What is the recommended management pathway for sexual dysfunction in Spinal Cord Injury (SCI) patients?

Management Pathway for Sexual Dysfunction in Spinal Cord Injury Patients

All SCI patients should receive early, structured sexual health counseling beginning in the acute rehabilitation phase, followed by a stepwise treatment algorithm starting with PDE5 inhibitors for erectile dysfunction, with progression to more invasive therapies only after failure of conservative measures. 1, 2, 3

Initial Assessment and Timing

Begin sexual health discussions during acute rehabilitation once the patient is medically stable, typically within the first weeks after injury. 4 Early intervention improves long-term sexual satisfaction and psychological adaptation. 3, 5

Neurological Assessment

• Assess T11-L2 dermatome sensation to determine capacity for psychogenic sexual arousal (preserved in upper motor neuron lesions). 3, 5
• Evaluate S3-5 sacral segments and reflexes to determine reflexogenic arousal potential (preserved unless complete lower motor neuron injury). 6, 3
• Test vulvar/penile sensitivity to touch, pressure, and vibration. 6, 5
• Document ASIA Impairment Scale classification, as complete injuries (ASIA A) have worse prognosis for sexual function recovery. 4, 7

Medical and Psychosocial Evaluation

• Screen for cardiovascular risk factors (diabetes, hypertension, hyperlipidemia) as erectile dysfunction signals increased cardiovascular mortality risk. 8, 1
• Measure total testosterone levels in all patients, particularly before initiating PDE5 inhibitor therapy. 8, 1
• Assess for depression and anxiety using validated screening tools, as these are both causes and consequences of sexual dysfunction. 8, 6
• Evaluate medication side effects from antihypertensives, antidepressants, and antispasmodics that may worsen sexual function. 8, 2

Stepwise Treatment Algorithm

Step 1: Education and Lifestyle Modifications

Provide comprehensive education about sexual potential based on injury level and completeness before attempting any treatments. 3, 5 This is critical as many patients have unrealistic expectations or lack knowledge about alternative sexual techniques.

• Encourage self-exploration including clitoral, vaginal (G-spot), cervical, and nipple stimulation in women, as these are conveyed by different innervation sources. 6
• Recommend smoking cessation, which reduces total mortality by 36% and improves endothelial function. 8, 1
• Advise weight loss and regular dynamic exercise to enhance endothelial function and erectile capacity. 8, 1
• Optimize comorbidity management including strict glycemic control, blood pressure control, and lipid management. 8, 1

Step 2: First-Line Pharmacotherapy

Oral PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) are first-line treatment for erectile dysfunction in SCI patients, with 93% efficacy in those with preserved neurological pathways. 1, 2, 7

Critical Prescribing Details:

• Sildenafil and vardenafil have 4-hour half-lives; patients must avoid nitrates for ≥24 hours. 4
• Tadalafil has a 17.5-hour half-life; patients must avoid nitrates for ≥48 hours. 4
• Absolute contraindication with concurrent nitrate use due to severe hypotension risk. 4, 8
• PDE5 inhibitors require adequate testosterone levels for full efficacy; check testosterone in non-responders. 8, 1

For Women:

• Consider PDE5 inhibitors on an individual basis for genital arousal difficulties, though evidence is limited. 6
• Flibanserin may be considered for hypoactive sexual desire disorder, though data in SCI populations are sparse. 6

Step 3: Adjunctive Testosterone Replacement (If Indicated)

For patients with testosterone <230 ng/dL and sexual dysfunction symptoms, testosterone replacement improves sexual function and enhances PDE5 inhibitor response. 8, 1

• Testosterone 230-350 ng/dL: Consider replacement if symptomatic. 8, 1
• Testosterone >350 ng/dL: Replacement not indicated. 8, 1
• Contraindicated in men seeking fertility as it suppresses spermatogenesis. 4, 8

Step 4: Address Secondary SCI Complications

Treat spasticity, pain, and incontinence as these directly impair sexual function and satisfaction. 4, 6

• Optimize antispasmodic regimens, recognizing some medications worsen sexual function. 4, 6
• Implement multimodal analgesia for neuropathic pain using gabapentinoids plus tricyclic antidepressants or SSRIs. 4
• Establish reliable bladder management with intermittent catheterization to reduce incontinence anxiety during sexual activity. 4

Step 5: Psychosexual Therapy (Concurrent with All Steps)

Psychosexual therapy should be offered to all SCI patients as adjunctive treatment, addressing psychological adaptation to injury and relationship dynamics. 8, 1, 3

• Cognitive-behavioral therapy improves communication about sexual concerns and reduces performance anxiety. 8, 1
• Partner involvement is essential for optimal treatment outcomes. 8, 1, 9
• Address lower self-esteem, depression, and dating concerns that commonly arise post-injury. 6, 3

Step 6: Second-Line Therapies (After PDE5 Inhibitor Failure)

Intracavernosal injection therapy with vasodilators (papaverine or prostaglandins) is the next option for men who fail oral medications. 8, 2, 7

• Vacuum erection devices (VEDs) are non-invasive mechanical alternatives. 8, 2, 7
• Intraurethral alprostadil suppositories provide another local therapy option. 8, 9

Step 7: Surgical Options (Refractory Cases Only)

Penile prosthesis implantation is reserved for patients who fail all less invasive treatments, with technical success rates of 97.5% at 2 years but increased complication rates in SCI patients. 8, 1, 7

• Infection rates range from 2-16%, potentially higher in SCI populations due to immunosuppression and skin breakdown risks. 1
• Requires careful patient selection and counseling about risks versus benefits. 1, 7

Management of Ejaculatory Dysfunction and Fertility (Males)

For anejaculatory dysfunction, use penile vibratory stimulation (PVS) as first-line treatment, progressing to electroejaculation (EEJ) if PVS fails. 2, 7, 3

• Structured vibratory stimulation protocol with or without midodrine can achieve ejaculation and potentially orgasm. 5
• Monitor for severe autonomic dysreflexia during ejaculation procedures, particularly in injuries above T6. 5
• Obtained sperm can be used for intrauterine or in-vitro fertilization. 2, 7

Pregnancy Considerations (Females)

Pregnancy is possible for women with SCI, with younger age at injury and pregnancy being significant predictors of success. 6

• Monitor closely for postural hypotension and autonomic dysreflexia throughout pregnancy. 6
• Anticipate decreased functional level (self-care, ambulation, upper-extremity tasks) during pregnancy. 6
• Watch for complications including pressure ulcers, excessive weight gain, and urological complications. 6

Common Pitfalls to Avoid

• Never delay sexual health discussions until patients ask; most will not initiate this conversation despite significant concerns. 3, 5
• Do not assume complete injuries have no sexual potential; approximately 50% of all SCI patients can achieve orgasm regardless of injury completeness, except complete lower motor neuron injuries affecting lowest sacral segments. 3
• Avoid prescribing PDE5 inhibitors without checking testosterone in non-responders, as hypogonadism prevents full efficacy. 8, 1
• Never combine PDE5 inhibitors with nitrates due to life-threatening hypotension risk. 4, 8
• Do not overlook iatrogenic sexual dysfunction from medications used to treat SCI complications. 8, 3

Referral Criteria

Refer to specialized sexual medicine urologist for:

• Failure of PDE5 inhibitors and second-line therapies 9, 3
• Complex fertility issues requiring assisted reproductive techniques 2, 7
• Consideration of penile prosthesis implantation 1, 7
• Persistent ejaculatory dysfunction despite conservative measures 9, 5

Refer to psychosexual therapist for:

• Significant psychological distress about sexual function 9, 3
• Relationship difficulties related to sexual changes 1, 5
• History of sexual trauma or preexisting sexual dysfunction 3, 5