SEMINARS I N NEUROLOGY-VOLUME
12, NO. 2 JUNE 1992
Penile Erection in Men with Spinal Cord or Cauda Equina Lesions
For several decades it has been a widespread belief that individuals with a spinal cord lesion (SCL) or cauda equina lesion are permanently and completely impotent and sterile. Even John Money (cited by Anderson and Cole') implied that paraplegia is sexually totally disabling. Fortunately, many investigations have shown that this is not true. However, Comarr and Vigue2 state that health professionals have been guilty of perpetuating the myth that disabled individuals are asexual; and, according to Anderson and Cole,l many people harbor the belief that a person with some degree of paralysis or deformity is unable to engage in sexual intercourse at all. On the other hand, Weiss and Diamond3 found a positive correlation between their SCL patients' avoidance of a conscious consideration of their sexuality and avoidance of a realistic acceptance of their physical disability. Likewise Lindner4 found that sexually nonfunctioning paraplegics showed decreased ability to engage in vocational training or other gainful hospital occupation and seemed to express their sexual disability symbolically through feelings of insecurity and helplessness. Those who were sexually potent did not have the same difficulty in relating to others. It appeared that maximum rehabilitation and successful hospital discharge had a high positive correlation with sexual potency and were negatively correlated with sexual impotence. T h e study indicates that sexual functioning is a basic factor among the motivations and dynamics of such chronic physical disabilities as paraplegia. Sexual dysfunction following SCL has fortunately attracted considerable attention from workers in the field, in large part, probably, because many of the people affected by SCL are young, active, and otherwise health^.^ Modern rehabilitation
techniques have given them much greater life expectancy,\nd considerably greater mobility. Preoccupation with future sexual performance occurs early and is quite prominent in the minds of persons with SCL.5 It is a common experience that SCL men may more easily accept their motor deficits, even when considerable, than their sexual problems. Some of these patients even indicate that, if they had the choice, they would rather regain their sex life than their motor function; the erectile dysfunction is a frustrating c o n d i t i ~ n . ~ However, as Yarkonyg pointed out, this kind of statement has not been substantiated by scientific studies. This review will primarily consider the physical aspects related to penile erection in SCL men, and not go into depth with the many other, equally important parts of sexual behavior. Furthermore, we do not distinguish between individuals with nontraumatic SCL or cauda equina lesions (including congenital spina bifida, sequelae after transverse myelitis, spinal cord tumors, and prolapsed discs) and traumatic spinal cord injuries since they have the same erection and fertility problems, although the last group constitutes the majority of the spinal cord-lesioned population.
NEUROLOGY Several reports on sexual function in SCL have reviewed and discussed the neurologic background for e r e ~ t i o n ; ~for - ~that ~ reason, it will be presented here only in bare outline. A parasympathetic center (reflex-activated center), located in segments S2-4 of the spinal cord, is the main mediator of erection; it effects vasodilation and opening of the arteriovenous
Centre for Spinal Cord Injured, Department T H , and Department o f Urology, Rigshospitalet, University o f Copenhagen, Copenhagen, Denmark Copyright O 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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Fin Biering-S@rensen,M.D., Ph.D., and Jens Slnksen, M.D.
PENILE ERECTION AND SPINAL CORD INJURY-BIERING-S@RENSEN, S~NKSEN
CONSEQUENCE OF SPINAL CORD OR CAUDA EQUINA LESIONS Following a sudden and complete spinal cord transection, three disorders of function become evideng4: (1) all voluntary movement below the level of the lesion is immediately and permanently lost; (2) all sensations are abolished; and (3) reflex function in all segments of the isolated spinal cord is completely lost (spinal shock). Less complete lesions of the spinal cord may result in little or no spinal shock, and the same is true for lesions that develop slowly. Guttmann18 distinguished three phases in the pathophysiology of the sexual organs: spinal shock, reflex return, and readjustment. SPINAL SHOCK
The phase of spinal shock lasts from a few hours to several weeks, during which time there is a complete or almost complete suppression of reflex activity below the level of the cord lesion. The male genital reflexes (reflex penile erection, bulbocavernosus and scrota1 reflexes) are abolished or profoundly depressed. The erectional and ejaculatory functions are abolished. In complete lesions, the penis may become enlarged and partially erect as a result of a passive engorgement of the corpora cavernosa from paralytic vasodilation following the interruption of the vasoconstrictor fibers in the anterolateral tracts of the spinal cord.ls T h e stage of spinal shock is believed to be due to the sudden interruption of the suprasegmental descending fiber systems that keep the spinal motor neurons in a continuous state of subliminal depolarization (ready to respond).24 The period of spinal shock is the main reason that it usually is impossible to predict sexual function, including erection and ejaculation, in SCL males within the first weeks after the injury.
RETURN OF REFLEXES
When spinal shock subsides, reflex activity and spasticity may appear in the lower extremities, and bladder and bowel function may become reflexogenic. In upper motor neuron lesions the erection reflex becomes one of the components of the autonomic functions of the isolated cord, taking part in the "mass response." In fact, it may appear, independent of cerebral participation, before the reflex responses of the skeletal muscles are fully developed. Tactile stimuli of varying type and intensity, including stimulation of the glans and around the penis, result in erection.I8 READJUSTMENT
Sexual readjustment after a SCL depends greatly on the particular person's wishes, experience, and sexual habits in the pre-SCL life, whether this applies to love play or actual methods of intercourse. It may also to a great extent depend on the cooperation and helpfulness of a partner.18 Siosteen et alZ5found that sexual readjustment after injury was closely and positively correlated with willingness to experiment with alternative sexual expressions and young age at injury. Physical and social independence and a high mood level were further positive determinants of sexual adaptation after injury.
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shunts in the corpora cavernosa. The efferents run in the nervi erigentes, but the final path is believed to be short adrenergic nerves that release norepinephrine and act on P receptors. T h e afferents transmitting penile sensation run in the pudendal nerve to the sacral center. A sympathetic center (psychogenically activated center), located in T11-L2, likewise mediates erection through fibers in the hypogastric nerves to the corpora cavernosa. Erection is sustained by compression of the veins between the expanded corpora and the tunica albuginea.
ERECTION IN MEN WITH SPINAL CORD LESIONS
Three types of erections after SCL have been des~ribed."?'~ Reflexogenic erection is induced by cutaneous or mucous membrane stimulation from areas below the level of the lesion, thus requiring an intact reflex arc, including S2-4. Rigidity of the penis can be obtained when the lesion is above T 11, whereas the erection will involve only the corpora cavernosa and not the corpus spongiosum when the level is caudal to T 11. Psychogenic erection is induced by psychic stimulation: visual, auditory, olfactory, as well as from dreams, memories, and fantasies. In SCL men with lesions below L2 it is believed to be mediated from the cerebral cortex via the thoracolumbar sympathetic outflow. This erection results only in swelling and lengthening of the penis without rigidity and therefore without the possibility of intromission. Mixed erection may occur when the level of the lesion is below L2 and above S2. The erectile response may differ individually regarding the duration and quality of the erection. so-called spontaneous erection is probably 99
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they had lost the capacity for psychogenic erection. Nevertheless, the data in Table 1 give some idea of the erectile capability of SCL men. FREQUENCY OF ERECTION IN MEN WITH SPINAL Tsuji et aP3 reported a very low frequency of CORD LESIONS successful coitus, as shown in Table 1, but this was Table 1 gives an overview of previously re- caused by the lack of an opportunity for the maported frequencies of erection and successful coi- jority of the patients in that study to test their sextus in SCL men. Several previous reviews and ual ability. On the other hand, Jackson3' found that studiesg~10~17~19~20~33~44 have stressed the difficulty in 75% of his group of SCL male athletes engaged interpreting the various results because of metho- successfully in intercourse. Even when men with SCL are able to achieve dologic factors. These include variability in subject selection and data collection (for instance, infor- erections, the quality and frequency of the erecmation may be obtained by questionnaire alone or tions experienced in many cases are not equivalent by personal interview), poorly described diagnostic to those of other men. Reflexogenic erections criteria for determining the level and extent of the often are extremely brief.46Bors and Comarr12also SCL; failure to identify variables such as age, du- reported that some paraplegics described reflex ration of SCL, and general health status; possible erections as occurring more readily with an empty surgical intervention such as external sphincter re- than with a full bladder. The possible influence of the type and level of section;45previous sexual experience; and opportunity for sexual activity. However, the most im- lesion is illustrated with the figures in Table 2, portant problem may be that the validity of from Bors and Comarr's study.12 In general, the retrospective reports obtained from men with SCL frequency of erection is higher among SCL men is not known. Thus, Kennedy and Over44found with incomplete than with complete lesions, with that among SCL men who were studied with upper than with lower motor neuron lesions (that strain-gauge measurement of penile tumescence is, SCL that do or do not preserve S2-4), and with when exposed to erotic material, several who had high rather than low levels of SCL." However, as anticipated they would achieve erection failed to pointed out by Comarr,14 even though the knowldo so, whereas others demonstrated penile tumes- edge about completeness and upper motor neuron cence during erotic stimulation despite claiming lesion, lower motor neuron lesion, or both, makes
Table 1. Erection (Any Type) and Successful Coitus in Men with Spinal Cord or Cauda Equina Lesions* Reference
Munro et al, 1 94826 Bors 1948 (see Bors and Comarr12) Talbot, 1 94gZ7 Bors et al, 1 95OZ8 Kuhn, 195OZ9 Talbot, 1955% Zeitlin et al, 1 95731 Bors and Cornarr, 1 96012 Money, 196OX Tsuji et al, 196133
-
Hohmann, 1966" Comarr, 1 97014 Jochheim and Wahle, 1 97035 Wahle and Jochheirn, 1 9703= Jackson, 1 97237 Piera, 1973% Fitzpatrick, 1 97415 Comarr and Vigue, 1 97839 Morley et al, 197g40 Uyttendaele et al, 197gZ2 Taylor and Coolican, 1 9884' Slot et al, 198g4' Zasler and Katz, 1 98943 Siosteen et al, 1 99OZ5
Erection
Successful Coitus (%)
84 157 200 34 29 208 100 529 14 638 46 25 150
74 87 64 88 86 69 86 81 79 54 73 72 82
33 23' 23 26 50 5
48 20 100 14 153 18 18 16 38 20 60
58 85 79 86 90 83 78 81 95 70 83
75 39t 21 69 66t 64
54-95%
5-75%
No. Men
271 9 'Includes complete and incomplete lesions, and full as well as partial erection. tNot stated that the frequency is the frequency of successful coitus.
(=a
38
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caused by covert intrinsic reflex stimulation in individuals with upper motor neuron lesion^.'^
PENILE ERECTION AND SPINAL CORD INJURY-BIERING-S@RENSEN, S@NKSEN Table 2.
Effect of Completeness and Upper versus Lower Motor Neuron Lesion on Erection and Successful Coitus*
T v ~ of e Lesion
No. Men
Erection
Successful Coitus (%j
Complete upper motor neuron Incomplete upper motor neuron Complete lower motor neuron Incomplete lower motor neuron All types of lesion 'Figures from Bors and Comarr.lz
PHYSICAL MANAGEMENT We will here describe some of the experiences gathered from the literature on the achievement of erection in individuals with SCL. SIMPLE METHODS
Kuhn2"ound that slight movements of the prepuce over a sharply circumscribed reflexogenous area, including the corona of the glans and the penile frenulum, was the most effective stimulus for the elicitation of penile erection, and almost invariably evoked complete penile erection within 30 seconds. Once elicited, it was possible to prolong erection indefinitely. Some patients claimed to have an increase in the number of erections with an indwelling urethral catheter. In general, there was a fairly close correlation between the vigor and frequency of skeletal muscle activity and the frequency of penile erection. A rather striking finding was the penile detumescence that occurred during digital (or other) stretch of the internal anal sphincter. ComarrJ4likewise presented a series of case reports illustrating the use of lower limb spasticity, catheter manipulation, precoital bladder
emptying, and application of hot towels to the penile shaft in facilitating or maintaining erections, and masturbation has been found to be helped by lubricant^.^' Further penile vibratory stimulation could improve the erection in 30% of patients.48 Erection can be improved or prolonged by an elastic band (constriction or retention band, rubber ring) carefully placed at the root of the penis to trap blood, and thereby maintain penile rigidity for a longer period.48 It is important to instruct SCL men not to use the band for more than 30 minutes at a time, to avoid ischemic damage. Artificial penile appliances of plastic material can be of help to some individuals with no or insufficient erection.23
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possible a general prognosis, it does not necessarily provide an accurate prognosis of future sexual function in the individual case. Furthermore, Siosteen et a125 found that the neurologic level and completeness of injury showed no significant correlation with sexuality. In a group of patients with complete or incomplete injuries Tsuji et a133found recovery of the erectile function in about 25% within 1 month after injury, in 60% within 6 months, and in 80% within 1 year. In 5%, the recovery occurred after 2 years. In those with cervical or thoracic vertebral injury, 30 to 40% regained the erectile function within 1 month, and 70 to 80% within 6 months. Only 10% of those with a lumbar vertebral injury recovered the erectile function within 1 month and 40% within 6 months.
VACUUM DEVICES
External devices in the form of vacuum pumps, either manual or electric, have been used for many years in the management of erectile dysfunction. The device consists of a plastic cylinder into which the flaccid penis is placed and subsequently engorged with blood by producing a vacuum within the device. Once adequate penile size has been attained, a constricting band is slid from the base of the device onto the base of the penile shaft to maintain the erection. T h e cylinder is then removed from the penis and sexual intercourse may be initiated. As previously stated, it is advisable to remove the constriction band after 30 minutes, and the skin should be monitored. Patients on anticoagulant medication and those with a bleeding disorder should not use this system. Lloyd et a1,49in a follow-up study of such a vacuum device in 13 SCL men, reported that 92% were able to achieve an erection sufficient for intercourse and indicated overall satisfaction with the device. With the use of the device, the frequency of intercourse increased. They emphasize the importance of instruction and adequate demonstration for the male user and partner prior to issuing the device. Zasler and K a t have ~ ~ ~recently presented an alternative vacuum device (Synergist erection sys-
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injection technique. The dose required may vary considerably from person to person, even among patients with the same degree and level of SCL. Lloyd and Richards" instructed their impotent men to alternate sides for the injection and vary the injection site along the lateral aspect of the penis to decrease the risk of fibrosis. In addition, we recommend a maximum of one injection a week." For training in self-injection, two to five consultations are usually required. The majority of SCL men seem to be quite satisfied with the intracavernous technique and feel that it gives them a new option. The men, as well as their partners, may derive psychologic benefit from restoration of erectile function that permits penile-vaginal intercourse. In a follow-up study of SCL men using self-injection,j5one indicated that it had not meant a general improvement in the relationship with his female partner, but it gave their sexual life an important supplement. One man PHARMACOLOGIC MANAGEMENT without a partner stated that it was an important psychologic support to know that he could have an INTRACAVERNOUS INJECTION erection if required. Intracavernous injection of vasoactive drugs to Virag et als%ave recently presented their 8produce erection was first reported in 1982 by year experience with intracavernous self-injection Vi~-ag,~O who used papaverine, a smooth muscle re- of vasoactive drugs in 615 impotent men, includlaxant that produces both vasodilation and relaxa- ing 12 with paraplegia or tetraplegia. In all, 87% tion of the sinusoidal spaces in the corpora caver- were available for follow-up: 114 episodes of pronosa. Brindley5' used intracavernosal injection of longed erections among 5 1 men represented less phenoxybenzamine and obtained full erection in than 3 per 1000 of the 38,475 recorded injections. two of three SCL men. Since that time, several re- All these patients were treated successfully. The ports have been published, primarily on the use of percentage of patients with nodules or permanent p a p a ~ e r i n e " . ~or ~ -a~ combination ~ of papaverine deformations was 2.8. No cases of intracavernous and phentolamine, a potent short-acting a-block- fibrosis were diagnosed. In 40 SCL men,57compliin- men ~ ~ - ~ ~cations . ~ ~ occurred frequently, 52% experiencing ing agent that causes v a s ~ d i l a t i o n , ~ ~ with SCL. some complication (prolonged erection, ecchymoIn SCL men it is the general experience that sis, and fibrosis) although fibrosis in this patient the denervated tissues are supersensitive to the group appeared less often in those with SCL than drugs used for intracavernous in those with vascular impotence. The difference Thus, the time of erection is longer and the quality may be related to the less frequent use by SCL men of erection is better in men with neurogenic im- or the much lower doses required. potence compared with men with vascular impoDisadvantages with injection therapy for ert e n ~ e . ~In' general, SCL males are younger and ectile dysfunction in SCL men thus appear to be: hence more likely to have normal vasculature. To (1) a risk of prolonged erection and of fibrosis in avoid sustained erection, the patient should begin the corporal tissue as a result of numerous injecwith low doses of papaverine, gradually increase t i o n ~ (2) ; ~ concern ~ regarding unknown long-term the dose, and add phentolamine only if necessary. side effect^;^' and (3) stress induced by injection The patient must be instructed to see his doctor o r therapy, a method too "technical" and therefore hospital when an erection lasts for more than 6 unacceptable to some patients.62 hours, to have the erection reversed. Sustained erection may require aspiration of blood from the CUTANEOUS APPLICATION corpora cavernosa and intracavernosal injection of Because of the potential complications caused an a-adrenergic agent. If the male partner is unable to perform the by injection therapy and the positive results obinjection himself because of motoric problems, the tained by Claes and Baert63in impotent men using female partner may be taught the intracavernous nitroglycerin plasters placed on the skin of the pe-
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tem), which consists of a soft, transparent silicone sheath with a thin pliable collar at its base. The unit is worn during intercourse. Proper sizing of the device is necessary. The device was demonstrated to both the patient and his partner under supervision. All 20 respondents reported successful vaginal intercourse after having used the device on at least 20 separate occasions. The device was reported to be easy to use and on the average it took 3 to 5 minutes to apply by the patient or his partner. The system differs from other vacuum devices in that theoretically it can be used for prolonged periods of time because of the absence of a constricting band. In those SCL patients with detrusor hyperreflexia and a resultant potential for reflex micturition, partner protection is provided by the device.
PENILE ERECTION AND SPINAL CORD INJURY-BIERING-S~REN~EN, S~NKSEN
SCL men used the implant-driven erection for sexual i n t e r c ~ u r s e Achievement .~~ of erection is certainly not an indication for this implant, but when it is in place it is possible to use it for erection.
EPILOGUE
Higginslhoted that, although the nature of sexual response may be altered, sexual activity persists and is enjoyed by a large segment of the SCL population. Actually, the majority of SCL men are enthusiastic about and have a need for sexual coun~eling.'~However, other factors may affect sexual function, including age, associated diseases, SURGICAL MANAGEMENT medication, partner relationships, and opportunities for sexual activity.76Kennedy and Over44rePENILE PROSTHESIS ported the important findings that, among SCL men, subjective sexual arousal was independent of The surgical insertion of penile prostheses tumescence levels and that SCL men who did not (rigid, semirigid, inflatable) has been used for a have erections were subjectively no less aroused by number of years in SCL menm-" to obtain erection film, spoken text, and fantasy than SCL men with for intercourse, and also to facilitate application of erections or men who did not have SCL. Therefore external condom-type urinary drainage devices as any claim that SCL men who gain erections are HOWwell as intermittent self-~atheterization.~~~;~ more "sexual" than SCL men who do not is untenever, complications such as infection, tissue breakable. Men who are unable to engage in intercourse down, and extrusion of the prosthesis occur more must therefore be encouraged to achieve sexual frequently in individuals with SCL than in other arousal and satisfaction through other activities, types of patients for whom penile prostheses are used. Extrusion or removal of the prosthesis has none of which is labeled inferior to intercourse. Our advice to a man with SCL who wants been the result in 16 to 25% of SCL patient^.^^,^^,^^ treatment of his erectile dysfunction will at the preFallon et alj2 even report that 48% of the prosthesent time be primarily to try out the physical manses in this series had to be revised or removed or agement methods, in particular a constriction band had failed during follow-up. T h e complication rate or vacuum device. If these procedures are found increased with the duration of follow-up. Because to be insufficient, we prefer to use the noninvasive of loss of sensation and vasomotor control, and pharmacologic procedure, with a plaster on the pepressure produced by the penile prosthesis, SCL nile shaft, and, after this, intracavernous injecmen represent a higher operative risk than other tions. Finally, we find that surgical management is men. In addition, urinary tract infection should the ultimate and is very seldom indicated for ernot be overlooked as another major risk factor for ectile dysfunction in SCL men. infection to develop around the prosthesis. Careful individual preoperative assessment is advised if a satisfactory result is to be achieved." It is imperaREFERENCES tive to select individuals for this procedure who have self-esteem and motivation, and who care for 1. Anderson TP, Cole TM. Sexual counseling of the physithemselves well in their activities of daily living.66 cally disabled. Postgrad Med 1975;58: 117-23
SACRAL ANTERIOR ROOT STIMULATOR
Brindley and coworker^^^-^^ have demonstrated that the sacral anterior root stimulator for bladder control can also be used to obtain erection. Of 38 SCL men, 26 were able to produce penile erection by means of the implant; the erection lasted without decrement for as long as stimulation continued, even as long as an In their longterm follow-up they found that 10 of 37 surviving
2. Comarr AE, Vigue M. Sexual counseling among male and female patients with spinal cord andlor cauda equina injury. Part 11. Am J Physical Med 1978;57: 215-27 3. Weiss AJ, Diamond MD. Sexual adjustment, identification, and attitudes of patients with myelopathy. Arch Phys Med Rehabil 1966;47:245-50 4. Lindner H. Perceptual sensitization to sexual phenomena in the chronic physically handicapped. J Clin Psychol 1953;9:67-8 5. Boller F, Frank E. Sexual dysfunction in neurological disorders. Diagnosis, management, and rehabilitation. New York: Raven Press, 1982:40-4
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nile shaft, we tested this procedure on men with SCL."' We used a Transderm-Nitro patch, 10 mg/ 24 hours (Ciba-Geigy), and found that, of 17 SCL men who had responded to intracavernous papaverine injections with sufficient erection, five reported an erection sufficient for vaginal penetration and seven had a partial erection. T h e complications with this method are primarily related to allergic dermatitis, which we did not observe, and headache, which requires only mild analgesics. We therefore suggest that this noninvasive treatment should be tried in SCL men before injection therapy is initiated.
6. Geisler WO, Jousse AT, Wynne-Jones M, Breithaupt D. Survival in traumatic spinal cord injury. Paraplegia 1983;21:364-73 7. DeVivo MJ, Kartus PL, Stover SL, Rutt RD, Fine PR. Seven-year survival following spinal cord injury. Arch Neurol 1987;44:872-5 8. Lamid S. Nocturnal penile tumescence studies in spinal cord injured males. Paraplegia 1985;23:26-31 9. Yarkony GM. Enhancement of sexual function a n d fertility in spinal cord-injured males. Am J Phys Med Rehabil l990;69:8 1-7 10. Bennett CJ, Seager SW, Vasher EA, McGuire EJ. Sexual dysfunction a n d electroejaculation in men with spinal cord injury: review. J Urol 1988;139:453-7 11. Beretta G, Zanollo A, Fanciullacci F, Catanzaro F. Intracavernous injection of papaverine in paraplegic males. Acta Eur Fertil 1986; 17:283-4 12. Bors E, Comarr AE. Neurological disturbances of sexual function with special reference to 529 patients with spinal cord injury. Urol Surv 1960;10: 191-222 13. Chapelle PA, Durand J , Lacert P. Penile erection following complete spinal cord injury in man. Br J Urol 1980;52:216-9 14. Comarr AE. Sexual function among patients with spinal cord injury. Urol Int 1970;25: 134-68 15. Fitzpatrick WF. Sexual function in the paraplegic patient. Arch Phys Med Rehabil 1974;55:221-7 16. Gott LJ. Anatomy a n d physiology of male sexual response a n d fertility as related to spinal cord injury. In Sha'ked A, ed: Human sexuality a n d rehabilitation medicine. Sexual functioning following spinal cord injury. Baltimore: Williams & Wilkins, 198 1:67-73 17. Griffith ER, Tomoko MA, Timms RJ. Sexual function in spinal cord-injured patients: a review. Arch Phys Med Rehabil 1973;54:539-43 18. Guttmann L. Spinal cord injuries. Comprehensive management a n d research, 2nd ed. Oxford: Blackwell Scientific Publications, 1976:474-505 19. Higgins GE Jr. Sexual response in spinal cord injured adults: a review of the literature. Arch Sex Behav 1979;8: 173-96 20. Kolodny RC, Masters W H , Johnson VE. Sex a n d the handicapped. In Kolodny RC, Masters W H , Johnson VE: Textbook of sexual medicine. Boston: Little, Brown, 1979:353-80 21. Tarabulcy E. Sexual function in the normal a n d in paraplegia. Paraplegia 1972; 10:20 1-8 22. Uyttendaele D, D'Hooghe M, Brusselmans W, DeGrote W, Claessens H . T h e sexual problem in tetra- a n d paraplegia. Physical and relational aspects. Acta O r t h o p Belg 1979;45:470-9 23. Verkuyl A. Sexual function in paraplegia a n d tetraplegia. In: Vinken P J , Bruyn GW, eds: Handbook of clinical neurology, vol. 26. Amsterdam: North-Holland Publishing, 1976:437-61 24. Adams DB, Victor M. Diseases of the spinal cord. In: Adarns DB, Victor M: Principles of neurology, 4th ed. New York: McGraw Hill, 1989:718-54 25. Siijsteen A, Lundqvist C , Blomstrand C, Sullivan L, Sullivan M. Sexual ability, activity, attitudes a n d satisfaction as part of adjustment in spinal cord-injured subjects. Paraplegia 1990;28:285-95 26. Munro D, Horne HW, Paull DP. T h e effect of injury to the spinal cord a n d cauda equina on the sexual potency of men. N Engl J Med 1948;239:903-11 27. Talbot HS. A report o n sexual function in paraplegics. J Urol 1949;61:265-70 28. Bors E, Engle ET, Rosenquist KC, Holliger VH. Fertility in paraplegic males: a preliminary report of endocrine studies. J Clin Endocrinol 1950; 103381-98 29. Kuhn RA. Functional capacity of the isolated human spinal cord. Brain 1950;73: 1-5 1 30. Talbot HS. T h e sexual function in paraplegia. J Urol 1955;73:91-100
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31. Zeitlin AB, Cottrell T L , Lloyd FA. Sexology of the paraplegic male. Fertil Steril 1957;8:337-44 32. Money J. Phantom orgasm in the dreams of paraplegic men a n d women. Arch Gen Psychiatry 1960;3:373-82 33. Tsuji I , Nakajima F, Morimoto J , Nounaka Y. T h e sexual function in patients with spinal cord injury. Urol I n t 1961;12:270-80 34. Hohmann GW. Some effects of spinal cord lesions o n experienced emotional feelings. Psychophysiology 1966; 3: 143-56 35. Jochheim KA, Wahle H. A study o n sexual function in 5 6 male patients with complete irreversible lesions of the spinal cord and cauda equina. Paraplegia 1970;8: 16670 36. Wahle H , Jochheim KA. Untersuchungen iiber neurogene Storungen d e r Sexualfunktion bei 5 6 querschnittgelahmten Mannern mit kompletten irreversiblen Schadigungen des Riickenmarks o d e r d e r Cauda equina. Fortschr Neurol Psychiatr 1970;38: 192-201 37. Jackson RW. Sexual rehabilitation after cord injury. Paraplegia 1972; 10:50-5 38. Piera JB. T h e establishment of a prognosis for genitosexual function in the paraplegic and tetraplegic male. Paraplegia 1973; 10:271-8 39. Comarr AE, Vigue M. Sexual counseling among male a n d female patients with spinal cord andlor cauda equina injury. Part I. Am J Phys Med 1978;57:107-22 40. Morley JE, Distiller LA, Lissoos I, et al. Testicular function in patients with spinal cord damage. H o r m Metab Res 1979; 11 :679-82 41. Taylor TKF, Coolican MJR. Injuries of the conus medullaris. Paraplegia 1988;26:393-400 42. Slot 0 , Drewes A, Andreasen A, Olsson A. Erectile a n d ejaculatory function of males with spinal cord injury. Int Disabil Stud 1989; 1 1:75-7 43. Zasler ND, Katz PG. Synergist erection system in the management of impotence secondary to spinal cord injury. Arch Phys Med Rehabil 1989;70:712-6 44. Kennedy S, Over R. Psychophysiological assessment of male sexual arousal following spinal cord injury. Arch Sex Behav 1990; 19: 15-27 45. Dollfus P, Jurascheck F, Adli G, Chapuis A. Impairment of erection after external sphincter resection. Paraplegia 1976; 13:290-3 46. Amelar RD, Dubin L. Sexual function a n d fertility in paraplegic males. Urology 1982;20:62-65 47. Francois N, Maury M. Sexual aspects in paraplegic patients. Paraplegia 1987;25:289-92 48. Francois N , Jouannet P, Maury M. La fonction genitosexuelle des paraplegiques. .J Urol (Paris) 1983; 89: 159-64 49. Lloyd EE, Toth LL, Perkash I. Vacuum tumescence: an option for spinal cord in.jured males with erectile dysfunction. SCI Nurs 1989;6:25-8 50. Virag R. Intracavernous injection of papaverine for erectile failure (Letter to the editor). Lancet 1982;2:938 51. Brindley GS. Cavernosal alpha-blockade: a new technique for investigating a n d treating erectile impotence. Br J Psychiatry 1983;143:332-7 52. Bodner DR, Lindan R, Leffler E, Kursh ED, Resnick MI. T h e application of intracavernous injection of vasoactive medications for erection in men with spinal cord injury. J Urol 1987;138:310-1 53. Sidi AA, Cameron JS, Duffy LM, Lange PH. Intracavernous drug-induced erections in the management of male erectile dysfunction: Experience with 100 patients. J Urol 1986; 135:704-6 54. Sidi AA, Cameron JS, Dykstra DD, Reinberg Y, Lange PH. Vasoactive intracavernous pharmacotherapy for the treatment of erectile impotence in men with spinal cord injury. J Urol 1987; 138:539-42 55. S ~ n k s e nJOR, Hansen EF, Biering-Sdrensen F, Colstrup H . Intracavernous self-injection for treatment of erective dysfunction in patients with spinal cord lesions.
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56.
57. 58.
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60. 61. 62. 63. 64. 65.
Ugeskr Laeger 1990;152:3006-9 (In Danish with summary in English) Virag R, Sussman H , Floresco J, Shoukry K. Late results on the treatment of neurogenic impotence by selfintracavernous-injection (SICI) of vasoactive drugs. World J Urol 1987;5: 166-70 Lloyd LK, Richards JS. Intracavernous pharmacotherapy for management of erectile dysfunction in spinal cord injury. Paraplegia 1989;27:457-64 Wyndaele JJ, deMeyer JM, deSy WA, Claessens H. Intracavernous injection of vasoactive drugs, an alternative for treating impotence in spinal cord injury patients. Paraplegia 1986;24:271-5 Virag R, Shoukry K, Floresco J, Nollet F, Greco E. Intracavernous self-injection of vasoactive drugs in the treatment of impotence: 8-year experience with 615 cases. J Urol 1991; 145:287-93 Jiinernann K-P, Alken P. Pharmacotherapy of erectile dysfunction: a review. Int J Impotence Res 1989;1:7193 Sidi AA, Reddy PK, Chen KK. Patient acceptance of and satisfaction with vasoactive intracavernous pharmacotherapy for impotence. J Urol 1988; 140:293-4 Sonksen J , Biering-S@rensen F. Transcutaneous nitroglycerin in the treatment of erectile dysfunction in spinal cord injured. Paraplegia 1992; (in press) Claes H, Baert L. Transcutaneous nitroglycerine therapy in the treatment of impotence. Urol Int 1989;44:30912 Arsdalen KNV, Klein FA, Hackler RH, Brady SM. Penile implants in spinal cord injury patients for maintaining external appliances. J Urol 1981; 126:331-2 Golji H. Experience with penile prosthesis in spinal cord injury patients. J Urol 1979; 12 1:288-9
66. Green BG, Sloan SL. Penile prostheses in spinal cord injured patients: combined psychosexual counselling and surgical regimen. Paraplegia 1986;24: 167-72 67. Iwatsubo E, Tanaka M, Takahashi K, Akatsu T. Non-inflatable penile prosthesis for the management of urinary incontinence and sexual disability of patients with spinal cord injury. Paraplegia 1986;24:307-10 68. Kabalin JN, Kessler R. Infectious complications of penile prosthesis surgery. J Urol 1988;139:953-5 69. Rossier AB, Fam BA. Indication and results of semirigid penile prostheses in spinal cord injury patients: Longterm followup. J Urol 1984; 131:59-61 70. Scott FB, Fishman IJ, Light JF. A decade of experience with the inflatable prosthesis. World J Urol 1983; 1:244-50 71. Smith AD, Sazama R, Lange PH. Penile prosthesis: adjunct to treatment in patients with neurogenic bladder. J Urol 1980; 124:363-4 72. Fallon B, Rosenberg S, Culp DA. Long-term followup in patients with an inflatable penile prosthesis. J Urol 1984; 132:270-1 73. Brindley GS, Rushton DN. Long-term follow-up of patients with sacral anterior root stimulator implants. Paraplegia 1990;28:469-75 74. Brindley GS, Polkey CE, Rushton DN. Sacral anterior root stimulators for bladder control in paraplegia. Paraplegia 1982;20:365-8 1 75. Brindley GS, Polkey CE, Rushton DN, Cardozo L. Sacral anterior root stimulators for bladder control in paraplegia: the first 50 cases. J Neurol Neurosurg Psychiatry 1986;49: 1104-14 76. Larsen E, Hejgaard N. Sexual dysfunction after spinal cord or cauda equina lesions. Paraplegia 1984;22: 66-74
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PENILE ERECTION AND SPINAL CORD INJURY-BIERING-SORENSEN, S~NKSEN
12, NO. 2 JUNE 1992
Penile Erection in Men with Spinal Cord or Cauda Equina Lesions
For several decades it has been a widespread belief that individuals with a spinal cord lesion (SCL) or cauda equina lesion are permanently and completely impotent and sterile. Even John Money (cited by Anderson and Cole') implied that paraplegia is sexually totally disabling. Fortunately, many investigations have shown that this is not true. However, Comarr and Vigue2 state that health professionals have been guilty of perpetuating the myth that disabled individuals are asexual; and, according to Anderson and Cole,l many people harbor the belief that a person with some degree of paralysis or deformity is unable to engage in sexual intercourse at all. On the other hand, Weiss and Diamond3 found a positive correlation between their SCL patients' avoidance of a conscious consideration of their sexuality and avoidance of a realistic acceptance of their physical disability. Likewise Lindner4 found that sexually nonfunctioning paraplegics showed decreased ability to engage in vocational training or other gainful hospital occupation and seemed to express their sexual disability symbolically through feelings of insecurity and helplessness. Those who were sexually potent did not have the same difficulty in relating to others. It appeared that maximum rehabilitation and successful hospital discharge had a high positive correlation with sexual potency and were negatively correlated with sexual impotence. T h e study indicates that sexual functioning is a basic factor among the motivations and dynamics of such chronic physical disabilities as paraplegia. Sexual dysfunction following SCL has fortunately attracted considerable attention from workers in the field, in large part, probably, because many of the people affected by SCL are young, active, and otherwise health^.^ Modern rehabilitation
techniques have given them much greater life expectancy,\nd considerably greater mobility. Preoccupation with future sexual performance occurs early and is quite prominent in the minds of persons with SCL.5 It is a common experience that SCL men may more easily accept their motor deficits, even when considerable, than their sexual problems. Some of these patients even indicate that, if they had the choice, they would rather regain their sex life than their motor function; the erectile dysfunction is a frustrating c o n d i t i ~ n . ~ However, as Yarkonyg pointed out, this kind of statement has not been substantiated by scientific studies. This review will primarily consider the physical aspects related to penile erection in SCL men, and not go into depth with the many other, equally important parts of sexual behavior. Furthermore, we do not distinguish between individuals with nontraumatic SCL or cauda equina lesions (including congenital spina bifida, sequelae after transverse myelitis, spinal cord tumors, and prolapsed discs) and traumatic spinal cord injuries since they have the same erection and fertility problems, although the last group constitutes the majority of the spinal cord-lesioned population.
NEUROLOGY Several reports on sexual function in SCL have reviewed and discussed the neurologic background for e r e ~ t i o n ; ~for - ~that ~ reason, it will be presented here only in bare outline. A parasympathetic center (reflex-activated center), located in segments S2-4 of the spinal cord, is the main mediator of erection; it effects vasodilation and opening of the arteriovenous
Centre for Spinal Cord Injured, Department T H , and Department o f Urology, Rigshospitalet, University o f Copenhagen, Copenhagen, Denmark Copyright O 1992 by Thieme Medical Publishers, Inc., 381 Park Avenue South, New York, NY 10016. All rights reserved.
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Fin Biering-S@rensen,M.D., Ph.D., and Jens Slnksen, M.D.
PENILE ERECTION AND SPINAL CORD INJURY-BIERING-S@RENSEN, S~NKSEN
CONSEQUENCE OF SPINAL CORD OR CAUDA EQUINA LESIONS Following a sudden and complete spinal cord transection, three disorders of function become evideng4: (1) all voluntary movement below the level of the lesion is immediately and permanently lost; (2) all sensations are abolished; and (3) reflex function in all segments of the isolated spinal cord is completely lost (spinal shock). Less complete lesions of the spinal cord may result in little or no spinal shock, and the same is true for lesions that develop slowly. Guttmann18 distinguished three phases in the pathophysiology of the sexual organs: spinal shock, reflex return, and readjustment. SPINAL SHOCK
The phase of spinal shock lasts from a few hours to several weeks, during which time there is a complete or almost complete suppression of reflex activity below the level of the cord lesion. The male genital reflexes (reflex penile erection, bulbocavernosus and scrota1 reflexes) are abolished or profoundly depressed. The erectional and ejaculatory functions are abolished. In complete lesions, the penis may become enlarged and partially erect as a result of a passive engorgement of the corpora cavernosa from paralytic vasodilation following the interruption of the vasoconstrictor fibers in the anterolateral tracts of the spinal cord.ls T h e stage of spinal shock is believed to be due to the sudden interruption of the suprasegmental descending fiber systems that keep the spinal motor neurons in a continuous state of subliminal depolarization (ready to respond).24 The period of spinal shock is the main reason that it usually is impossible to predict sexual function, including erection and ejaculation, in SCL males within the first weeks after the injury.
RETURN OF REFLEXES
When spinal shock subsides, reflex activity and spasticity may appear in the lower extremities, and bladder and bowel function may become reflexogenic. In upper motor neuron lesions the erection reflex becomes one of the components of the autonomic functions of the isolated cord, taking part in the "mass response." In fact, it may appear, independent of cerebral participation, before the reflex responses of the skeletal muscles are fully developed. Tactile stimuli of varying type and intensity, including stimulation of the glans and around the penis, result in erection.I8 READJUSTMENT
Sexual readjustment after a SCL depends greatly on the particular person's wishes, experience, and sexual habits in the pre-SCL life, whether this applies to love play or actual methods of intercourse. It may also to a great extent depend on the cooperation and helpfulness of a partner.18 Siosteen et alZ5found that sexual readjustment after injury was closely and positively correlated with willingness to experiment with alternative sexual expressions and young age at injury. Physical and social independence and a high mood level were further positive determinants of sexual adaptation after injury.
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shunts in the corpora cavernosa. The efferents run in the nervi erigentes, but the final path is believed to be short adrenergic nerves that release norepinephrine and act on P receptors. T h e afferents transmitting penile sensation run in the pudendal nerve to the sacral center. A sympathetic center (psychogenically activated center), located in T11-L2, likewise mediates erection through fibers in the hypogastric nerves to the corpora cavernosa. Erection is sustained by compression of the veins between the expanded corpora and the tunica albuginea.
ERECTION IN MEN WITH SPINAL CORD LESIONS
Three types of erections after SCL have been des~ribed."?'~ Reflexogenic erection is induced by cutaneous or mucous membrane stimulation from areas below the level of the lesion, thus requiring an intact reflex arc, including S2-4. Rigidity of the penis can be obtained when the lesion is above T 11, whereas the erection will involve only the corpora cavernosa and not the corpus spongiosum when the level is caudal to T 11. Psychogenic erection is induced by psychic stimulation: visual, auditory, olfactory, as well as from dreams, memories, and fantasies. In SCL men with lesions below L2 it is believed to be mediated from the cerebral cortex via the thoracolumbar sympathetic outflow. This erection results only in swelling and lengthening of the penis without rigidity and therefore without the possibility of intromission. Mixed erection may occur when the level of the lesion is below L2 and above S2. The erectile response may differ individually regarding the duration and quality of the erection. so-called spontaneous erection is probably 99
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they had lost the capacity for psychogenic erection. Nevertheless, the data in Table 1 give some idea of the erectile capability of SCL men. FREQUENCY OF ERECTION IN MEN WITH SPINAL Tsuji et aP3 reported a very low frequency of CORD LESIONS successful coitus, as shown in Table 1, but this was Table 1 gives an overview of previously re- caused by the lack of an opportunity for the maported frequencies of erection and successful coi- jority of the patients in that study to test their sextus in SCL men. Several previous reviews and ual ability. On the other hand, Jackson3' found that studiesg~10~17~19~20~33~44 have stressed the difficulty in 75% of his group of SCL male athletes engaged interpreting the various results because of metho- successfully in intercourse. Even when men with SCL are able to achieve dologic factors. These include variability in subject selection and data collection (for instance, infor- erections, the quality and frequency of the erecmation may be obtained by questionnaire alone or tions experienced in many cases are not equivalent by personal interview), poorly described diagnostic to those of other men. Reflexogenic erections criteria for determining the level and extent of the often are extremely brief.46Bors and Comarr12also SCL; failure to identify variables such as age, du- reported that some paraplegics described reflex ration of SCL, and general health status; possible erections as occurring more readily with an empty surgical intervention such as external sphincter re- than with a full bladder. The possible influence of the type and level of section;45previous sexual experience; and opportunity for sexual activity. However, the most im- lesion is illustrated with the figures in Table 2, portant problem may be that the validity of from Bors and Comarr's study.12 In general, the retrospective reports obtained from men with SCL frequency of erection is higher among SCL men is not known. Thus, Kennedy and Over44found with incomplete than with complete lesions, with that among SCL men who were studied with upper than with lower motor neuron lesions (that strain-gauge measurement of penile tumescence is, SCL that do or do not preserve S2-4), and with when exposed to erotic material, several who had high rather than low levels of SCL." However, as anticipated they would achieve erection failed to pointed out by Comarr,14 even though the knowldo so, whereas others demonstrated penile tumes- edge about completeness and upper motor neuron cence during erotic stimulation despite claiming lesion, lower motor neuron lesion, or both, makes
Table 1. Erection (Any Type) and Successful Coitus in Men with Spinal Cord or Cauda Equina Lesions* Reference
Munro et al, 1 94826 Bors 1948 (see Bors and Comarr12) Talbot, 1 94gZ7 Bors et al, 1 95OZ8 Kuhn, 195OZ9 Talbot, 1955% Zeitlin et al, 1 95731 Bors and Cornarr, 1 96012 Money, 196OX Tsuji et al, 196133
-
Hohmann, 1966" Comarr, 1 97014 Jochheim and Wahle, 1 97035 Wahle and Jochheirn, 1 9703= Jackson, 1 97237 Piera, 1973% Fitzpatrick, 1 97415 Comarr and Vigue, 1 97839 Morley et al, 197g40 Uyttendaele et al, 197gZ2 Taylor and Coolican, 1 9884' Slot et al, 198g4' Zasler and Katz, 1 98943 Siosteen et al, 1 99OZ5
Erection
Successful Coitus (%)
84 157 200 34 29 208 100 529 14 638 46 25 150
74 87 64 88 86 69 86 81 79 54 73 72 82
33 23' 23 26 50 5
48 20 100 14 153 18 18 16 38 20 60
58 85 79 86 90 83 78 81 95 70 83
75 39t 21 69 66t 64
54-95%
5-75%
No. Men
271 9 'Includes complete and incomplete lesions, and full as well as partial erection. tNot stated that the frequency is the frequency of successful coitus.
(=a
38
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caused by covert intrinsic reflex stimulation in individuals with upper motor neuron lesion^.'^
PENILE ERECTION AND SPINAL CORD INJURY-BIERING-S@RENSEN, S@NKSEN Table 2.
Effect of Completeness and Upper versus Lower Motor Neuron Lesion on Erection and Successful Coitus*
T v ~ of e Lesion
No. Men
Erection
Successful Coitus (%j
Complete upper motor neuron Incomplete upper motor neuron Complete lower motor neuron Incomplete lower motor neuron All types of lesion 'Figures from Bors and Comarr.lz
PHYSICAL MANAGEMENT We will here describe some of the experiences gathered from the literature on the achievement of erection in individuals with SCL. SIMPLE METHODS
Kuhn2"ound that slight movements of the prepuce over a sharply circumscribed reflexogenous area, including the corona of the glans and the penile frenulum, was the most effective stimulus for the elicitation of penile erection, and almost invariably evoked complete penile erection within 30 seconds. Once elicited, it was possible to prolong erection indefinitely. Some patients claimed to have an increase in the number of erections with an indwelling urethral catheter. In general, there was a fairly close correlation between the vigor and frequency of skeletal muscle activity and the frequency of penile erection. A rather striking finding was the penile detumescence that occurred during digital (or other) stretch of the internal anal sphincter. ComarrJ4likewise presented a series of case reports illustrating the use of lower limb spasticity, catheter manipulation, precoital bladder
emptying, and application of hot towels to the penile shaft in facilitating or maintaining erections, and masturbation has been found to be helped by lubricant^.^' Further penile vibratory stimulation could improve the erection in 30% of patients.48 Erection can be improved or prolonged by an elastic band (constriction or retention band, rubber ring) carefully placed at the root of the penis to trap blood, and thereby maintain penile rigidity for a longer period.48 It is important to instruct SCL men not to use the band for more than 30 minutes at a time, to avoid ischemic damage. Artificial penile appliances of plastic material can be of help to some individuals with no or insufficient erection.23
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possible a general prognosis, it does not necessarily provide an accurate prognosis of future sexual function in the individual case. Furthermore, Siosteen et a125 found that the neurologic level and completeness of injury showed no significant correlation with sexuality. In a group of patients with complete or incomplete injuries Tsuji et a133found recovery of the erectile function in about 25% within 1 month after injury, in 60% within 6 months, and in 80% within 1 year. In 5%, the recovery occurred after 2 years. In those with cervical or thoracic vertebral injury, 30 to 40% regained the erectile function within 1 month, and 70 to 80% within 6 months. Only 10% of those with a lumbar vertebral injury recovered the erectile function within 1 month and 40% within 6 months.
VACUUM DEVICES
External devices in the form of vacuum pumps, either manual or electric, have been used for many years in the management of erectile dysfunction. The device consists of a plastic cylinder into which the flaccid penis is placed and subsequently engorged with blood by producing a vacuum within the device. Once adequate penile size has been attained, a constricting band is slid from the base of the device onto the base of the penile shaft to maintain the erection. T h e cylinder is then removed from the penis and sexual intercourse may be initiated. As previously stated, it is advisable to remove the constriction band after 30 minutes, and the skin should be monitored. Patients on anticoagulant medication and those with a bleeding disorder should not use this system. Lloyd et a1,49in a follow-up study of such a vacuum device in 13 SCL men, reported that 92% were able to achieve an erection sufficient for intercourse and indicated overall satisfaction with the device. With the use of the device, the frequency of intercourse increased. They emphasize the importance of instruction and adequate demonstration for the male user and partner prior to issuing the device. Zasler and K a t have ~ ~ ~recently presented an alternative vacuum device (Synergist erection sys-
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injection technique. The dose required may vary considerably from person to person, even among patients with the same degree and level of SCL. Lloyd and Richards" instructed their impotent men to alternate sides for the injection and vary the injection site along the lateral aspect of the penis to decrease the risk of fibrosis. In addition, we recommend a maximum of one injection a week." For training in self-injection, two to five consultations are usually required. The majority of SCL men seem to be quite satisfied with the intracavernous technique and feel that it gives them a new option. The men, as well as their partners, may derive psychologic benefit from restoration of erectile function that permits penile-vaginal intercourse. In a follow-up study of SCL men using self-injection,j5one indicated that it had not meant a general improvement in the relationship with his female partner, but it gave their sexual life an important supplement. One man PHARMACOLOGIC MANAGEMENT without a partner stated that it was an important psychologic support to know that he could have an INTRACAVERNOUS INJECTION erection if required. Intracavernous injection of vasoactive drugs to Virag et als%ave recently presented their 8produce erection was first reported in 1982 by year experience with intracavernous self-injection Vi~-ag,~O who used papaverine, a smooth muscle re- of vasoactive drugs in 615 impotent men, includlaxant that produces both vasodilation and relaxa- ing 12 with paraplegia or tetraplegia. In all, 87% tion of the sinusoidal spaces in the corpora caver- were available for follow-up: 114 episodes of pronosa. Brindley5' used intracavernosal injection of longed erections among 5 1 men represented less phenoxybenzamine and obtained full erection in than 3 per 1000 of the 38,475 recorded injections. two of three SCL men. Since that time, several re- All these patients were treated successfully. The ports have been published, primarily on the use of percentage of patients with nodules or permanent p a p a ~ e r i n e " . ~or ~ -a~ combination ~ of papaverine deformations was 2.8. No cases of intracavernous and phentolamine, a potent short-acting a-block- fibrosis were diagnosed. In 40 SCL men,57compliin- men ~ ~ - ~ ~cations . ~ ~ occurred frequently, 52% experiencing ing agent that causes v a s ~ d i l a t i o n , ~ ~ with SCL. some complication (prolonged erection, ecchymoIn SCL men it is the general experience that sis, and fibrosis) although fibrosis in this patient the denervated tissues are supersensitive to the group appeared less often in those with SCL than drugs used for intracavernous in those with vascular impotence. The difference Thus, the time of erection is longer and the quality may be related to the less frequent use by SCL men of erection is better in men with neurogenic im- or the much lower doses required. potence compared with men with vascular impoDisadvantages with injection therapy for ert e n ~ e . ~In' general, SCL males are younger and ectile dysfunction in SCL men thus appear to be: hence more likely to have normal vasculature. To (1) a risk of prolonged erection and of fibrosis in avoid sustained erection, the patient should begin the corporal tissue as a result of numerous injecwith low doses of papaverine, gradually increase t i o n ~ (2) ; ~ concern ~ regarding unknown long-term the dose, and add phentolamine only if necessary. side effect^;^' and (3) stress induced by injection The patient must be instructed to see his doctor o r therapy, a method too "technical" and therefore hospital when an erection lasts for more than 6 unacceptable to some patients.62 hours, to have the erection reversed. Sustained erection may require aspiration of blood from the CUTANEOUS APPLICATION corpora cavernosa and intracavernosal injection of Because of the potential complications caused an a-adrenergic agent. If the male partner is unable to perform the by injection therapy and the positive results obinjection himself because of motoric problems, the tained by Claes and Baert63in impotent men using female partner may be taught the intracavernous nitroglycerin plasters placed on the skin of the pe-
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tem), which consists of a soft, transparent silicone sheath with a thin pliable collar at its base. The unit is worn during intercourse. Proper sizing of the device is necessary. The device was demonstrated to both the patient and his partner under supervision. All 20 respondents reported successful vaginal intercourse after having used the device on at least 20 separate occasions. The device was reported to be easy to use and on the average it took 3 to 5 minutes to apply by the patient or his partner. The system differs from other vacuum devices in that theoretically it can be used for prolonged periods of time because of the absence of a constricting band. In those SCL patients with detrusor hyperreflexia and a resultant potential for reflex micturition, partner protection is provided by the device.
PENILE ERECTION AND SPINAL CORD INJURY-BIERING-S~REN~EN, S~NKSEN
SCL men used the implant-driven erection for sexual i n t e r c ~ u r s e Achievement .~~ of erection is certainly not an indication for this implant, but when it is in place it is possible to use it for erection.
EPILOGUE
Higginslhoted that, although the nature of sexual response may be altered, sexual activity persists and is enjoyed by a large segment of the SCL population. Actually, the majority of SCL men are enthusiastic about and have a need for sexual coun~eling.'~However, other factors may affect sexual function, including age, associated diseases, SURGICAL MANAGEMENT medication, partner relationships, and opportunities for sexual activity.76Kennedy and Over44rePENILE PROSTHESIS ported the important findings that, among SCL men, subjective sexual arousal was independent of The surgical insertion of penile prostheses tumescence levels and that SCL men who did not (rigid, semirigid, inflatable) has been used for a have erections were subjectively no less aroused by number of years in SCL menm-" to obtain erection film, spoken text, and fantasy than SCL men with for intercourse, and also to facilitate application of erections or men who did not have SCL. Therefore external condom-type urinary drainage devices as any claim that SCL men who gain erections are HOWwell as intermittent self-~atheterization.~~~;~ more "sexual" than SCL men who do not is untenever, complications such as infection, tissue breakable. Men who are unable to engage in intercourse down, and extrusion of the prosthesis occur more must therefore be encouraged to achieve sexual frequently in individuals with SCL than in other arousal and satisfaction through other activities, types of patients for whom penile prostheses are used. Extrusion or removal of the prosthesis has none of which is labeled inferior to intercourse. Our advice to a man with SCL who wants been the result in 16 to 25% of SCL patient^.^^,^^,^^ treatment of his erectile dysfunction will at the preFallon et alj2 even report that 48% of the prosthesent time be primarily to try out the physical manses in this series had to be revised or removed or agement methods, in particular a constriction band had failed during follow-up. T h e complication rate or vacuum device. If these procedures are found increased with the duration of follow-up. Because to be insufficient, we prefer to use the noninvasive of loss of sensation and vasomotor control, and pharmacologic procedure, with a plaster on the pepressure produced by the penile prosthesis, SCL nile shaft, and, after this, intracavernous injecmen represent a higher operative risk than other tions. Finally, we find that surgical management is men. In addition, urinary tract infection should the ultimate and is very seldom indicated for ernot be overlooked as another major risk factor for ectile dysfunction in SCL men. infection to develop around the prosthesis. Careful individual preoperative assessment is advised if a satisfactory result is to be achieved." It is imperaREFERENCES tive to select individuals for this procedure who have self-esteem and motivation, and who care for 1. Anderson TP, Cole TM. Sexual counseling of the physithemselves well in their activities of daily living.66 cally disabled. Postgrad Med 1975;58: 117-23
SACRAL ANTERIOR ROOT STIMULATOR
Brindley and coworker^^^-^^ have demonstrated that the sacral anterior root stimulator for bladder control can also be used to obtain erection. Of 38 SCL men, 26 were able to produce penile erection by means of the implant; the erection lasted without decrement for as long as stimulation continued, even as long as an In their longterm follow-up they found that 10 of 37 surviving
2. Comarr AE, Vigue M. Sexual counseling among male and female patients with spinal cord andlor cauda equina injury. Part 11. Am J Physical Med 1978;57: 215-27 3. Weiss AJ, Diamond MD. Sexual adjustment, identification, and attitudes of patients with myelopathy. Arch Phys Med Rehabil 1966;47:245-50 4. Lindner H. Perceptual sensitization to sexual phenomena in the chronic physically handicapped. J Clin Psychol 1953;9:67-8 5. Boller F, Frank E. Sexual dysfunction in neurological disorders. Diagnosis, management, and rehabilitation. New York: Raven Press, 1982:40-4
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nile shaft, we tested this procedure on men with SCL."' We used a Transderm-Nitro patch, 10 mg/ 24 hours (Ciba-Geigy), and found that, of 17 SCL men who had responded to intracavernous papaverine injections with sufficient erection, five reported an erection sufficient for vaginal penetration and seven had a partial erection. T h e complications with this method are primarily related to allergic dermatitis, which we did not observe, and headache, which requires only mild analgesics. We therefore suggest that this noninvasive treatment should be tried in SCL men before injection therapy is initiated.
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VOLUME 12, NUMBER 2 JUNE 1992
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SEMINARS IN NEUROLOGY
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PENILE ERECTION AND SPINAL CORD INJURY-BIERING-SORENSEN, S~NKSEN
