Ejaculation and Orgasm: 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 spinal cord injury (SCI). The scientific literature focuses on potentiating erection and on the sperm retrieval procedures for fertility 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, adaptation to limitations, and promotion of a positive outlook for sexual potential via experimen- tation. Key words: ejaculation, erection, orgasm, spinal cord injury 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 pleasure 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 erections 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 Psychiatry, Division of Sexual Medicine; 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- physiology 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 vibrator 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 sexual stimulation 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.