Looking Beyond the Chair: Psycho-Perceptual Predictors of Sexual Distress and Sexual Satisfaction in Individuals with Spinal Cord Injury.

Despite a large body of biomedical research, little is known about the psychological and perceptual predictors of sexual satisfaction (SS) and sexual distress (SD) post spinal cord injury (SCI). Guided by a bio-psycho-perceptual framework, this cross-sectional research aimed at assessing SS and SD in a large SCI sample using validated patient-reported outcome measures (PROM). Significant correlates and predictors of SS and SD were also identified. Ninety-one men and women with SCI completed PROMs of SS and SD, as well as psychological (mood, sexual and body esteem) and perceptual (interoceptive awareness, trait mindfulness, sexual mindfulness) factors. Neurological profiles were also assessed, along with experience of orgasm. Correlates of SS and SD were first identified using Pearson's correlations, then multiple hierarchical regression models were computed to isolate predictors. Orgasm experience and psychological factors emerged as moderate correlates of both SS and SD, while neurological factors did not. Interoceptive awareness and trait mindfulness showed weak associations with SD and none with SS. Among the tested predictors, experience of orgasm emerged as the strongest for SS (ß = -.29, p < .01), followed by mood, which predicted SS and SD. Sexual and body esteem was predictive of SD only. In sexually active participants, sexual mindfulness predicted both SS (ß = 0.55, p < .001) and SD (ß = -0.56, p < .001) above and beyond all other variables. This study reveals unique aspects of SS and SD postinjury and supports further consideration of psychological and perceptual dimensions of SCI sexuality in rehabilitation research.

How long does the effect of botulinum toxin in neurogenic patients last? An analysis of the subset of "good responders".

BACKGROUND: The aim of this study was to assess long-term efficacity of botulinum neurotoxin A (BoNT-A) in the treatment of neurogenic detrusor overactivity (NDO). MATERIALS AND METHODS: This was a retrospective monocentric study in a reference center. We included patients who received intradetrusor BoNT-A for NDO between 2001 and 2015. The focus of our analysis was on patients defined as "good responders" (≥ 5 injections of intradetrusor BoNT-A over a period of ≥5 years). The primary endpoint was the evaluation of long-term efficacity of BoNT-A. Recurrent NDO was monitored by the use of cystomanometry before the first injection and 1 month after each injection. The secondary objective was to assess the influence of NDO's etiology, age, and sex on the long-term efficacity of the treatment. RESULTS: A total of 107 patients were included (60.7% with spinal cord injury [SCI] and 36.4% with multiple sclerosis [MS]). The mean follow-up period was 83.7 months (66; 120). The mean number of injections was of 8.9 (5; 21). A total of 67.3% (n = 72) of patients were still controlled by treatment at the end of their follow-up period. Therapeutic failure occurred in 30 patients (26.1%) with a cessation of BoNT-A treatment at 76 months on average (median: 82.5 months). There was no significant impact of age (P = .42), sex (P = .35), or NDO's etiology (MS vs SCI; P = .54) on long-term efficacy of BoNT-A treatment. CONCLUSION: The results of our study indicate that the application of BoNT-A seems to be an effective and durable treatment in a large number of neurogenic patients after more than 10 years of follow-up. However, botulinum toxin tolerance occurred in approximately 25% of patients.

Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex.

BACKGROUND: The bladder exstrophy-epispadias complex is a rare congenital malformation associated with severe dysfunction of the genital and urinary tracts and requiring a staged surgical reconstruction. AIM: The primary aims of this study were to report the sexuality, infertility, and urinary incontinence outcomes in a cohort of men born with bladder exstrophy-epispadias complex. The secondary aim was to highlight some predictive factors of infertility in this population. METHODS: We conducted a descriptive, cross-sectional study of men diagnosed with classic presentations of bladder exstrophy or epispadias. OUTCOMES: Patients were asked to complete 4 validated questionnaires: the International Index of Erectile Function (IIEF)-5, the Erection Hardness Score (EHS), the Self-Esteem and Relationship, and the International Consultation Incontinence modular Questionnaire-Short Form. Fertility potential was assessed with semen analysis and a non-validated questionnaire. RESULTS: 38 Patients 18-64 years old (M [mean] = 32.2) completed the questionnaires. The average IIEF-5 score was 18.1/25 (ranging from 3-25; SE = 7.62), with results indicating that 55% of the sample had normal erectile function. Results also showed higher scores for patients with normal spermatozoa concentration (M = 22.75, SE = 1.89, P = .08) than for those with oligospermia (M = 17.30, SE = 8.53, P = .08). Results on the IIEF-5 also indicated higher scores for patients who conceived children without assisted reproductive technologies (ART) (M = 22.83, SE = 2.317, P = .02) than for patients without children (M = 15.76, SE = 8.342, P = .02). The average EHS was 3.43/4 (ranging from 1-4, SE = 0.9). EHS was higher for patients who had reconstruction than for patients who had cystectomy (M = 3.88, SE = 1.07 and 2.78, SE = 1.09, P = .02). The average total Self-Esteem and Relationship score was 67.04/100 (ranging from 10.71-96.43, SE = 22.11). The average total International Consultation Incontinence modular Questionnaire-Short Form score was 4.97/21 (ranging from 0-18, SE = 5.44), higher score indicating more urinary incontinence. Among the patients surveyed, 31.6% were parents at the time of study and 50% of them benefited from ART. With regards to the 14 semen analyses performed, only 7.1% produced normal results and 44.7% indicated that ejaculation was weak and dribbling. CLINICAL TRANSLATION: Erectile function appears to be decreased and psychological aspects of sexuality indicate low self-esteem about sexual relationship. Although ethical problems could not allow prospective spermograms, our cohort is large enough to provide significant data. CONCLUSIONS: Early sperm storage for future ART, sexual medicine management, and complementary genital reconstruction in adulthood constitute potential treatment options for this population. Reynaud N, Courtois F, Mouriquand P, et al. Male Sexuality, Fertility, and Urinary Continence in Bladder Exstrophy-Epispadias Complex. J Sex Med 2017;15:314-323.

Assessment of sexual function in women with neurological disorders: A review.

BACKGROUND: Although the rehabilitation of sexual function has been identified as a top priority among women presenting neurological conditions, sexual function is rarely assessed in this clinical group. OBJECTIVES: To review published assessment tools of sexual dysfunction in women with neurological conditions including multiple sclerosis (MS), spinal cord injury (SCI), Parkinson disease, stroke, traumatic brain injury. METHODS: A systematic literature review was conducted with Medline via PubMed, PubMed Central, and Medline databases. RESULTS: There are three reliable methods to assess sexual dysfunctions in women with neurological conditions: physiological assessments of reflexes and perineal sensitivity testing, self-reporting questionnaires on sexual function and sexual satisfaction, and electrophysiological assessments. Physiological assessments of sacral and thoracolumbar reflexes have mainly been conducted among women with SCI. When performed, they reveal the existence of a psychogenic and/or reflex sexual potential in those women. Other forms of physiological assessments include vulvar sensitivity testing in women with SCI, quantitative sensory testing and pudendal somatosensory evoked potentials in MS populations. A few validated self-reporting measures are also available to assess sexual potential and sexual satisfaction, although mostly in women with SCI and MS. CONCLUSION: Despite high prevalence rates and important clinical implications, sexual dysfunction is not systematically assessed in women presenting various neurological conditions. Several well-validated tools exist for such assessments, which could be used for sexual rehabilitation in these patients. The implementation of systematic assessments of sexual potential is feasible and renewed efforts should be made to do so in clinical practice.

Sexual dysfunction in patients with spinal cord lesions.

Many aspects of sexuality can be disrupted following a spinal cord lesion (SCL). It can alter an individual's self-esteem and body image, interfere with positioning and mobility, introduce unexpected problems with incontinence and spasticity, decrease pleasure, and delay orgasm. Sexual concerns in men can involve erectile function, essential for intercourse, ejaculation function, necessary for fertility, and the ability to reach orgasm. In women they can involve concerns with vaginal lubrication, genital congestion, and vaginal infections, which can all go unnoticed, and orgasm, which may be lost. All of these concerns must be addressed during rehabilitation as individuals with SCL continue to live an active sexual life, and consider sexuality among their top priority for quality of life. This chapter describes the impact of SCL on various phases of men's and women's sexual responses and on various aspects of sexuality. Treatments are described in terms of what is currently available and what is specific to the SCL population. New approaches in particular for women are described, along with tips from sexual counseling which consider an overall approach, taking into account the primary, secondary, and tertiary consequences of the SCL on the individual's sexuality. Throughout the chapter, attempts are made to integrate neurophysiologic knowledge, findings from the literature on SCL, and clinical experience in sexual rehabilitation.

The control of male sexual responses.

Male sexual responses are reflexes mediated by the spinal cord and modulated by neural circuitries involving both the peripheral and central nervous system. While the brain interact with the reflexes to allow perception of sexual sensations and to exert excitatory or inhibitory influences, penile reflexes can occur despite complete transections of the spinal cord, as demonstrated by the reviewed animal studies on spinalization and human studies on spinal cord injury. Neurophysiological and neuropharmacological substrates of the male sexual responses will be discussed in this review, starting with the spinal mediation of erection and its underlying mechanism with nitric oxide (NO), followed by the description of the ejaculation process, its neural mediation and its coordination by the spinal generator of ejaculation (SGE), followed by the occurrence of climax as a multisegmental sympathetic reflex discharge. Brain modulation of these reflexes will be discussed through neurophysiological evidence involving structures such as the medial preoptic area of hypothalamus (MPOA), the paraventricular nucleus (PVN), the periaqueductal gray (PAG), and the nucleus para-gigantocellularis (nPGI), and through neuropharmacological evidence involving neurotransmitters such as serotonin (5-HT), dopamine and oxytocin. The pharmacological developments based on these mechanisms to treat male sexual dysfunctions will complete this review, including phosphodiesterase (PDE-5) inhibitors and intracavernous injections (ICI) for the treatment of erectile dysfunctions (ED), selective serotonin reuptake inhibitor (SSRI) for the treatment of premature ejaculation, and cholinesterase inhibitors as well as alpha adrenergic drugs for the treatment of anejaculation and retrograde ejaculation. Evidence from spinal cord injured studies will be highlighted upon each step.

Using sympathetic skin responses in individuals with spinal cord injury as a quantitative evaluation of motor imagery abilities.

BACKGROUND: Motor imagery (MI) ability should be evaluated in selected individuals with spinal cord injury (SCI) who can benefit from MI training in their rehabilitation program. Electrodermal activity seems to be a reliable indicator for assessing MI ability. However, individuals with SCI have a variety of autonomic dysfunctions. OBJECTIVE: This study aimed to investigate electrodermal responses (EDRs) elicited by MI. DESIGN: A cost-utility analysis of EDR above and below the lesion level in individuals with complete or incomplete SCI (n = 30) versus a control group of individuals who were healthy (n = 10) was used. METHOD: The EDR was recorded above and below the lesion level during MI of a drinking action. Duration, latency, and amplitude of EDR were the outcome measures. RESULTS: Hand and foot EDR in the control group occurred with the same pattern and similar latencies, suggesting a common efferent sympathetic pathway to sweat glands of the hand and foot mediating a sympathetic skin response. Individuals with SCI elicited responses above the lesion level. The EDR amplitude was correlated to the lesion level and autonomic dysreflexia history. No foot response was recorded in individuals with complete cervical and thoracic motor lesions. Foot response with a lower amplitude and higher latency occurred in participants with incomplete motor lesion, suggesting a link between the descending motor pathway and sympathetic function. LIMITATIONS: The small sample of individuals with incomplete SCI limits the generalization of the results obtained at the foot site. CONCLUSIONS: Electrodermal response above the lesion level may be a reliable index for assessing MI ability in individuals with SCI. It is a noninvasive, user-friendly method for clinicians to consider before enrolling individuals in MI training.

Side effects of intradetrusor botulinum toxin injections on ejaculation and fertility in men with spinal cord injury: preliminary findings.

UNLABELLED: Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? The beneficial effect of intradetrusor botulinum toxin (BT) injections on hyperactive bladders in individuals with spinal cord injury is known from the literature, but its potential effect on ejaculation and fertility through diffusion is not. As BT injection paralyses the bladder muscle, it may also paralyse the muscular envelopes of the adjacent reproductive organs and lead to potential negative side effects, which have not been studied yet. This study provides preliminary data on the potential negative side effects of BT injections on semen volume and retrograde ejaculation, as well as some potential beneficial effects on semen quality. OBJECTIVE: To investigate the effect of botulinum neurotoxin A on ejaculation potential and fertility. Intradetrusor injection of botulinum neurotoxin A is most commonly used nowadays to treat overactive bladder in patients with spinal cord injury (SCI). PATIENTS AND METHODS: Retrospective analyses were carried out of 11 patients with complete lesions from C5 to T6 who had received botulinum (BT) injections for their overactive bladder and who had undergone ejaculation tests before and after BT treatment. RESULTS: BT treatment was found effective in improving bladder function in up to 85% of the cases. While no patients maintained natural ejaculation following their SCI, BT treatment was found to increase the incidence of retrograde ejaculation (vibrostimulation) in 46% of cases and to diminish semen volume in 77% of cases, from an average of 1.8 mL to 1 mL. Semen quality was slightly improved following BT treatment, sperm mobility increased in 67% of cases, sperm vitality in 50% and semen culture improved in 43%. CONCLUSIONS: BT treatment has beneficial and detrimental effects on ejaculation function. The detrimental effects involve retrograde ejaculation and reduced semen volume, which are explained by the spread of toxin to the bladder neck, reducing its tonus, and to the smooth muscle sexual accessory organs, reducing the strength of their contraction. The beneficial effects are explained by the reduced contamination of the semen by urinary infection, which may improve spermatogenesis and subsequent semen quality. The results are discussed in terms of their clinical implications and advice to patients.

Assessing and conceptualizing orgasm after a spinal cord injury.

OBJECTIVES: To provide a questionnaire for assessing the sensations characterizing orgasm. To test the hypothesis that orgasm is related to autonomic hyperreflexia (AHR) in individuals with a spinal cord injury (SCI). SUBJECTS AND METHODS: A total of 97 men with SCI, of whom 50 showed AHR at ejaculation and 39 showed no AHR, were compared. Ejaculation was obtained through natural stimulation, vibrostimulation or vibrostimulation combined with midodrine (5-25 mg). Cardiovascular measures were recorded before, at, and after each test. Responses to the questionnaire were divided into four categories: cardiovascular, muscular, autonomic and dysreflexic sensations. RESULTS: Significantly more sensations were described at ejaculation than with sexual stimulation alone. Men with SCI who experienced AHR at ejaculation reported significantly more cardiovascular, muscular, autonomic and dysreflexic responses than those who did not. There was no difference between men with complete and those with incomplete lesions. CONCLUSIONS: The findings show that the questionnaire is a useful tool to assess orgasm and to guide patients in identifying the bodily sensations that accompany or build up to orgasm. The findings also support the hypothesis that orgasm may be related to the presence of AHR in individuals with SCI. Data from able-bodied men also suggest that AHR could be related to orgasm, as increases in blood pressure are observed at ejaculation along with cardiovascular, autonomic and muscular sensations.

Perceived physiological and orgasmic sensations at ejaculation in spinal cord injured men.

INTRODUCTION: With the advances in penile vibrator stimulation (PVS), most spinal cord injured (SCI) men can self-ejaculate. Oral midodrine may further increase ejaculation success, while maintaining autonomy. Since most SCI men attempt ejaculation for sexual rather than reproductive purposes, self-ejaculation should be emphasized and sensations explored. AIMS: Explore (i) self-ejaculation success rate in SCI men; (ii) vascular parameters indicative of autonomic dysreflexia (AD) during sexual stimulation and ejaculation; and (iii) sensations associated with ejaculation. METHODS: Ejaculation was assessed on 81 SCI men with complete ASIA A (49%) and incomplete B to D lesions (51%), subdivided into tetraplegics (C2-T2), paraplegics sensitive to AD (T3-T6), paraplegics not sensitive to AD (T7-T10), paraplegics with lesions to the emission pathway (T11-L2), and paraplegics with lesions interrupting the emission-ejaculation pathways (L3-below). Natural stimulation was attempted first followed, if negative, by PVS followed, if again negative, by PVS combined with oral midodrine (5-25 mg). MAIN OUTCOME MEASURES: Ejaculation success, systolic and diastolic blood pressure, and perceived physiological and orgasmic sensations. RESULTS: Overall 91% reached ejaculation, 30% with natural stimulation, 49% with PVS and 12% with midodrine plus PVS. Midodrine salvaged up to 27% depending upon the lesion. Physiological and orgasmic sensations were perceived significantly more at ejaculation than sexual stimulation. Tetraplegics did not differ from paraplegics sensitive to AD on perceived cardiovascular and muscular sensations, but perceived significantly more autonomic sensations, and generally more physiological sensations than lower lesions unsensitive to AD. CONCLUSION: Most SCI men can self-ejaculate and perceive physiological and orgasmic sensations. The climactic experience of ejaculation seems related to AD, few sensations being reported when AD is not reached, pleasurable climactic sensations being reported when mild to moderate AD is reached, and unpleasant or painful sensations reported with severe AD. Sexual rehabilitation should emphasize self-ejaculation and self-exploration and consider cognitive reframing to maximize sexual perceptions.

Blood pressure changes during sexual stimulation, ejaculation and midodrine treatment in men with spinal cord injury.

OBJECTIVES: To explore the effectiveness of various sources of self-stimulation, including oral midodrine, in triggering ejaculation in men with spinal cord injury (SCI), and to document the systematic variations in blood pressure at ejaculation and consider a revised definition of autonomic dysreflexia. PATIENTS AND METHODS: The study included 62 men with SCI lesions from C2 to L2. Ejaculation potential was assessed with various sources of stimulation, beginning with natural stimulation, followed, if the test was negative, by penile vibrator stimulation (PVS) followed, if the test was again negative, by PVS combined with oral midodrine, started at 5 mg and increased in 5 mg steps up to 25 mg. The success rate of ejaculation was recorded, as were blood pressure (BP) changes measured at baseline and at ejaculation (or on the last trial if the test was negative). Reported sensations were also recorded and compared during positive and negative tests. RESULTS: Overall, 89% of the patients reached ejaculation with one mode or another of stimulation. When patients had a negative result with natural stimulation, 56% were salvaged by PVS, and when PVS was negative, another 22% were salvaged by midodrine combined with PVS. The mean systolic BP increased by 35 mmHg at ejaculation during PVS and by 11 mmHg after midodrine, and a subsequent 29 mmHg at ejaculation during PVS combined with midodrine. By contrast, negative tests showed a relatively stable BP; the difference in changes in BP during positive and negative tests was significant (P < 0.01). Increases in BP during positive tests declined significantly more often within the limits of autonomic dysreflexia than negative tests (P < 0.01). CONCLUSION: These results support the view that most men with SCI can obtain an ejaculation when a wide spectrum of stimulation is used, including natural stimulation, PVS, and PVS combined with oral midodrine. Positive tests were associated with significant increases in BP, in contrast to negative tests, where BP was relatively stable. This suggests that significant changes in BP are required for ejaculation and that insignificant changes are predictive of future failure. As most changes in BP during positive tests also fall within the criterion of autonomic dysreflexia, a revised definition of autonomic dysreflexia should be considered to encourage safe experiences with ejaculation and safe use of midodrine.

[Comparative study of the acceptability of the SpeediCath Set and Actreen set catheterization sets in patients performing self-catheterization]. / Etude d'acceptabilité du set de sondage SpeediCath Set comparativement à Actreen Set chez des patients pratiquant l'autosondage.

OBJECTIVE: To compare SpeediCath Set to Actreen Set in terms of performance, acceptability and safety, in patients performing self-catheterization. MATERIAL AND METHODS: Four questionnaires were completed during this multicentre, randomized, crossover study: initial, after having tested each of the two products and patient preference at the end of the study. RESULTS: Analysis was based on 29 men performing self-catheterization. The SpeediCath Set was found to be superior to the Actreen Set in terms of ease of introduction (p=0.0055), ease of emptying (p=0.0157), quality of lubricant (p<0.0001), urethral tolerance and possibility of catheterization in bed (p= 0.0157). The patients 'global assessment was clearly in favour of SpeediCath Set (70 +/- 2.3 versus 5.7 +/- 2.5; p=0.0156) and 65.5% of patients preferred to use SpeediCath Set in the future. CONCLUSION: SpeediCath Set facilitates catheterization and improves the urethral tolerance compared to Actreen Set, with a marked patient preference in favour of SpeediCath Set.