, but their ejaculatory capacity is able-bodied women, an increase in sympa- severely compromised. These reflex erec- thetic tone during sexual stimulation, tions can occur spontaneously, irrespective through anxiety-provoking stimulation,47 ex- of sexual awareness. Reflex erections can be ercise,48 or ephedrine,49 contributes posi- maintained through spasm, touch, sexual tively to both genital and subjective aspects activity, or sperm retrieval methods, but they of sexual response.33 Psychogenic-mediated can be lost with too much stimulation, as can genital vasocongestion (as measured objec- be seen with some positional changes in tively by photoplethysmography) in women intercourse and even with vibrostimulation. with SCI is associated with sensory preserva- Because of this, men with complete injury tion in the T11-L2 dermatomes where the above T12 whose sacral reflexes are unim- sympathetic pathways controlling genital paired often still need erection enhancement function originate.33 Because able-bodied to improve the reliability and predictability men are more subjectively aware of their of their reflex erections for sexual activity. arousal (erection) than women, the loss of These reflex erections respond well to such this reliable and well-reinforced awareness oral medications as the phosphodiesterase 5 after SCI may be one of the feedback loop (PDE5) inhibitors that are dependant on suf- deficiencies that prevent men with SCI from ficient (NO) sources. Men with capitalizing on their orgasmic capabilities as UMN lesions have this well as women with SCI do. However, men’s available not so much through mental sexual ultimate potential may be the same. arousal but through release of NO by touch Discussions with patients in sexual reha- stimulus to the penis (NO from both neuronal bilitation reveal that men with SCI who are and endothelial sources enters the smooth orgasmic either have incomplete lesions and/ muscle cell and produces the second messen- or have learned to incorporate or “ride” the ger cGMP, which in turn relaxes the smooth sensory or cerebral afferents generated by muscle and initiates penile ). stimulus of their genitalia, the hypersensitive PDE5 inhibitors inhibit the enzyme that de- 12 TOPICS IN SPINAL CORD INJURY REHABILITATION/SUMMER 2002

stroys cGMP, thereby allowing cGMP to Men with LMN lesions are dependent on remain longer in the cell, facilitating the their thoracolumbar centers to achieve psy- erection.52 Reflex erections are also sensitive chogenic erections. Unfortunately, stimula- to the intracavernosal injection of small tion of the thoracolumbar pathways also elic- doses of direct neurotransmitters such as its seminal emission. Men with LMN SCI

prostaglandin E1 that increase the cAMP who must maintain a high mental arousal to Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 level in the smooth muscle cell53 resulting in produce a psychogenic erection may find its relaxation and initiating erection. Al- that an unwanted, dribbling emission has though the studies of sildenafil did not show been triggered, resulting in detumescence. any significant effect on either the ability to These men with LMN injury will also have a ejaculate or sexual interest, it is my experi- disruption of the second phase of ejaculation ence that some men with SCI who undergo and poor somatic motor control of the stri- vibrostimulation for sperm retrieval benefit ated perineal muscle group. Other men with from the maintenance of a rigid erection incomplete LMN injuries may have more either through oral PDE5 inhibitors or reliable ejaculation or even orgasmic sensa- intracavernosal injection. The continuing tion if there is enough nerve recruitment in presence of a reliable erection may help some the sacral area. Erection enhancement, usu- men with SCI ejaculate on any particular day ally in the form of direct neurotransmitter if their ejaculation reflex is hard to attain, but replacement (intracavernosal injection of this has not been verified with qualitative prostaglandin), is often required to elicit an research. This theory is supported by one erection. In men with LMN lesions who study where sildenafil treatment was associ- cannot initiate an erection on their own, ated with significant improvements in over- PDE5 inhibitors are less effectual,56,57 be- all satisfaction, including frequency of cause there is less NO at the nerve endings to ejaculation and orgasm.54 Alternately, a rigid enter the smooth muscle cell in the first place. erection does not guarantee ejaculation in the Men with LMN complete lesions therefore men with complete UMN lesions who un- have fewer successful options for erection dergo vibrostimulation,22 because many enhancement. other factors, in particular the amplitude and speed of the vibrator,38,55 are more predictive. Summary Ejaculation to vibrostimulation has varying success rates; the best rate has been quoted as Although erection physiology has been 95% in those men with injuries higher than extensively studied in recent years, the scien- T12.38 However, rigidity of the penis and tific study of the sexual neurophysiology and retraction of the penis away from the body other extraneural factors involved in ejacula- have been helpful in eliciting ejaculation, tion and orgasm in men with SCI is in its possibly by potentiating the afferents of the infancy. Further investigation into the neuro- sacral reflex. Sometimes the reflex erection physiology of orgasm and its interpretation will rapidly disappear with the vibratory after SCI needs to be done. Future research stimulus, and the penis may remain flaccid should aim to provide a descriptive and until just prior to ejaculation where there may physiological definition of orgasm after SCI be acute filling of the glans alone. that could then be applied to proper surveys Ejaculation and Orgasm 13

and well-designed clinical trials. Further also need to take the patients’ pursuit of sexual study of the predictors of ejaculation and pleasure and gratification as seriously as the orgasm (physical examination markers, more “medical” sexual function and fertility techniques of attainment, and medical or consequences. psychological factors that inhibit or facilitate There are three principles of sexual reha- the capacity) and reduction of negative con- bilitation. The first is to maximize the innate Downloaded from http://meridian.allenpress.com/tscir/article-pdf/8/1/1/1983155/dktr-k2la-dg50-gj7h.pdf by guest on 25 September 2021 sequences of sexual activity (such as auto- physiology, even if that means experimenting nomic dysreflexia and incontinence) would with new mental and physical sources of greatly assist in the sexual rehabilitation of sexual stimulation. A second principle is a- men after SCI. daptation to limitations that remain, includ- The span of sexual consequences after SCI ing acceptance of such things as erection en- is great, extending from the physiological loss hancement and vibrostimulation. Men with of sexual function and fertility to the psycho- SCI and their partners need to communicate dynamic meaning of such changes. Men with with one another about their sexual experi- SCI have to learn about their new sexual body. ences and live through these experimenta- After injury, the perseverance or alteration of tions. This is the way the third principle, one sexual function may potentiate or hinder espousing a positive outlook on future sexual another. Men with SCI need to learn how to potential, is gained. Whether men with SCI coordinate new body signs as facilitatory or will ultimately fulfill their erectile, ejacula- inhibitory to their sexual functioning. As cli- tory, and orgasmic potential depends on the nicians and researchers, we need to listen to motivation and hope generated within them- what are, understandably, often vague or selves, by their partners, and by the interest of struggling descriptors of new sensations and responsible health care clinicians who can responses that the patients experience. We direct and encourage them in this quest.

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