Part 1: Men
Many people associate spinal cord injury with a loss of sexual ability, particularly in males, but the truth is that paralysis no longer spells an end to either sexual intercourse or fatherhood.About half of all men with SCI are unable to get or maintain an erection without aid, and 95 percent cannot ejaculate, said Richard E. Berger, MD, a Professor in the UW Department of Urology and co-director of the UW Medical Center's Reproductive and Sexual Medicine Clinic. Both problems, Berger said, can now be addressed in a variety of ways.
Perhaps the simplest method for producing an erection is to use a vacuum pump that fits over the penis and draws blood into the penis via suction. A constricting ring is then placed at the base of the penis to maintain the erection. This method is very effective, providing satisfactory results in 80 to 90 percent of the men who try it, and it is totally non-invasive. However, care must be taken to avoid leaving the constricting ring on for more than half an hour at a time in order to prevent the risk of clotting blood in the penis.
A vacuum pump generally costs less than $500, Berger said. Drawbacks are that it requires planning in order to have the equipment on hand, and some couples find the devices intrusive or "kinky". They can also cause bruising on the penis if they are pumped too hard or too long.
Another method for producing an erection is to inject a small amount of a drug, usually prostaglandin E-1, directly into the penis to increase the blood flow. "Essentially, it tells the blood vessels to do what usually the nerves tell them to do," Berger explained. "What's used is a small insulin needle (like those used by diabetics), so even for men with some sensation it's not
very painful.
As with the suction/constriction method, the dose is adjusted to work for about 30 minutes, to avoid the dangers of an erection that lasts too long.The first injections are given in the clinic, in order to establish the correct dosage, Berger said. Penile injections can only be used once per day, and there is some risk of scarring in the penis, so Berger recommends that they not be used more often than twice per week. But many men with SCI prefer this method because it is quick and does not require bulky equipment. The drug works for 60-70% of those who try it, and costs about $10 to $20 per injection, depending on how much is used each time.
If a man with tetraplegia lacks the manual dexterity to operate a vacuum pump or give himself an injection, his partner can learn to do it for him. Many couples learn to think of these acts as part of the build-up to having sex, and even find that they enhance excitement.
When neither a vacuum pump nor injections produce the desired results, men with SCI may opt to have a semi-rigid or inflatable device surgically implanted in the penis. There are many types of penile implants, but the ones that work best for men without sensation are self-contained inflatable systems, Berger said. In these systems, a small pump -- usually located toward the tip
of the penis -- inflates the implant with fluid when an erection is desired. With SCI, lack of sensation can lead to erosion problems in which the implants work their way out through the skin. Implants that become flaccid when not in use create less pressure, and therefore less risk of erosion.
Penile implants are also useful for men who have trouble using a condom catheter due to retraction of the penis. However, the placement of a penile implant damages the erectile tissue in the penis. If the implant is later removed, this tissue will not function as well as it did before the implant was put in. Implants are also expensive, costing $10,000 or more for the implant itself and the surgery to install it, Berger said, "so we advise people to try other more reversible methods first."
Technology and medicine can make intercourse possible for men with SCI, but the sex act is not the same as before injury. Without genital sensation and/or orgasm, men with SCI usually learn to focus on alternative forms of stimulation. Other areas of the body often become more sensitive, especially around the areas where normal sensation ends, Berger said. "When men with spinal injuries dream," he added, "they generally don't dream of themselves with spinal injury. They can feel everything. I've had some people tell me they put themselves almost into a dream state when they have sex."
Men with paralysis also become more focused on their partners' pleasure, "and that gives them pleasure," Berger said. "They like to watch. Also, there's a certain amount of just wanting to function as normally as possible. To realize that they can sexually function and sexually satisfy their partner is satisfying and pleasurable when it occurs. Sex is still mostly between the ears."
Fertility
In most cases, the testicles continue making sperm after spinal cord injury, but ejaculation is impeded. So the challenge for men with SCI who want to become fathers is to get the sperm out of their bodies so it can be used for insemination. There are three basic techniques--two to induce ejaculation, and one involving surgical removal of sperm through a small incision in the scrotum. Because the surgical method can cause scarring and possible blockage of the vas deferens, Berger said, "you generally try the other methods first."One of these is to place a vibrator against the head of the penis to stimulate a reflex ejaculation. This method has been in use for about 13 years, and works best on men with injuries above L2, in whom the necessary reflexes are most likely to be intact. A new vibrator has brought the success rate for this method up to about 70%, Berger said. "It is also something people can use at home, and then inseminate at home using a vaginal syringe...which makes the whole thing a lot less clinical."
The second method, which has been in use for 6 or 7 years, is to stimulate the prostate gland, the seminal vesicles, and the vas deferens with an electric probe inserted in the rectum. The stimulation causes the glands to contract, producing an artificial ejaculation. For patients who have sensation, electroejaculation can be painful and needs to be done under an anesthetic, Berger said, but "fortunately, most people who need it can't feel it."
Both vibratory stimulation and electroejaculation can cause autonomic dysreflexia, so blood pressure is monitored closely during both procedures. "If someone starts to elevate, we stop." Those patients who do experience autonomic dysreflexia during the procedure can be treated with the drug nifedipine before future sessions to control the problem.
Another concern with induced ejaculation is sperm activity levels or motility, which may be low, especially at first, Berger said. In men who don't ejaculate, sperm sits in the tract for long periods, which reduces motility. Motility can often be improved with repeated stimulation, and by treating the newly-acquired sperm in the laboratory with two drugs that increase cell energy levels.
With these methods, Berger said, his clinic has achieved a pregnancy rate close to 30%. "It depends on how persistent people are," he added. Under the best of circumstances with uninjured people, the pregnancy rate is only about 20% per month, so it can take several tries before insemination is successful. In the last 5 years, Berger estimates that his clinic has enabled about 20 men with SCI to become fathers.
*pre-viagra era