What is human sexuality?
"In the broadest sense, sexuality encompasses all the feelings, attitudes, and behaviors that contribute to a person's sense of being a man or a woman both publicly and privately. Healthy sexuality represents a natural extension of affection, tenderness, and companionship between two people" (Firestone, Firestone & Catlett, 2006).
The physical act of intercourse is not all that defines your sexuality. When we talk about sexuality, we mean more than what goes on behind your bedroom doors. Sexuality is the intimacy between you and your partner, your preferences, your body image and desires.
The definition above is not usually what most people think of when they think of sex. This is especially true when people have experienced a spinal cord injury (SCI). Some questions that come up are:
- Does my SCI affect my sexual function?
- What kind of physical changes can I expect?
- Will I have orgasms?
- What I be able to maintain an erection?
- Will I be able to satisfy my partner?
- What about bowel and bladder accidents?
- What are the risks of having sex?
How has SCI affected my sexual function?
A spinal cord injury changes many parts of the body. This is especially true for those body parts that are at or below the level of the injury. SCI can change the way your bladder and bowel function. Your SCI has most likely changed your sexual function. This can be changes in sensation, the ability to achieve orgasm, or the ability to get and maintain an erection. For many men, having an erection is one of the first questions on their minds.
Will I be able to get an erection?
Erections are a combination of nerve stimulation (touch) and a vascular (blood flow) response. Changes in sexual function depend on level of injury and if the injury is complete or incomplete. Each person's function will be affected differently, so it is important to understand the basics of how erections happen.
The three types of erections and how they are affected by SCI
- Psychogenic: This type of erection may come from sights, sounds or thoughts that are arousing. For many men after SCI, having an erection by just thinking about something sexy may not work so well. This is because the area of the spinal cord responsible for psychogenic erections is located at T11 and below. When a spinal cord injury is above this level, the message from your brain cannot get through the damaged part of your spinal cord.
For men that might be able to get a psychogenic erection, the penis often gets longer and fuller, but still may not be rigid enough for intercourse. Pay attention to what causes you to have an erection. It could be useful in the future.
- Reflexogenic: It is also called a reflex or spontaneous erection. This type of erection comes from physical touch or stimulation to your penis or genitals. Stroking, touching or caressing the penis can produce this response. The ability to get a reflex erection is controlled by nerves found in the lowest part of the spinal cord (S2-3-4). Reflex erections from touch are possible in most men with an injury at T10 or above. Psychogenic erections from arousing thoughts, sights or sounds are not usually possible.
Some men with SCI may notice an erection when changing their catheter, cleaning their genitals or even when pulling clothes or blankets over their body. This stimulation to the penis may produce an erection even if it was not intended. Reflex erections can sometimes be brief and can happen at inconvenient times.
- Spontaneous/Nocturnal: If you have ever woken up with an erection at night or early morning without stimulation, you have had a spontaneous erection. These can occur during sleep or when your bladder is full. With men that do not experience erectile dysfunction these can occur 3-5 times per night on average. Some men after SCI may still get spontaneous erections during the night and/or in the morning. How long the erection lasts will help you determine its usefulness for sexual activity.
Things (besides spinal cord injury) that can affect erections
- High cholesterol
- Tobacco use
- Alcohol use
- Treatment for prostate cancer
- MS or Parkinson's disease
What can I do to help get and maintain an erection?
- Constriction bands (cock rings)
- If you are able to get a full, firm reflex erection, using a constriction band can help keep the blood in the penis for a longer time.
- Constriction bands are cheap and reusable.
- Do not use metal rings or leave them on for longer than 20-30 minutes.
- May cause some bruising, especially if you are on blood thinners.
- Vacuum Erection Device (VED/penis pump)
- Helps to pull the blood into the penis by vacuum device.
- Used with a constriction band (usually comes with the pump) to maintain the erection.
- Manual (hand pump) or battery operated
- Viagra (sildenafil), Cialis (tadalafil), Levitra (vardenafil), Staxyn (vardenafil), Stendra (avanafil).
- Medications do not cause an erection, they help an erection become more rigid or last longer.
- DO NOT use with nitroglycerin products. The nitroglycerin ointment that is used for autonomic dysreflexia can cause an unsafe drop in blood pressure when used with these medications.
- Take about an hour to take effect.
- Potential side effects include headache, nasal stuffiness, flushing, low blood pressure and priapism. Priapism is when the penis stays erect for too long.
- Most medications do not work well when taken with fatty foods, which take longer to digest.
- Costs of these medications vary.
- Urethral suppositories (Muse)
- A thin suppository with the medication Alprostadil, which helps relax the blood vessels of the penis causing increased blood flow into the penis and blood retention in the penis.
- It is expensive. There is no generic form available.
- It is not as effective as injections. It produces erection in 30-40% of men.
- Penile injection therapy
- Any combination of one to four medications injected directly into the muscle of the penis. This relaxes the blood vessels of the penis, causing increased blood flow into the penis and keeps the blood in the penis.
- Compounded or mixed medication has to be made at a special pharmacy that may not be available in some areas of the country.
- It can be expensive. Cost varies based on pharmacy and the amount of medication needed.
- It is highly adjustable in both quantity and concentration.
- It is very effective, with an 88% success rate in SCI men.
- It works within 10-15 minutes.
- It is not affected by diet.
- It can work for upper and lower motor neuron injuries.
- Potential side effects include priapism, penile scarring, pain, bleeding at the injection site, bruising and infection.
- Surgically implanted prosthesis
- This is a three-piece penile prosthesis.
- Surgical risks (infection, anesthesia).
- You cannot go back. The cylinders are placed in the muscle of the penis. This causes structural damage making it impossible to go back to achieving erections spontaneously or with other methods.
- Has a risk of penile erosion.
- Has a risk of mechanical device failure.
- It is very predictable, natural feeling and has the appearance of erection.
Will I be able to ejaculate?
Like many other functions, ejaculation is affected by SCI. The process of ejaculation is even more complex than an erection. Very few men with a complete SCI have ejaculations.
Sometimes the spinal cord injury prevents the bladder neck from closing and semen will go into the bladder instead of out of the penis — this is called retrograde ejaculation. Retrograde ejaculation does not cause harm to you and the semen comes out with your urine.
Even if you think you are not able to ejaculate, there is still a chance that some semen may come out. You will still need to use birth control if you do not want to have children.
Will I have orgasms?
Your specific ability to have an orgasm after SCI is unknown but many people report they are able to have some form of orgasm after their injury. How that orgasm will feel or how your body will react is really up to you to explore and find out.
There are many parts of your body that can feel good and provide a pleasant sexual response. These areas of the body are called the erogenous zones and are not only in the genital area. Using all of your senses can also be helpful. Instead of focusing on what the penis can and cannot do, try experimenting with all of your senses.
- Verbal expressions, sounds or music can set the mood. Imagination can also be powerful.
- Consider sharing fantasies with your partner.
- Try looking at arousing images.
- Consider using candles, incense or perfume.
- Some people report heightened sensitivity in the areas where they can still feel, explore touch on the head, neck, lips, arms and nipples.
- Some people report increased ability to achieve orgasm through use of vibration. Using sexual devices and vibrators can be modified for people with limited mobility.
- There are many types of vibrators and massagers. They can be helpful to use to explore your sensation and the ability to achieve orgasm. Some vibrators have been created for achieving ejaculation in SCI for collecting sperm. The Ferticare and Viberect are two. These vibrators tend to be expensive. They produce intense vibration that can be too stimulating at times for people with some sensation.
- Some vibrators that are more readily available include The Fairy Wand, The Magic Wand and The Wahl Massager. For more information about sexual aides and devices, request a copy of the Patient Education document entitled 'Pleasure Able.'
- BE AWARE: the use of vibration can put you at risk for autonomic dysreflexia. Speak with your provider before using vibration. It is important to discuss how to evaluate and manage autonomic dysreflexia.
Satisfying your partner
Fears over changes in your sexual function after SCI decrease as you become more comfortable with your body. The more aware you are of your sexuality, the better you will be able to satisfy your partner. You may find there are other parts of sexuality that you and your partner enjoy more. The physical act of sex may not be as important as other aspects of sexuality.
What are the risk factors of having intercourse with SCI?
Autonomic dysreflexia (AD): AD is a rise in blood pressure resulting from a stimulus below your level of injury. You are at risk if you have an injury at T6 and above.
AD may occur during sexual activity. Here are some ways AD can be triggered:
- Rough stimulation of the genital area
- Using a vibrator for stimulation
- Infection or inflammation of the testicles
If you experience AD symptoms during sex, immediately stop the activity. Put yourself into a sitting position. Be sure you have also removed all tight clothing, binders and compression hoses. If this does not stop the AD symptoms, call your medical provider or 911. Generally, the AD symptoms will stop after the activity stops.
You may want to discuss AD with your health care provider prior to having sex to develop a plan in case it occurs. If you are prone to AD, it may be wise to have Nitroglycerin Ointment 2% available. Speak with your provider further to get more education on this medication.
Bladder and bowel:
- Be sure to empty your bladder before any sexual activity.
- A suprapubic catheter can be taped to the lower abdomen to keep it out of the way and prevent pulling.
- Stick to a regular bowel program. Do your bowel program before sexual activity so your bowels are empty.
- Use a pillow or wedge under your pelvis to tilt it upward. This will aid in penetration and keep pressure off the bladder and lower bowel.
- Damage to skin from shearing, pressure or rubbing can happen during sexual activity.
- Padding and positioning can help prevent pressure and friction injuries.
- Monitor skin for redness and injury.
- Remove pressure from the area if anything develops.
- Use plenty of lubrication.
- Be sure to wash and dry the genital area with soap and water before and after sexual activity.
Do not forget...
All men should have yearly exams of the penis, prostate and testicles. This exam will monitor for changes, problems and cancer. When you call to schedule an appointment, ask if the office and examination table are wheelchair accessible. Also ask if staff members can assist with transfers, positioning and preparation for the exam. It is still possible to get sexually transmitted diseases such as herpes, syphilis and AIDS. Remember to use protection!
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- Denil J, Ohl DA, Smythe C. Vacuum erection device in spinal cord injured men: patient and partner satisfaction. 1996. Arch Phys Med Rehabil. 77(8): 750-753.
- Firestone, RW, Firestone, LA, and Catlett, J. (2006). Sex and love in intimate relationships. American Psychological Association, Washington D.C.
- Johnson, KMM, Lanig, IS. (1996). Promotion and maintenance of sexual health in individuals with spinal cord injury. In I.S. Lanig (Eds.), Practical guide to health promotion after spinal cord injury (171-202). Gaithersburg, Maryland: Aspen Publication.