Pulse article: opioid prescription for pain after spinal cord damage (SCD), differences from recommended guidelines, and a proposed algorithm for the use of opioids for pain after SCD.

Study design: Online questionnaire of spinal cord injury (SCI) physicians. Objectives: The objective of this study is to characterize the approach to opioid prescription for persons with spinal cord damage (SCD). Setting: An international online questionnaire. Methods: A survey was posted online and circulated among international societies within the field of SCI medicine from August to November 2018. Results: One hundred and twenty-three physicians responded to the survey. Of these, 107 (92%) managed pain for persons with SCD. Most (82%) felt that opioid prescription was appropriate for uncontrolled acute pain, but fewer (67%) felt it was appropriate for chronic pain. Of those who felt opioids had a role in the treatment of neuropathic pain, 46% did not think there should be a specific upper limit of opioid dose. The majority (85%) would continue prescribing high doses (250 morphine milligram equivalent (MME) doses/day) if that dose were effective. Tramadol was the most common opioid prescribed first line. Conclusion: Most physicians who responded to this survey prescribe opioids for intractable pain after SCD. A significant proportion of respondents believed that there should not be a specific upper limit of opioid dose prescribed if the drug is tolerated; this does not align with current recommendations. Most physicians do not feel influenced in their prescribing habits by regulatory bodies. If physicians decide to taper an opioid that is being tolerated well, it is most commonly related to a fear of the patient developing an opioid-use disorder. The authors propose an algorithm that may help align practice patterns with current recommended practice guidelines.

The neurologic control of arousal and orgasm with specific attention to spinal cord lesions: Integrating preclinical and clinical sciences.

Preclinical research in animal models is important for understanding the neural pathways and pathophysiology underlying changes in sexual function after SCI. In vivo animal models, primarily rodents, have provided valuable information on the central pathways regulating sexual arousal and orgasm; however, further research is required in females and preclinical modeling of SCI that can be better translated to men and women. Translation of the autonomic and somatic regulation of sexual responses from preclinical models through clinical research correlates well with respect to the peripheral-spinal systems involved. However, due to the nature of sexual responses, parallel studies are necessary in animals and humans. Human studies of individuals with SCIs have provided information about the neurologic control of arousal and orgasm. Psychogenic arousal is related to the preservation of sensation at T11-L2 whereas orgasm requires the presence of an intact sacral reflex arc. Studies point to evidence of a spinal pattern generator at L3-5. Because of the exact nature of SCIs, further research using neuroimaging will be beneficial, not only to elucidate the neurological control of sexual responses after SCI, but also in able-bodied individuals. Understanding and ameliorating the effects of SCI on sexual function is important to the well-being and quality of life of individuals with SCIs and their partners, thus future research should focus more on this important topic.

Sexual concerns after Spinal Cord Injury: An update on management.

BACKGROUND: Spinal Cord Injury (SCI) causes neurological impairment with resultant neurogenic sexual dysfunction which can compound preexisting psychological and medical sexual concerns. Understanding these concerns is important in managing the lifelong needs of persons with SCIs. OBJECTIVES: To provide an overview of the impact of SCI on sexuality along with a framework for treatment of sexual concerns. To briefly review male infertility and its treatments and pregnancy in females after SCI. METHODS: Interdisciplinary literature review and synthesis of information. RESULTS: The average age at SCI is increased, thus persons with SCIs may have preexisting sexual concerns. Sexual activity and satisfaction are decreased after SCI. Psychogenic sexual arousal is related to remaining sensation in the T11-L2 dermatomes. Orgasm occurs in approximately 50% of persons with SCIs with all injuries except subjects with complete lower motor neuron (LMN) injuries affecting the lowest sacral segments A structured approach to treatment including assessing preinjury function, determining the impact of injury, education, assessing and treating iatrogenic sexual dysfunction and treatment of concomitant problems is recommended. Basic and advanced methods to improve sexual arousal and orgasm are discussed and treatment of anejaculation and issues associated with pregnancy and SCI are reviewed. CONCLUSIONS: Sexual satisfaction is impaired after SCI; however, education and new therapies can improve responsiveness. Future research is warranted to improve sexual function and fertility potential in persons with SCIs.

Measurement of sexual functioning after spinal cord injury: preferred instruments.

BACKGROUND/OBJECTIVE: To determine the utility of certain instruments to assess sexuality and fertility after SCI, an expert panel identified key areas to study and evaluated available instruments. These were rated according to certain predefined criteria. METHODS: The authors divided sexual issues into male and female sexual function, male reproductive function, and female reproductive function. The instruments that have been used most frequently to measure these aspects of sexual function over the past 5 years were identified by expert consensus. Finally, these instruments were subjected to a critical review. RESULTS: The Female Sexual Function Index (FSFI), measurement of vaginal pulse amplitude (VPA), the International Index of Erectile Function (IIEF), and the measurement of ejaculatory function and semen quality were considered appropriate measures to assess sexual responses and reproductive function after SCI. There were no measures identified to assess female reproductive function. CONCLUSIONS: For clinical trials aiming to improve sexual function after SCI, the FSFI or the IIEF is currently preferred. Although VPA is an appropriate means to assess female sexual responses, it is only useful for laboratory studies and is too invasive for use in clinical trials. For assessment of male fertility potential, assessment of ejaculatory capacity and semen analysis are recommended.

Recommendations for discussing sexuality after spinal cord injury/dysfunction in children, adolescents, and adults.

BACKGROUND/OBJECTIVE: To review the literature and provide a framework for sex education for the child, adolescent, or adult with a spinal cord injury (SCI) or disorder. METHODS: Discussion and review of the literature. RESULTS: There is a paucity of research available regarding the impact of SCIs and disorders on sexuality in children and adolescents; however, there is a significant body of literature on this topic in adults. Recommendations based on these findings are presented. Guidelines regarding sexuality in children and adolescents with general disabilities may be adapted for the education of children and adolescents with SCIs and disorders. CONCLUSIONS: Parents, partners, and persons with SCIs and disorders should be provided with age-appropriate information about sexuality that includes specific information with respect to SCIs and disorders. Although there has been a significant increase in information that is available about the impact of sexuality in adults after SCI, more information is needed about the effects of SCIs and disorders on the healthy sexual development of children and adolescents.

Development of international standards to document sexual and reproductive functions after spinal cord injury: preliminary report.

Clinicians need standard terminology to communicate effectively about remaining autonomic function in persons after spinal cord injury. This article illustrates the development of standard nomenclature that describes the impact of injury on sexual functioning. A standard anatomic diagnosis and a secondary means of describing the presence of male and female sexual dysfunction, genital arousal, and orgasmic function are discussed.