Investigation of Sexual Function in Men with Spinal Cord Injury in a Rehabilitation Hospital in Turkey
Keywords: Rehabilitation, sexual function, spinal cord injury
Spinal Cord (SC) injury is most commonly seen in young and sexually active males and causes severe disability. In the literature, it is reported that 85–100% of males with SC injury have erectile dysfunction (ED),,,, ejaculation rates vary between 0 and 52%,, and orgasm rates between 40.7 and 65%.,,,,
There are three types of erections in people with SC injuries: reflexogenic erection, psychogenic erection, and mixed erection. A parasympathetic center located in S2-4 mediates reflex erection, and a sympathetic center located in T11-L2 mediates psychogenic erection. Mixed erection is possible when the level of lesion is between L2 and S2, but the quality of erection differs individually. On the other hand, most of these erections, whether reflex or psychogenic, were inadequate to maintain satisfactory intercourse in patients with SC injury. As a result, most studies revealed that satisfaction with intercourse and overall sexual satisfaction is insufficient after SC injury.,,,,,
Normal ejaculation necessitates integration of supraspinal inputs with the T10-L2 and S2-S4 spinal segments. Sympathetic innervation from T10-L2 provides emission of semen into the urethra simultaneously with the closure of the bladder neck. The S2-4 segment provides motor and sensory innervation of the penis along with the projectile ejaculation of semen. Ejeculatory dysfunction occurs in most males with SC injuries.
Although the sexual stimulation-response cycle ends up with orgasm, orgasm is hard to define and is subjective. Unfortunately, the orgasm potential of SC injured males is ignored and orgasm is frequently confused with ejaculation. The psychological and physical challenges experienced by persons with SC injuries can affect sexual arousal, and ultimately desire and orgasmic capacity.
Although the most important goal for clinicians is to maintain movement and ambulation after SC injury, it is found that for people with SC injury, sexual function is the most important function that affects quality of life for paraplegics and the second most important function that affects quality of life for tetraplegics after hand/arm movement., In a previous review, improvement of sexual function was reported to be one of the most important targets for people with SC injuries along with motor, bladder, and bowel function improvements. Moreover, it is known that psychological stress and quality of life in males with SC injury are related to sexual function.,, According to the results of another study, sexual dysfunction is the most common problem after spasticity and chronic pain in SC injury and is also the most common problem that is left untreated. The low prevalence of reported treatment rates for sexual function may have two explanations: first, treatment options are not always available, and second, patients may avoid treatment due to social and personal inhibition. In addition, factors such as 1. limited access to treatment 2. when evidence-based treatment options are available, clinician's and patient's limited knowledge of these options, potential benefits, and side effects of treatment, and 3. Patient's preference may affect treatment rates. Although sexual education is considered important by people with SC injuries, the rates of sexual education given by health professionals in the literature are only 8.5–53%.,,,,,
As a result, it is obvious that sexual function is one of the most important functions for males with SC injuries and sexual dysfunction is very common, whereas sexual education provided by health care professionals is inadequate. Moreover, there are wide ranges and conflicting results about sexual dysfunction and the frequency of education of these patients.,,,,,,, So the aim of the present study was to investigate sexual desire, erection, ejaculation, orgasm, satisfaction with sexual life, and the level of sexual education of male SC injured persons in a single rehabilitation center in Turkey.
Eighty-one inpatient males with SC injuries between the ages of 18 and 65 years who were consulted to the sexual rehabilitation unit were included in the study retrospectively. In this unit, patients with neurological diseases who are thought to have sexual dysfunction and who want to discuss sexual issues are evaluated, educated, and their treatment (Phosphodiesterase 5 inhibitors, intracavernosal injection, etc.) is organized. Patients who have previously known sexual dysfunction or other neurological comorbidities were not included. Demographic and clinical characteristics of the persons including the age, level of education, marital status, duration of injury, injury etiology, ambulation level, and motor function level according to the American Spinal Cord Injury Association Impairment Scale were recorded. Additionally, participants were asked whether they were sexually active or not before the time of injury, and when was the time of first sexual intercourse after their injury.
Sexual function was measured with the International Index of Erectile Function (IIEF) and “International Spinal Cord Injury Male Sexual Function Basic Data Set.” The IIEF and the data set were routinely administered by the first author during the consultation with the patients who were referred to our hospital's sexual rehabilitation unit.
IIEF was validated by the Turkish Society of Andrology in 2002. Although the IIEF is a self-reported questionnaire, a face-to-face interviewing technique was preferred in order to minimalize the risk of misunderstanding due to senility or low educational levels. It involves 15 questions grouped under five categories: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall sexual satisfaction. The IIEF evaluates the last 4 weeks. The erectile function domain was assesed by the 1st–5th and 15th questions, with scores of 1–10 indicating severe ED, 11–16 moderate ED, 17–25 mild ED, and 26–30 normal erectile function. Likewise, intercourse satisfaction was estimated by the sixth to eighth questions and scored between 0 and 15. The sixth to eighth questions evaluate the number of sexual intercourse attempts, whether or not the intercourse was enjoyable, and the number of satisfying instances of sexual intercourse. Orgasmic function was evaluated by 9th and 10th questions and scored between 0 and 10. The 9th and 10th questions evaluate ejaculation and orgasm/climax frequency with sexual stimulation or intercourse, respectively. Sexual desire was estimated by the 11th and 12th questions and scored between 2 and 10. The 11th and 12th questions evaluate the frequency and intensity of sexual desire, respectively. Overall sexual satisfaction was estimated by the 13th and 14th questions and scored between 2 and 10. The 13th and 14th questions evaluate the satisfaction with overall sexual life and sexual relationship with patient's own partner, respectively. Higher scores indicate better sexual function.
Erection, ejaculation, and orgasmic functions were also evaluated using the “International Spinal Cord Injury Male Sexual Function Basic Data Set.” In this data set, psychogenic erection, reflex erection, ejaculation, and orgasmic functions are classified as “Normal,” “Reduced/Altered,” “Absent,” or “Unknown.”
Additionally, this study interrogated whether the patients were informed about the sexual dysfunction and treatment related to SC injury or not, and whether the persons were sexually active or not before the time of injury, and the time of first sexual intercourse after SC injury.
The study was approved by the ethics committee of Ankara Numune Training and Research Hospital (Decision number: 2457/2019). Each participant provided written informed consent prior to enrollment in the study.
Statistical analyses were performed by using SPSS version 11.5 software. Descriptive statistics were provided as mean ± standard deviation or median (minimum–maximum) for continuous variables, while the number of cases and percentages were used for nominal variables.
Demographic and clinical characteristics of the patients are presented in [Table 1]. Seventy-three (90.1%) people were never informed by health care providers about sexual dysfunction in SC injury and its treatment. Seventy-five (92.6%) people were sexually active before the time of injury, whereas only 16 (19.8%) had sexual intercourse after SC injury. The mean time of first sexual intercourse after SC injury was 488.2 days (SD ± 444.8; range 60–1460; median 270). Erection, ejaculation, and orgasmic function of the persons according to the “International Spinal Cord Injury Male Sexual Function Basic Data Set” are presented in [Table 2]. According to this data, normal psychogenic erection, reflex erection, ejaculation, and orgasmic function rates of the patients were 16, 18.5, 4.9, and 7.4%, respectively. Sexual functions of the patients according to the IIEF are presented in [Table 3]. This shows that levels of sexual desire were moderately high or very high in 88.9% of patients, 82.7% of patients had moderate or severe erectile dysfunction, and 92.6% of patients were moderately or very dissatisfied with their overall sexual life.
The results of this study revealed that only a very low number of persons with SC injury are informed by their health care providers about sexual dysfunction after SC injury and its treatment. According to our results, sexual desire in males with SC injury is high, but only a few of them have sexual intercourse after their injury, and the time of first intercourse is approximately 16 months after injury. More than half of people have severe ED, only 4.9% of persons have normal ejaculation, and orgasmic function/intercourse satisfaction/overall sexual satisfaction of people with SC injuries were severely damaged.
According to the literature, sexual dysfunction is one of the most commonly seen and important dysfunctions that affect quality of life after SC injury, and regaining sexual function is one of the most important functional priorities for people with SC injuries., But it is also the most common problem that is left untreated. Sexual rehabilitation of patients with SC injuries is inhibited due to several reasons, such as staff discomfort when talking about sexuality, limited knowledge of the staff about sexual rehabilitation, discriminatory staff attitudes, and patient behaviors such as seeking for sexual information elsewhere, or inadequate state of readiness to talk about sexuality., These handicaps can be associated with the education of staff on sexual rehabilitation and with the socio-cultural characteristics of the SC injured persons and finally result in different rates reported from different countries and even differences between rehabilitation centers in the same country. There are three different studies from Turkey that reveal conflicting results about the rates of education regarding sexual dysfunction after SC injury reporting rates of 8.5, 18.2, and 46.7%. This rate is 9.9% in our study. In another study by Tepper et al., it is reported that 45% of people with SC injuries received consultancy and education about sexual problems, and 48% of these patients found this service sufficient. In their up-to-date community-based study from Australia, New PW et al. found 53% of patients with traumatic SC injuries and 30% of patients with nontraumatic SC injuries are educated about sexual functions. However, it is also reported that only 18% of them were satisfied/very satisfied with this education. In this study, 66% of the patients reported that they wanted to have more information about the impact of SC injury on sexuality, and the authors made recommendations for rehabilitation professionals about sexual education of patients with SC injuries. According to these recommendations, rehabilitation professionals should provide general information to people with SC injury early after onset of an event and continue to provide further consultancy services individually thereafter. Since SC injured persons' needs and interest in sexuality education changes over time, particularly in the early months after SC injury, multiple offerings about consultation are necessary and appropriate. The needs of lesbian, gay, bisexual, transgender, and intersex persons with SC injury must be recognized and addressed in the same manner as those who are heterosexual. Partners of people with SC injuries should also be included in education and counselling. The P-LI-SS-IT (permission, limited information, specific suggestions, and intensive therapy) model is proposed as a four-level model that can be used by the interdisciplinary rehabilitation team to facilitate the delivery of process-focused counseling. It is also recommended that a needs assessment of rehabilitation staff should be undertaken periodically to identify training requirements in relation to providing sexual education to people with SC injury.
ED types and rates may differ from person to person according to the level of lesion in patients with SC injury. In the literature, the rates of ED and moderate-severe ED in different studies were 86–100%,, and 73–87.3%,,,, respectively. These results are compatible with ours as 91.4% of patients had ED and 82.7% of patients had moderate-severe ED in our study. As ED can be treated effectively by several different strategies,, males with SC injuries should be evaluated carefully and managed appropriately for ED.
Although most SC injured males experience ED, it was also reported that 93.6% of them can achieve some type of erection. On the other hand, most of these erections, whether reflex or psychogenic, were inadequate to maintain satisfactory intercourse. According to Morrison et al., 72.1% of patients were dissatisfied with intercourse, and 51.2% of them were dissatisfied with overall sexual life. Likewise in another study by Choi et al., 65% of patients were sexually active, but none were very satisfied, and 62.2% were dissatisfied with their sexual life after SC injury. Biering-Sørensen et al. found that 75% of male patients can have an erection, but 46% were dissatisfied with overall sexual life in their study group. Finally, in a recent study, Gomes et al. reported a 39.6% overall satisfaction rate. Compatible with the literature, reflex and psychogenic erection rates of our patients were 77.8 and 56.7%, respectively, but 93.8% were dissatisfied with overall sexual life and 95% were dissatisfied with their sexual relationship with their partner.
Ejeculatory dysfunction occurs in most males with SC injuries. Without medical help, 0–52% (median 15%) of patients can induce ejaculation via masturbation or intercourse., This ratio is 9% according to Brackett et al. and 16% according to Chéhensse et al. In another study, 95% of SC injured males reported ejaculation problems. These results are again compatible with our results as only 4.9% of our patients reported normal ejaculation.
However, dry orgasm without ejaculation occurs approximately 13% of the times. This data is also supported by the results of our study, as 7.4% of males with SC injuries reported normal orgasmic function and 4.9% reported normal ejaculation. In our study, the mean score of the 10th question of the IIEF (When you had sexual stimulation or intercourse, how often did you have the feeling of orgasm or climax?) was 1 ± 1.6 (range, 0–5; median, 0). In a controlled study by Sipski et al., the same value was 2.4 ± 1.9 (range, 0–5; median, 2) in the study group and 4.6 ± 0.7 (range, 3–5; median, 5) in the control group, and the difference was statistically significant. Morrison et al. reported normal orgasmic function in 9.3% of SC injured persons and severe orgasmic dysfunction in 76.8%. Different studies found orgasm rates between 40.7 and 65%,,, but it is highlighted that the quality of orgasm is diminished.
Although Cardoso et al. reported sexual desire is not altered after SC injury, there are many more studies reporting decreased sexual desire.,,, According to Reitz et al.'s study, 14% of patients reported decreased/absent sexual desire, whereas 32.5% reported decreased/absent sexual desire according to Morrison et al. This ratio is 11.1% in the present study. Except from Cardoso et al.'s study, the studies mentioned above do not have a control group, so future studies will need to include control groups to make a final conclusion about the status of sexual desire in patients with SC injuries.
The first limitation of our study was the inclusion of patients in the acute, subacute, and chronic periods, with a very different disease duration. The retrospective nature of our study may be considered as the second limitation.
Sexual education provided by medical professionals is not adequate after SC injury. Although sexual desire is high in males with SC injuries, erection, ejaculation, and orgasmic function deteriorate dramatically resulting in overall sexual dissatisfaction.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
[Table 1], [Table 2], [Table 3]