Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex.

BACKGROUND: The bladder exstrophy-epispadias complex is a rare congenital malformation associated with severe dysfunction of the genital and urinary tracts and requiring a staged surgical reconstruction. AIM: The primary aims of this study were to report the sexuality, infertility, and urinary incontinence outcomes in a cohort of men born with bladder exstrophy-epispadias complex. The secondary aim was to highlight some predictive factors of infertility in this population. METHODS: We conducted a descriptive, cross-sectional study of men diagnosed with classic presentations of bladder exstrophy or epispadias. OUTCOMES: Patients were asked to complete 4 validated questionnaires: the International Index of Erectile Function (IIEF)-5, the Erection Hardness Score (EHS), the Self-Esteem and Relationship, and the International Consultation Incontinence modular Questionnaire-Short Form. Fertility potential was assessed with semen analysis and a non-validated questionnaire. RESULTS: 38 Patients 18-64 years old (M [mean] = 32.2) completed the questionnaires. The average IIEF-5 score was 18.1/25 (ranging from 3-25; SE = 7.62), with results indicating that 55% of the sample had normal erectile function. Results also showed higher scores for patients with normal spermatozoa concentration (M = 22.75, SE = 1.89, P = .08) than for those with oligospermia (M = 17.30, SE = 8.53, P = .08). Results on the IIEF-5 also indicated higher scores for patients who conceived children without assisted reproductive technologies (ART) (M = 22.83, SE = 2.317, P = .02) than for patients without children (M = 15.76, SE = 8.342, P = .02). The average EHS was 3.43/4 (ranging from 1-4, SE = 0.9). EHS was higher for patients who had reconstruction than for patients who had cystectomy (M = 3.88, SE = 1.07 and 2.78, SE = 1.09, P = .02). The average total Self-Esteem and Relationship score was 67.04/100 (ranging from 10.71-96.43, SE = 22.11). The average total International Consultation Incontinence modular Questionnaire-Short Form score was 4.97/21 (ranging from 0-18, SE = 5.44), higher score indicating more urinary incontinence. Among the patients surveyed, 31.6% were parents at the time of study and 50% of them benefited from ART. With regards to the 14 semen analyses performed, only 7.1% produced normal results and 44.7% indicated that ejaculation was weak and dribbling. CLINICAL TRANSLATION: Erectile function appears to be decreased and psychological aspects of sexuality indicate low self-esteem about sexual relationship. Although ethical problems could not allow prospective spermograms, our cohort is large enough to provide significant data. CONCLUSIONS: Early sperm storage for future ART, sexual medicine management, and complementary genital reconstruction in adulthood constitute potential treatment options for this population. Reynaud N, Courtois F, Mouriquand P, et al. Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex. J Sex Med 2017;15:314-323.

Validation of a Self-Report Questionnaire Assessing the Bodily and Physiological Sensations of Orgasm.

INTRODUCTION: Despite a plethora of research on sexual functioning during the past decades, the field is still lacking standardized measurements specifically characterizing orgasm. Although several validated tools are available to assess sexual function in healthy and clinical populations, items on orgasm are limited to frequency or dichotomous responses. A neurophysiologic model of orgasm developed from previous research in able-bodied and spinally injured populations offers a promising framework for the construction of a new questionnaire. AIM: To develop and validate a brief self-report measurement of orgasm by the assessment of bodily and physiologic sensations perceived during climax by able-bodied individuals. Although the currently available tool focuses on the phenomenological sensations associated with climax, the goal of this questionnaire was to capture the more specific genital and extragenital sensations associated with orgasm. MAIN OUTCOME MEASURES: The current Bodily Sensations of Orgasm questionnaire and the Orgasm Rating Scale. METHODS: Data from previous research conducted on individuals with spinal cord injury and the available empirical literature provided a pool of 45 items organized into four categories, which were reviewed by an expert panel. Upon review, a 28-item questionnaire was created and administered to a community sample of 227 participants, including men and women, 18 to 73 years old. RESULTS: Exploratory factor analyses supported the four-factor model, in which orgasm is comprised of extragenital sensations, genital sensations and spasms, nociceptive sensations, and sweating responses. Overall, a high degree of internal consistency was found for the final 22-item questionnaire (Cronbach α = 0.87), with individual reliability coefficients showing moderate to high internal consistency (r = 0.65-0.79) for each dimension. Overall temporal stability of the measurement was acceptable (r = 0.74). Using the Orgasm Rating Scale, satisfying convergent validity was confirmed, thereby indicating that the two measurements are complementary. CONCLUSION: The Bodily Sensations of Orgasm questionnaire allows for a brief evaluation of the physical and physiologic sensations associated with orgasm. Findings also suggest perceptual differences between men and women with regard to climax, with women reporting a larger repertoire of climactic sensations during orgasm.

Genital Sensory Detection Thresholds and Patient Satisfaction With Vaginoplasty in Male-to-Female Transgender Women.

INTRODUCTION: Gender-affirming surgery is common for the treatment of gender dysphoria, but its effect on genital sensitivity is not well known. AIMS: To investigate genital sensory detection thresholds in male-to-female transgender women postoperatively and their relation to psychological well-being and variables of satisfaction. METHODS: Prospective study on 28 transgender women at least 18 years old operated on at least 3 months before the study by a single surgeon (N.M.J.). MAIN OUTCOME MEASURES: Medical complications; sensory detection thresholds for light touch, pressure, and vibration; and questionnaires on general and sexual satisfaction, sexual function, depression, and psychological well-being. RESULTS: Sensory detection thresholds ranged from 0.07 to 2.82 g for light touch, with the neck being most sensitive; from 20.23 to 34.64 g for pressure, with similar results for the neck and clitoris; and from 0.0052 to 0.0111 V for vibration, with similar findings for all stimulation points. Satisfaction with the appearance of the labia, vulva, clitoris, and sexual function was good to very good. Frequency of sexual activities increased significantly postoperatively for orogenital stimulation and decreased significantly for frequency of fantasies (t = -4.81; P < .0001). Orgasmic function was reported by 80% of participants. Psychological adjustment was good to very good, with low depression scores. Sexual satisfaction was statistically and positively correlated with vaginal function and depth, clitoral sensation, appearance of the vulva and labia minora, and natural lubrication and negatively correlated with depression scores. CONCLUSION: Gender-affirming surgery yields good results for satisfaction with appearance and function. Genital sensitivity showed the best results with pressure and vibration.

Sexuality for women with spinal cord injury.

The authors conducted a review of the literature on women's sexuality after spinal cord injury, including studies from 1990 to 2011 retrieved from PubMed. Several facets of a woman's sexuality are negatively affected by after spinal cord injury, and consequently, sexual satisfaction has been shown to decrease, which also negatively affects quality of life. Neurogenic bladder is common after spinal cord injury, and the resulting urinary incontinence is a top therapeutic priority of this population. To improve sexual satisfaction and quality of life for women with spinal cord injury, future research needs to explore the effects of urinary incontinence on various aspects of sexuality.

The assessment of sensory detection thresholds on the perineum and breast compared with control body sites.

INTRODUCTION: Few studies explored multiple sensory detection thresholds on the perineum and breast, but these normative data may provide standards for clinical conditions such as aging, genital and breast surgeries, pathological conditions affecting the genitals, and sexual function. AIMS: The aim of this study was to provide normative data on sensory detection thresholds of three sensory modalities on the perineum and breast. METHODS: Thirty healthy women aged between 18 and 35 years were assessed on the perineum (clitoris, labia minora, vaginal, and anal margin), breast (lateral, areola, nipple), and control body locations (neck, forearm, abdomen) for three sensory modalities (light touch, pressure, vibration). MAIN OUTCOME MEASURES: Average detection thresholds for each body location and sensory modality and statistical comparisons between the primary genital, secondary sexual, and neutral zones were the main outcome measures. RESULTS: Average detection thresholds for light touch suggest that the neck, forearm, and vaginal margin are most sensitive, and areola least sensitive. No statistical difference is found between the primary and secondary sexual zones, but the secondary sexual zone is significantly more sensitive than the neutral zone. Average detection thresholds for pressure suggest that the clitoris and nipple are most sensitive, and the lateral breast and abdomen least sensitive. No statistical difference is found between the primary and secondary sexual zone, but they are both significantly more sensitive than the neutral zone. Average detection thresholds for vibration suggest that the clitoris and nipple are most sensitive. The secondary sexual zone is significantly more sensitive than the primary and neutral zone, but the latter two show no difference. CONCLUSION: The current normative data from sensory detection threshold are discussed in terms of providing standard values for research and clinical conditions. Additional analysis from breast volume, body mass index, hormonal contraception, menstrual cycle, and sexual orientation do not seem to influence the results. Sexual abstinence and body piercing may have some impact.

Surgical outcomes and patients' satisfaction with suprapubic phalloplasty.

INTRODUCTION: Many techniques, specifically forearm free flap phalloplasty, are used in penile reconstructive surgery. Although satisfying, a major disadvantage is the large, stigmatizing scar on the donor site, which leads many patients to explore alternatives. AIM: The aim of this study is to assess the outcomes and satisfaction of patients offered the choice between metaidioplasty, forearm free flap, and suprapubic phalloplasty. METHODS: Medical outcomes from the three-stage surgery were collected from the hospital files of 24 patients, who were also interviewed to assess their satisfaction, sexual function, and psychosexual well-being. MAIN OUTCOME MEASURES: Medical complications, anthropometric measures, and interviewing questionnaire on satisfaction with appearance, sexual function, and psychological variables. RESULTS: Duration of surgery and of hospital stay was relatively short in the first (1 hour 30 minutes; 3 days) and last (1 hour 40 minutes; 3 days) stage of surgery involving tissue expansion and neophallus release. These two stages were associated with few complications (17% and 4% minor complications respectively, 12% additional complications with hospitalization for the first stage). The second stage involving tubing was associated with longer surgery and hospital stay (2 hour 15 minutes; 5 days) and had more complications (54% minor complications and 29% requiring hospitalization) although fewer than one-step surgery. No loss of neophallus was reported. Overall, 95% of patients were satisfied with their choice of phalloplasty, 95% with the appearance, 81% with the length (Mean = 12.83 cm), and 71% with the circumference (Mean = 10.83 cm) of their neophallus. Satisfactory appearance was significantly correlated (P < 0.01) with penile length (r = 0.69) and diameter (r = 0.77). Sexual satisfaction was significantly correlated with penile diameter (r = 0.758), frequency of orgasm (r = 0.71), perceived importance of voiding while standing (r = 0.56), presurgery satisfaction with sexuality (r = 0.58), current masculine-feminine scale (r = 0.58), attractive-unattractive scale (r = 0.69), and happy-depressed scale (r = 0.63). CONCLUSION: Suprapubic phalloplasty, despite the lack of urethroplasty, offers an interesting alternative for patients concerned with the stigmatizing scar on the donor site.

Breastfeeding Following Spinal Cord Injury: Consumer Guide for Mothers.

The World Health Organization (WHO) recommends that infants be breastfed exclusively for the first 6 months of age. However, there are few resources available on the effects a spinal cord injury (SCI) can have for breastfeeding mothers. It is difficult to find information to address the unique challenges women with SCI experience when planning or trying to breastfeed. Our international team, including women with SCI, health care providers, and SCI researchers, aims to address the information gap through the creation of this consumer guide. The purpose of this consumer guide is to share the most common issues women with SCI experience during breastfeeding and provide information, practical suggestions, recommendations, and key resources in lay language. General information about breastfeeding is available on the internet, in books, or from friends and health care providers. We do not intend to repeat nor replace general breastfeeding information or medical advice. Breastfeeding for mothers with SCI is complex and requires a team of health care providers with complementary expertise. Such a team may include family physician, obstetrician, physiatrist, neurologist, occupational and physical therapist, lactation consultant, midwife, and psychologist. We hope this consumer guide can serve as a quick reference guide for mothers with SCI planning of trying to breastfeed. This guide will also be helpful to health care providers as an educational tool.

Motherhood after Spinal Cord Injury: Breastfeeding, Autonomic Dysreflexia, and Psychosocial Health: Clinical Practice Guidelines.

The World Health Organization (WHO) recommends that children be breastfed exclusively for the first 6 months of age. This recommendation may prove challenging for women with spinal cord injury (SCI) who face unique challenges and barriers to breastfeeding due to the impact of SCI on mobility and physiology. Tailored provision of care from health care professionals (HCPs) is important in helping women navigate these potential barriers. Yet, HCPs often lack the confidence and SCI-specific knowledge to meet the needs of mothers with SCI. An international panel of clinicians, researchers, consultants, and women with lived experience was formed to create an accessible resource that can address this gap. A comprehensive survey on breastfeeding complications, challenges, resources, and quality of life of mothers with SCI was conducted, along with an environmental scan to evaluate existing postpartum guidelines and assess their relevance and usability as recommendations for breastfeeding after SCI. Building on this work, this article provides evidence-based recommendations for HCPs, including but not limited to general practitioners, obstetricians, pediatricians, physiatrists, lactation consultants, nurses, midwives, occupational therapists, and physiotherapists who work with prospective and current mothers with SCI.

Looking Beyond the Chair: Psycho-Perceptual Predictors of Sexual Distress and Sexual Satisfaction in Individuals with Spinal Cord Injury.

Despite a large body of biomedical research, little is known about the psychological and perceptual predictors of sexual satisfaction (SS) and sexual distress (SD) post spinal cord injury (SCI). Guided by a bio-psycho-perceptual framework, this cross-sectional research aimed at assessing SS and SD in a large SCI sample using validated patient-reported outcome measures (PROM). Significant correlates and predictors of SS and SD were also identified. Ninety-one men and women with SCI completed PROMs of SS and SD, as well as psychological (mood, sexual and body esteem) and perceptual (interoceptive awareness, trait mindfulness, sexual mindfulness) factors. Neurological profiles were also assessed, along with experience of orgasm. Correlates of SS and SD were first identified using Pearson's correlations, then multiple hierarchical regression models were computed to isolate predictors. Orgasm experience and psychological factors emerged as moderate correlates of both SS and SD, while neurological factors did not. Interoceptive awareness and trait mindfulness showed weak associations with SD and none with SS. Among the tested predictors, experience of orgasm emerged as the strongest for SS (ß = -.29, p < .01), followed by mood, which predicted SS and SD. Sexual and body esteem was predictive of SD only. In sexually active participants, sexual mindfulness predicted both SS (ß = 0.55, p < .001) and SD (ß = -0.56, p < .001) above and beyond all other variables. This study reveals unique aspects of SS and SD postinjury and supports further consideration of psychological and perceptual dimensions of SCI sexuality in rehabilitation research.

Side effects of intradetrusor botulinum toxin injections on ejaculation and fertility in men with spinal cord injury: preliminary findings.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The beneficial effect of intradetrusor botulinum toxin (BT) injections on hyperactive bladders in individuals with spinal cord injury is known from the literature, but its potential effect on ejaculation and fertility through diffusion is not. As BT injection paralyses the bladder muscle, it may also paralyse the muscular envelopes of the adjacent reproductive organs and lead to potential negative side effects, which have not been studied yet. This study provides preliminary data on the potential negative side effects of BT injections on semen volume and retrograde ejaculation, as well as some potential beneficial effects on semen quality. OBJECTIVE: To investigate the effect of botulinum neurotoxin A on ejaculation potential and fertility. Intradetrusor injection of botulinum neurotoxin A is most commonly used nowadays to treat overactive bladder in patients with spinal cord injury (SCI). PATIENTS AND METHODS: Retrospective analyses were carried out of 11 patients with complete lesions from C5 to T6 who had received botulinum (BT) injections for their overactive bladder and who had undergone ejaculation tests before and after BT treatment. RESULTS: BT treatment was found effective in improving bladder function in up to 85% of the cases. While no patients maintained natural ejaculation following their SCI, BT treatment was found to increase the incidence of retrograde ejaculation (vibrostimulation) in 46% of cases and to diminish semen volume in 77% of cases, from an average of 1.8 mL to 1 mL. Semen quality was slightly improved following BT treatment, sperm mobility increased in 67% of cases, sperm vitality in 50% and semen culture improved in 43%. CONCLUSIONS: BT treatment has beneficial and detrimental effects on ejaculation function. The detrimental effects involve retrograde ejaculation and reduced semen volume, which are explained by the spread of toxin to the bladder neck, reducing its tonus, and to the smooth muscle sexual accessory organs, reducing the strength of their contraction. The beneficial effects are explained by the reduced contamination of the semen by urinary infection, which may improve spermatogenesis and subsequent semen quality. The results are discussed in terms of their clinical implications and advice to patients.

Peritraumatic dissociation as a mediator of peritraumatic distress and PTSD: a retrospective, cross-sectional study.

The objective of the present article was to examine the mediational significance of peritraumatic dissociation in the relationship between peritraumatic distress and posttraumatic stress disorder (PTSD). A total of 71 individuals with spinal cord injuries completed interviews and questionnaires measuring PTSD symptomatology, peritraumatic dissociation, and peritraumatic distress. Peritraumatic dissociation was found to partially mediate the relationship between peritraumatic distress and PTSD symptomatology. These findings provide support for the hypothesis that peritraumatic distress and peritraumatic dissociation significantly impact PTSD severity. The findings also support the hypothesis that peritraumatic dissociation is provoked by peritraumatic distress. The results further indicate that although peritraumatic dissociation seems to be a significant risk factor for PTSD, it is not necessary for the development of PTSD; the presence of peritraumatic distress may be sufficient. These findings highlight the importance of investigating peritraumatic reactions after a traumatic event in order to identify individuals at risk for developing PTSD. Such a practice may help prevent the development of chronic conditions.

Risk factors for posttraumatic stress disorder in persons with spinal cord injury.

PURPOSE: Many of the events that cause spinal cord injury (SCI) are traumatic events that can result in posttraumatic stress disorder (PTSD). It therefore appears that most persons with SCI are at risk for developing PTSD. This study retrospectively examined risk factors for PTSD symptoms in a sample of 71 persons with SCI. METHOD: The Structured Clinical Interview for DSM-IV was used to assess full and partial PTSD diagnoses. Self-administered questionnaires were used to measure potential risk factors. RESULTS: Results indicated that 11% of the participants met the criteria for full PTSD, and an additional 20% met the criteria for partial PTSD at some point after their SCI. Hierarchical linear regression analyses revealed that trauma history, peritraumatic reactions, and intolerance of uncertainty predicted the number of PTSD symptoms. CONCLUSION: This study highlights the importance of trauma history, peritraumatic reactions, and intolerance of uncertainty in the development of PTSD symptoms. Patients at risk for PTSD should be identified early in the rehabilitation process and could benefit from psychological interventions with the aim of preventing PTSD development.

Implementation of a sexuality interview guide in stroke rehabilitation: a feasibility study.

BACKGROUND: Although people who sustain a stroke can experience sexual difficulties, few address them during rehabilitation. OBJECTIVES: Explore the feasibility of implementing a Sexuality Interview Guide (SIG) in stroke rehabilitation and describe the factors perceived as influencing its implementation. MATERIALS AND METHODS: Using a mixed research design, the SIG was implemented for four months in a rehabilitation hospital. The frequency with which clinicians addressed sexuality and their level of comfort pre-post implementation was measured. Perceived factors influencing implementation were determined through individual interviews and focus groups with five stroke clients, 15 clinicians and a coordinator. A paired-specimen Wilcoxon test was used to explore differences in pre- post-level of comfort. Qualitative data was analyzed by two independent evaluators using thematic analysis. RESULTS: The SIG was used 28 times and clinicians' level of comfort in addressing sexuality improved significantly (p = 0.001). The factors perceived as influencing implementation were: the acceptability of the SIG, the individual characteristics, the context of the rehabilitation hospital and the implementation process. CONCLUSION: This study showed that the SIG can be used in stroke rehabilitation and that, with sufficient financial and human resources, and training for clinicians, it would be feasible to implement it in usual care.Implications for rehabilitationThe Sexuality Interview Guide (SIG) can be used in stroke rehabilitation and helps clinicians to target stroke clients who want to include sexuality in their rehabilitation.The best time to approach sexuality using the SIG, according to all participants, was in outpatient rehabilitation.For inpatient clients, it was more appropriate to use the SIG as they approach a weekend home trial or rehabilitation discharge.Training for clinicians working in post-stroke sexual rehabilitation, administrative policies and procedures and access to a sexual health specialist for consultation or referral purpose, would be important facilitators in integrating sexuality into clinical practices.

Assessing and conceptualizing orgasm after a spinal cord injury.

OBJECTIVES: To provide a questionnaire for assessing the sensations characterizing orgasm. To test the hypothesis that orgasm is related to autonomic hyperreflexia (AHR) in individuals with a spinal cord injury (SCI). SUBJECTS AND METHODS: A total of 97 men with SCI, of whom 50 showed AHR at ejaculation and 39 showed no AHR, were compared. Ejaculation was obtained through natural stimulation, vibrostimulation or vibrostimulation combined with midodrine (5-25 mg). Cardiovascular measures were recorded before, at, and after each test. Responses to the questionnaire were divided into four categories: cardiovascular, muscular, autonomic and dysreflexic sensations. RESULTS: Significantly more sensations were described at ejaculation than with sexual stimulation alone. Men with SCI who experienced AHR at ejaculation reported significantly more cardiovascular, muscular, autonomic and dysreflexic responses than those who did not. There was no difference between men with complete and those with incomplete lesions. CONCLUSIONS: The findings show that the questionnaire is a useful tool to assess orgasm and to guide patients in identifying the bodily sensations that accompany or build up to orgasm. The findings also support the hypothesis that orgasm may be related to the presence of AHR in individuals with SCI. Data from able-bodied men also suggest that AHR could be related to orgasm, as increases in blood pressure are observed at ejaculation along with cardiovascular, autonomic and muscular sensations.

Correction: International spinal cord injury male sexual function and female sexual and reproductive function basic data sets-version 2.0.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Blood pressure changes during sexual stimulation, ejaculation and midodrine treatment in men with spinal cord injury.

OBJECTIVES: To explore the effectiveness of various sources of self-stimulation, including oral midodrine, in triggering ejaculation in men with spinal cord injury (SCI), and to document the systematic variations in blood pressure at ejaculation and consider a revised definition of autonomic dysreflexia. PATIENTS AND METHODS: The study included 62 men with SCI lesions from C2 to L2. Ejaculation potential was assessed with various sources of stimulation, beginning with natural stimulation, followed, if the test was negative, by penile vibrator stimulation (PVS) followed, if the test was again negative, by PVS combined with oral midodrine, started at 5 mg and increased in 5 mg steps up to 25 mg. The success rate of ejaculation was recorded, as were blood pressure (BP) changes measured at baseline and at ejaculation (or on the last trial if the test was negative). Reported sensations were also recorded and compared during positive and negative tests. RESULTS: Overall, 89% of the patients reached ejaculation with one mode or another of stimulation. When patients had a negative result with natural stimulation, 56% were salvaged by PVS, and when PVS was negative, another 22% were salvaged by midodrine combined with PVS. The mean systolic BP increased by 35 mmHg at ejaculation during PVS and by 11 mmHg after midodrine, and a subsequent 29 mmHg at ejaculation during PVS combined with midodrine. By contrast, negative tests showed a relatively stable BP; the difference in changes in BP during positive and negative tests was significant (P < 0.01). Increases in BP during positive tests declined significantly more often within the limits of autonomic dysreflexia than negative tests (P < 0.01). CONCLUSION: These results support the view that most men with SCI can obtain an ejaculation when a wide spectrum of stimulation is used, including natural stimulation, PVS, and PVS combined with oral midodrine. Positive tests were associated with significant increases in BP, in contrast to negative tests, where BP was relatively stable. This suggests that significant changes in BP are required for ejaculation and that insignificant changes are predictive of future failure. As most changes in BP during positive tests also fall within the criterion of autonomic dysreflexia, a revised definition of autonomic dysreflexia should be considered to encourage safe experiences with ejaculation and safe use of midodrine.

Perceived physiological and orgasmic sensations at ejaculation in spinal cord injured men.

INTRODUCTION: With the advances in penile vibrator stimulation (PVS), most spinal cord injured (SCI) men can self-ejaculate. Oral midodrine may further increase ejaculation success, while maintaining autonomy. Since most SCI men attempt ejaculation for sexual rather than reproductive purposes, self-ejaculation should be emphasized and sensations explored. AIMS: Explore (i) self-ejaculation success rate in SCI men; (ii) vascular parameters indicative of autonomic dysreflexia (AD) during sexual stimulation and ejaculation; and (iii) sensations associated with ejaculation. METHODS: Ejaculation was assessed on 81 SCI men with complete ASIA A (49%) and incomplete B to D lesions (51%), subdivided into tetraplegics (C2-T2), paraplegics sensitive to AD (T3-T6), paraplegics not sensitive to AD (T7-T10), paraplegics with lesions to the emission pathway (T11-L2), and paraplegics with lesions interrupting the emission-ejaculation pathways (L3-below). Natural stimulation was attempted first followed, if negative, by PVS followed, if again negative, by PVS combined with oral midodrine (5-25 mg). MAIN OUTCOME MEASURES: Ejaculation success, systolic and diastolic blood pressure, and perceived physiological and orgasmic sensations. RESULTS: Overall 91% reached ejaculation, 30% with natural stimulation, 49% with PVS and 12% with midodrine plus PVS. Midodrine salvaged up to 27% depending upon the lesion. Physiological and orgasmic sensations were perceived significantly more at ejaculation than sexual stimulation. Tetraplegics did not differ from paraplegics sensitive to AD on perceived cardiovascular and muscular sensations, but perceived significantly more autonomic sensations, and generally more physiological sensations than lower lesions unsensitive to AD. CONCLUSION: Most SCI men can self-ejaculate and perceive physiological and orgasmic sensations. The climactic experience of ejaculation seems related to AD, few sensations being reported when AD is not reached, pleasurable climactic sensations being reported when mild to moderate AD is reached, and unpleasant or painful sensations reported with severe AD. Sexual rehabilitation should emphasize self-ejaculation and self-exploration and consider cognitive reframing to maximize sexual perceptions.

Assessment of sexual function in women with neurological disorders: A review.

BACKGROUND: Although the rehabilitation of sexual function has been identified as a top priority among women presenting neurological conditions, sexual function is rarely assessed in this clinical group. OBJECTIVES: To review published assessment tools of sexual dysfunction in women with neurological conditions including multiple sclerosis (MS), spinal cord injury (SCI), Parkinson disease, stroke, traumatic brain injury. METHODS: A systematic literature review was conducted with Medline via PubMed, PubMed Central, and Medline databases. RESULTS: There are three reliable methods to assess sexual dysfunctions in women with neurological conditions: physiological assessments of reflexes and perineal sensitivity testing, self-reporting questionnaires on sexual function and sexual satisfaction, and electrophysiological assessments. Physiological assessments of sacral and thoracolumbar reflexes have mainly been conducted among women with SCI. When performed, they reveal the existence of a psychogenic and/or reflex sexual potential in those women. Other forms of physiological assessments include vulvar sensitivity testing in women with SCI, quantitative sensory testing and pudendal somatosensory evoked potentials in MS populations. A few validated self-reporting measures are also available to assess sexual potential and sexual satisfaction, although mostly in women with SCI and MS. CONCLUSION: Despite high prevalence rates and important clinical implications, sexual dysfunction is not systematically assessed in women presenting various neurological conditions. Several well-validated tools exist for such assessments, which could be used for sexual rehabilitation in these patients. The implementation of systematic assessments of sexual potential is feasible and renewed efforts should be made to do so in clinical practice.

Stroke and sexual functioning: A literature review.

BACKGROUND: Stroke has multiple impacts on patients' sexual functioning, be it directly caused by the neurological lesion (s) or indirectly triggered via other psychophysiological processes. Despite a growing number of publications, sexuality is still rarely addressed in the stroke literature - yet, patients have indicated their need for sexual rehabilitation services. OBJECTIVE: To provide a literature review on post-stroke sexual functioning as well as available rehabilitation programs targeting patients' sexuality. METHODS: A systematic literature review was conducted on PubMed using the following key words and their combination: "stroke", "sexuality", "stroke characteristics", "hemisphere", "sexual", and "sexual dysfunction". RESULTS: Existing data suggests the existence of significant associations between stroke and male and female sexual dysfunction (SD) as well as desire/libido and sexual satisfaction. The exact contribution of patients' neurological profile (stroke laterality, location, and severity) on their SD remains inconclusive with research providing mixed findings. Psychological factors are shown to play a significant part in the development of patients' SDs. A few intervention programs have been developed to specifically guide health professionals when addressing patients' needs regarding their sexual recovery. CONCLUSION: Sexual rehabilitation needs to be an integrative part of stroke patients' rehabilitation process, preferably at the interdisciplinary level.

Women's Sexual Health and Reproductive Function After SCI.

Sexual function and to a lesser extent reproduction are often disrupted in women with spinal cord injuries (SCI), who must be educated to better understand their sexual and reproductive health. Women with SCI are sexually active; they can use psychogenic or reflexogenic stimulation to obtain sexual pleasure and orgasm. Treatment should consider a holistic approach using autonomic standards to describe remaining sexual function and to assess both genital function and psychosocial factors. Assessment of genital function should include thoracolumbar dermatomes, vulvar sensitivity (touch, pressure, vibration), and sacral reflexes. Self-exploration should include not only clitoral stimulation, but also stimulation of the vagina (G spot), cervix, and nipples conveyed by different innervation sources. Treatments may consider PDE5 inhibitors and flibanserin on an individual basis, and secondary consequences of SCI should address concerns with spasticity, pain, incontinence, and side effects of medications. Psychosocial issues must be addressed as possible contributors to sexual dysfunctions (eg, lower self-esteem, past sexual history, depression, dating habits). Pregnancy is possible for women with SCI; younger age at the time of injury and at the time of pregnancy being significant predictors of successful pregnancy, along with marital status, motor score, mobility, and occupational scores. Pregnancy may decrease the level of functioning (eg, self-care, ambulation, upper-extremity tasks), may involve complications (eg, decubitus ulcers, weight gain, urological complications), and must be monitored for postural hypotension and autonomic dysreflexia. Taking into consideration the physical and psychosocial determinants of sexuality and childbearing allows women with SCI to achieve positive sexual and reproductive health.