Sex after paralysis

Sexual identity is a significant and encompassing aspect of one's personality – sexuality plays an essential role in how we feel about ourselves, how we relate to others, how others relate to us.

To be sure, paralysis often impacts people's sexuality, including changes in physical functioning, sensation and response. Self-image can be shaken.

Paralysis affects a man's sexuality both physically and psychologically. They question, "can I still do it?" Men worry that sexual pleasure is a thing of the past. Men wonder if they can have sex again at all, whether they can attract a partner, whether the partner will stay, whether having children is possible.

It is true that, after disease or injury, men often face changes in their relationships and sexual activity. Emotional changes occur, of course, and these too can affect a person's sexuality.

While the range of sexual options may be different, physical attraction and sexual activity are realistic expectations – no matter the level or completeness of paralysis.

Erections

Erections are the number one issue after paralysis. Normally, men have two types of erections, psychogenic and reflex.

Psychogenic erections result from sexual thoughts or seeing or hearing something stimulating. The brain sends these arousing messages through the nerves of the spinal cord that exit at the T10-L2 levels, then relays them to the penis, resulting in tumescence.

The ability to have a psychogenic erection depends on the level and extent of paralysis. Generally, men with an incomplete injury at a low level are more likely to have psychogenic erections than men with high-level, incomplete injuries. Men with complete injuries are less likely to experience psychogenic erections.

A reflex erection occurs when there is direct physical contact to the penis or other erotic areas such as the ears, nipples or neck. A reflex erection is involuntary and can occur without sexual or stimulating thoughts.

The nerves that control a man's ability to have a reflex erection are located in the sacral area (S2–S4) of the spinal cord. Most paralyzed men are able to have a reflex erection with physical stimulation unless the S2–S4 pathway is damaged.

Spasticity is known to interfere with sexual activity in some people with SCI. During genital stimulation, spasticity is more likely to be increased and autonomic dysreflexia may occur, thus requiring temporary cessation of sexual activity. In addition, ejaculation has been reported to decrease spasticity for up to 24-hours.

Erectile Dysfunction

Erection may be the first issue, but ejaculation is not far behind as the number two issue for men after paralysis.

Researchers report that ejaculation occurs in up to 70 percent of men with incomplete lower-level injuries, and in as many as 17 percent of men with complete lower-level injuries. Ejaculation occurs in about 30 percent of men with incomplete upper-level injuries and almost never in men with complete upper-level injuries.

While many men who are paralyzed can still "get it up," the erection may not be hard enough or last long enough for sexual activity. This condition is called erectile dysfunction (ED).

Numerous treatments and products (pills, pellets, shots and implants) are available for treating ED but paralyzed men may have special concerns or problems with their use. It is important to see your doctor or urologist for accurate information on the various treatments as they relate to specific conditions.

Orgasm: a study of 45 men with SCI and 6 able-bodied controls demonstrated that 79 percent of the men with incomplete lesions and 28 percent of those with complete injuries achieved orgasm in the laboratory setting.

Paralyzed men with ED should have a thorough physical exam by a urologist familiar with their condition before using any medications or assistive devices.

Men with spinal cord injuries above the T6 level must be watchful for signs of autonomic dysreflexia (AD). Signs include flushing in the face, headaches, nasal congestion and/or changes in vision.

Managing ED

Research and reported experience of men with paralysis show that Viagra, Cialis and Levitra significantly improve the quality of erections and the satisfaction of sex life in most men with ED who have injuries between T6 and L5. Men who have low or high blood pressure or vascular disease should not take these drugs.

Some medications cannot be taken with ED drugs – make sure to consult your physician especially if you are likely to experience autonomic dysreflexia.

Penile injection therapy involves injecting a drug (papavarine or alprostadil) or a combination of drugs into the side of the penis. This produces an erection that can last for an hour or two and is firm enough for sexual intercourse in about 80 percent of men, regardless of age or the cause of ED.

If not used correctly, these drugs can result in a prolonged erection, called priapism, which, untreated, can damage the penile tissue. Other risks from the injection are bruising, scarring or infection. An injection erection is a more difficult option for those with limited hand function.

Other options to manage ED include:

MUSE
A medicated urethral system erection (MUSE) is when a medicated pellet (alprostadil, the same drug used in penile injection therapy) is placed into the urethra for absorption into the surrounding tissue. Intraurethral medications are not generally considered to be effective in men with SCI and are seldom prescribed.

Vacuum pumps
Beyond drug options, vacuum pumps produce an erection. The penis is placed in a cylinder and the air is pumped out, causing blood to be drawn into the erectile tissues. Tumescence is maintained by placing an elastic constriction ring around the base of the penis.

It's important to remove the ring after intercourse to avoid the risk of skin abrasion or breakdown. A battery-operated vacuum model is an available option. Premature loss of rigidity and lack of spontaneity are unwanted side effects.

Penile prosthesis
A penile prosthesis is often the last treatment option for ED. It is permanent and requires surgery in which an implant is inserted directly into the erectile tissues.

There are various types of implants available, including semi-rigid or malleable rods and inflatable devices. Generally, the penis may not be as firm as a natural erection.

There are risks of mechanical breakdown, and the danger that the implant could cause infection or push out through the skin. Research showed that 67 percent of females interviewed were satisfied with results of implant treatment for their partner's ED.

Fertility

Fertility is the third biggest issue: Men with paralysis usually experience a change in their ability to biologically father a child, due to the inability to ejaculate.

Some men experience retrograde ejaculation in which semen travels in reverse, back into the bladder. The number of sperm a man produces does not usually drop in the months or years after paralysis. However, the motility (movement) of the sperm is considerably lower than for non-paralyzed men. There are options, though, for enhancing the ability to father children.

Penile vibratory stimulation (PVS) is an inexpensive and fairly reliable way to produce an ejaculation at home. Vibrostimulation is most successful in men with SCI above T10. A variety of vibrators/massagers are available for this purpose. Some are specifically designed with the output power and frequency required to induce ejaculation while minimizing skin problems.

Rectal probe electroejaculation (RPE) is an option (albeit in a clinic with several technicians around) if the vibratory method is not successful. RPE places an electrical probe in the rectum, and a controlled electrical stimulation produces an ejaculation. Electroejaculation is generally a safe and effective way to obtain a sperm sample, although using a vibratory stimulus generally produces samples with better sperm motility than from electrostimulation.

If sperm cannot be retrieved using PVS or RPE, minor surgery can be performed to remove sperm from the testicle.

The sperm from men with SCI are healthy but usually not strong swimmers, and often not hardy enough to penetrate the egg. As a result of their reduced motility, the sperm need a little high-tech help. Men with SCI stand a good chance of becoming biological fathers when they have access to specialized clinics and care.

The recent development of intracytoplasmic sperm injection (ICSI), which involves the direct injection of a single mature sperm into an oocyte (egg), can often solve the problem of conception.

While there are many success stories, high-tech assisted fertility is not a slam-dunk. It can be emotionally draining and also quite expensive. Get the facts and treatment options from a fertility specialist experienced in issues of paralysis.

Some couples grappling with infertility have successfully utilized donor sperm (from a sperm bank) to impregnate the woman. Couples may also want to explore the very rewarding options available to adopt children.

Intimacy following stroke, injury, or disease

Heart disease, stroke or surgery doesn't mean that a satisfying sex life must end. After the first phase of recovery is over, people find that the same forms of lovemaking they enjoyed before are still rewarding.

It is myth that resuming sex often causes a heart attack, stroke or sudden death. Still, fears about performance can greatly reduce sexual interest. After recovery, stroke survivors may feel depressed. This is normal, and in 85 percent of the cases it goes away within three months.

To be sure, a man can continue or initiate a romantic and intimate relationship with a partner after a paralyzing disease or injury. Good communication with his partner is essential. It is important for both partners to understand the physical changes that have occurred, but it is equally important to talk about each other's feelings. The couple can then explore and experiment with different ways to be romantic and intimate.

For people with limited arm and hand function, it is often necessary to ask caregivers to provide physical assistance prior to sexual activity. Help might be needed with undressing, preparation, and positioning.

Many couples consider oral-genital intercourse. Whatever seems satisfying and pleasurable is acceptable as long as both partners agree.

Here's something in the adaptive equipment realm for men with paralysis: IntimateRider is a swing chair that offers a natural gliding motion to improve what the company calls "sexual mobility." The IntimateRider was designed by a C6-C7 tetraplegic to improve his sex life after spinal cord injury. The chair moves with very little pushing effort, allowing the pelvis to thrust during sex.

While it's been said that the largest sex organ is the brain, it's not always easy to make major adjustments in one's sexual persona. Professional counseling can help in working through feelings of fear or anxiety over establishing or continuing a healthy relationship after paralysis. A counselor can also work with couples on healthy ways to communicate their needs and feelings.

Safe sex

The risk of sexually transmitted disease (STD) is the same both before and after paralysis. STDs include diseases such as gonorrhea, syphilis, herpes and the HIV virus. These can cause other medical problems, such as infertility, urinary tract infections, pelvic inflammatory disease, vaginal discharge, genital warts and AIDS. The safest, most effective way to prevent sexually transmitted diseases is to use a condom with a spermicidal gel.

Resources

If you are looking for more information on sexual health or have a specific question, our information specialists are available business weekdays, Monday through Friday, toll-free at 800-539-7309 from 9am to 5pm ET.

Additionally, the Reeve Foundation maintains a fact sheet on male sexuality with additional resources from trusted Reeve Foundation sources. Check out our repository of fact sheets on hundreds of topics ranging from state resources to secondary complications of paralysis.

We also encourage you to reach out to other support groups and organizations, including:

Sources: The American Urological Association, University of Miami Miller School of Medicine, Cleveland Clinic

This project was supported, in part by grant number 90PR3002, from the U.S. Administration for Community Living, Department of Health and Human Services, Washington, D.C. 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration for Community Living policy.