New Beginnings: Sexual Relationships

Posted by Nurse Linda in Life After Paralysis on January 13, 2022 # Relationships

A couple sitting on a couch. The man's arm is around the woman and they are reading a book. There is a wheelchair next to themOne way of a new beginning is forming relationships with other people. Within that selection of individuals, you may decide you want to begin a romantic relationship. This can be rekindling with a known partner or starting a completely new relationship. How you choose to proceed is with what is comfortable for you. As an individual in a committed relationship, you may be feeling uncertain about how your body will respond and perform or even how to move forward. If you are in a new relationship, you will want to know what will be different and what will be the same.

There are always questions about sexual relationships with neurological trauma or disease. The sexual response occurs in four phases. Men and women may move through the phases at different paces, as individuals have different timing of phase segments. The four phases are excitement, plateau, orgasm, and resolution.

In the first phase, which is excitement or desire, the body begins to have physical changes in the erogenous zones. These are areas where sexual desire and responses will occur. The body responds with increased muscle tension, quickened heart rate, blushing of the skin, breast enlargement and nipple changes, increased blood flow to the genitals and lubrication of the sexual organs. These changes occur in both men and women but at different degrees.

If you have had a brain injury, parts of your brain may not respond as quickly or as much as before injury. It may take more time and stimulation to create a sexual desire. In others with brain injury, sexual excitement may be increased or occur with even just a slight arousal. For these individuals, you will need to learn to control your urges to an appropriate venue. With spinal cord injury, the responses may not appear below the level of injury. In neurological disease, arousal may be inconsistent.

Adaptions to neurological issues are possible with the use of the incorporation of different senses. You may find that you did not have an issue prior but now need additional stimulations such as more touching in erogenous areas such as ‘tickle spots,’ ears and mouth. More foreplay may be needed through visual stimulation, touch, smells, and word. You can explore these parts of your body and activities with your partner or alone. Remember, sexual actions are mostly psychological.

For individuals that find they are hypersexual or aroused in non-appropriate situations, you can utilize alternative thoughts. If the issue becomes a problem for you, medications are available to assist with control but not the elimination of desire.

The second phase of sexual response is arousal or plateau. These titles may seem contradictory, but they are the same. The intensity of sexual arousal is heightened and maintained (or plateau of waiting for the next step). In this phase, all the conditions of the excitement phase are greatly intensified.

Individuals with brain injury, stroke, spinal cord injury or neurological diseases with tone (spasticity) may have interference with increased muscle spasms. This can lead to difficulty with body positioning for sex. Muscle cramps can develop. You may find the timing is critical with tone. The best time for sex may be after therapy or exercise when your muscles are tired, making tone less apt to interfere. Medication can be used to relax tone but finding a position that works for you is the best option. Use pillows or body supports like liberator wedges to help your muscles find a position that works.

Orgasm or climax is the third phase. This is the shortest phase but also the most intense. Involuntary muscle contractions begin in the genitals but can also occur in the rest of your body. There is a release or euphoria that occurs. Individuals with sensation loss can achieve phantom orgasms above the level of injury through stimulation of the erogenous zones in the body where they do have sensation.

Often, Autonomic Dysreflexia (AD) can occur in any phase of sexual response but especially in the orgasm phase. Ironically, symptoms of AD and orgasm can overlap. If you are just getting used to sexual experiences, you will want to have your blood pressure monitored. In the orgasm phase, blood pressure and heart rate are increased, just as with AD, except these parameters will return to normal quickly. There may also be a body rash, just as with AD. Many individuals dismiss AD symptoms during sex. Therefore, it is important to know your typical blood pressure and to check it during sex. After a while, you will distinguish between AD and orgasm. I know, ‘what a way to kill the mood, Nurse Linda’ but it is important for your health. If AD is an issue, medication to control it can be used. AD will not prevent you from sexual experiences if treated.

The final phase is resolution. In this phase, the body returns to its normal state. There is a relaxed feeling and often fatigue. The length of this time varies by the individual until sex can be performed again.

If the sensation is diminished or absent, sexual satisfaction can still be achieved. There are some different options for men and women.

Erectile dysfunction for men is an issue in neurological injuries and diseases. The source is nerve communication, not the same as elderly men. Men may have reflex erections (above S2-4) or psychogenic erections (below S2-4), or a combination of both, that are unreliable for sexual intercourse. However, there are treatments. Oral medications such as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis) are commonly used. Your healthcare professional should be consulted for the best medication choice for you.

If erectile medications are not the answer for you, some men will opt for intra-cavernosal medications such as alprostadil (Caverject). This is injected into either side or both sides of the penis for an erection. Vacuum devices increase blood flow to the penis to obtain an erection is also an option. In the past, some men opted for implantable rods for erection. These can still be obtained, but there are so many other options that these are less used today. Some functional electrical implants can also be used for sexual function in men.

It may come as a surprise that some women prefer a non-erect penis during sex. A technique called ‘stuffing’ is inserting a flaccid penis into the vagina. It is easier for the woman to manipulate the penis to the area where the most pleasure is gained.

Ejaculation is typically diminished in spinal cord injury, as with some other neurological diseases. High amplitude vibrators such as Ferticare and Viberect have changed the way ejaculation can occur. Many individuals will use these devices, especially for pregnancy purposes. This has reduced the number of medical ejaculation procedures as it can be done in your own home, in privacy.

Women’s options have expanded. Be sure to have lubricant on hand. Lubrication is an issue for women in arousal but also for the prevention of injury to the vagina. Women will find their catheter or bowel program lubricant might be too drippy for sexual activity. Water-based lubricants are better for sexual experiences. Lubricants such as ASTROGLIDE provides better coverage. For individuals with some sensation, the heat-activated his and her lubricants are effective.

Vibration can stimulate lubrication in some women. This can become part of foreplay. The Ferticare vibrator provides high amplitude and therefore high stimulation but can also trigger AD episodes in women. The Lelo vibrator has pulsation options that are less apt to trigger AD. Over-the-counter vibrators may work as well. These can be used on the outside of the body and in the genital area as well as in the vaginal canal. Lubrication is a must.

For clitoral stimulation, the Eros is a device with a small cup that is placed over the clitoris. A slight suction increases blood flow, leading to increased lubrication and overall sexual response. There are a few women who take erectile medication to enhance their sexual experience, but this has been met with minimal results.

There are some activities that will assist in the enjoyment of sex with neurological issues. Planning is very helpful. First, plan your bowel program accordingly. Either have a bowel program prior to sex or earlier in the day. With body spasms and contractions, a bowel movement in the middle of sex is not great timing. Empty your bladder prior to sex to reduce urinary incontinence. Indwelling catheters may be removed prior to sex and then reinserted. Indwelling and suprapubic catheters kept in place should be taped to the abdomen or thigh to avoid pulling the catheter at the point of insertion. Catheters can be pulled out during sex leading to damage to the urethra.

Many individuals use sexual enhancement devices (sex toys) to improve their sexual function and response. Not everyone is comfortable buying these in a store, but online has opened a new avenue for privacy. Vibrators come in all types. They can be used for stimulation of the breasts, genitals, or ‘tickle spots’ of the body. Some will use them to enhance their finger and hand function.

Always practice safe sex. Pregnancy for women is always a possibility even if they are not menstruating unless menopause has occurred. Transmission of sexual diseases is always a possibility, especially if you do not know your partner’s sexual history or are not in a monogamous relationship. Also, safe sex includes a partner that does not take advantage of you sexually or just in general. If you are even the slightest bit uncomfortable in a relationship, sexual or not, it is time to move on. You deserve the best in life. Nurse Linda

Pediatric Consideration:

Teens will have questions about sex. This blog is a safe place to start. You can hand it to your teen. If they are comfortable asking questions, great. If not, find a reliable person who can answer their questions. A therapist with experience in teen issues would be best.

For younger children, answer questions at their developmental age. Celebrities often laugh about their explicit sex talk with toddlers. This is inappropriate as they do not have a developed libido, nor do they have a concept about sexual relationships. Developmental level is always the best.

Be open to your child. Try to remember their worldview. Nurse Linda

Linda Schultz is a leader, teacher, and provider of rehabilitation nursing for over 30 years. In fact, Nurse Linda worked closely with Christopher Reeve on his recovery and has been advocating for the Reeve Foundation ever since.

In our community, Nurse Linda is a blogger where she focuses on contributing functional advice, providing the "how-to" on integrating various healthcare improvements into daily life, and answering your specific questions. Read her blogs here.

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The National Paralysis Resource Center website is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $8,700,000 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.