Female sexual function after spinal cord injury.

Over the past 10 years, studies of the impact of spinal cord injuries on female sexuality have expanded from questionnaire studies in small populations with unknown levels and degrees of injury to laboratory-based analyses of women with known injury patterns. These studies have provided detailed information on how specific injury patterns affect specific aspects of the female sexual response. Research findings have supported the hypothesis that the sympathetic nervous system is regulatory for psychogenic genital vasocongestion and that orgasm is a reflex response of the autonomic nervous system. Based on these results, a new system for the classification of sexual function in women with spinal cord injury (SCI) is proposed. Moreover, studies related to the treatment of sexual dysfunction in women with cord injury are reviewed.

Reproductive issues for women with spina bifida.

BACKGROUND/OBJECTIVES: Few studies have adequately examined the unique issues of women with spina bifida as they enter their reproductive years. Most studies are anecdotal, retrospective case studies that contribute little to our understanding of the physiological effects of the disability on the reproductive system and, conversely, the effects of the reproductive endocrine changes on the woman's disability. The purpose of this article was to review previously published reports on the reproductive issues facing female adolescents and women and to ascertain the current knowledge so that future research needs can be established. METHODS: Multiple MEDLINE searches were performed for publications from 1957 through the present pertaining to females/women with spina bifida and/or disabilities. Papers were then chosen if information was provided on menarche, menstruation and sexual maturation, gynecologic issues, sexual function, birth control, pregnancy outcomes, and menopause. These were then reviewed and classified according to the level of evidence (as defined by Ball et al). RESULTS: More than 150 titles and abstracts were reviewed for inclusion. Of these, 75 papers met the guidelines for the subject content. Studies were stratified by level of evidence and included 1 study at level 3, 71 studies at level 4, and 3 studies at level 5. CONCLUSION: Little research has examined the reproductive issues of women with spina bifida and women with other neurologic disabilities. Future controlled prospective research studies are needed to examine issues related to puberty and sexual and gynecologic issues throughout the life span and pregnancy in these populations.

Effects of vibratory stimulation on sexual response in women with spinal cord injury.

Women with spinal cord injuries (SCIs) have predictable alterations in sexual responses. They commonly have a decreased ability to achieve genital sexual arousal. This study determined whether the use of vibratory stimulation would result in increased genital arousal as measured by vaginal pulse amplitude in women with SCIs. Subjects included 46 women with SCIs and 11 nondisabled control subjects. Results revealed vibratory clitoral stimulation resulted in increased vaginal pulse amplitude as compared with manual clitoral stimulation in both SCI and nondisabled subjects; however, these differences were not statistically significant. Subjective levels of arousal were also compared between SCI and nondisabled control subjects. Both vibratory and manual clitoral stimulation resulted in significantly increased arousal levels in both groups of subjects; however, statistically significant differences between the two conditions were only noted in nondisabled subjects. Further studies of the effects of repetitive vibratory stimulation are underway.

Research from the Model Spinal Cord Injury Systems: findings from the current 5-year grant cycle.

This issue of the Archives of Physical Medicine and Rehabilitation is dedicated to current research findings of the Model Spinal Cord Injury Systems (MSCIS) program. The MSCIS grants were established by the Rehabilitation Services Administration in the 1970s. Now administered by the National Institute on Disability and Rehabilitation Research within the Office of Special Education and Rehabilitation Services in the US Department of Education, the program has included 27 spinal cord injury centers in the United States over the years. In the current 5-year grant cycle (2000-2005), there are 16 designated regional MSCIS centers. In addition to establishing a comprehensive system of care, the grantees contribute patient data to the National Spinal Cord Injury Database (which now contains data on 30,532 subjects with follow-up of up to 30 y). In addition, the MSCIS grants enable the conduct of site-specific and collaborative research projects. To highlight the research findings of the program, the MSCIS have produced a special dissemination effort during each of the previous 5 grant cycles, with this issue of the Archives representing the latest of these endeavors. This article provides a brief history of the MSCIS program and highlights the important findings of the 17 original research articles contained in this issue.

Effects of gender on neurologic and functional recovery after spinal cord injury.

OBJECTIVE: To assess gender differences in neurologic and functional outcome measures in persons with spinal cord injury (SCI). DESIGN: Case series. SETTINGS: Model Spinal Cord Injury Systems (MSCIS) throughout the United States. PARTICIPANTS: People (N=14,433) admitted to an MSCIS within 30 days of injury. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Improvement in American Spinal Injury Association (ASIA) motor index score, ASIA Impairment Scale, level of injury, and FIM instrument scores after SCI. RESULTS: When examining subjects grouped by severity of injury, changes in ASIA motor index total scores, from system admission to 1-year anniversary, were significantly greater for women than men with either complete ( P =.035) or incomplete ( P =.031) injuries. Functional comparison of men and women, using the FIM motor subscale, revealed that men had higher FIM motor scores at rehabilitation discharge among those with motor-complete injuries, except for those with C1-4 and C6 neurologic levels. Women with motor-incomplete high tetraplegia (C1-4 levels) had higher discharge FIM motor scores than did similarly afflicted men. There were no significant differences in FIM motor scores among men and women with other levels of motor incomplete SCI. CONCLUSIONS: Gender differences in SCI were seen in several areas. Women may have more natural neurologic recovery than men; however, for a given level and degree of neurologic injury, men tend to do better functionally than women at time of discharge from rehabilitation. Future prospective study of the effects of estrogen on neurologic recovery and the effects of gender on functional potential are recommended.

Lack of justification for routine abdominal ultrasonography in patients with chronic spinal cord injury.

Little evidence-based research is available to indicate which procedures should routinely be performed for screening exams in patients with spinal cord injuries (SCIs). It had been the procedure to routinely perform abdominal ultrasonography on a yearly basis at our medical center. Therefore, we conducted a retrospective study to determine whether the repetition of these procedures resulted in detection of any pathology warranting treatment that otherwise would have gone undetected. The electronic records of 174 individuals were reviewed, along with a total of 359 abdominal ultrasounds and exams. High incidences of abnormal findings were found in the liver, pancreas, spleen, gallbladder, and kidney; however, no specific interventions were noted solely on the basis of the ultrasound findings. Moreover, no added benefits could be documented through the performance of repetitive exams. We recommend that further evidence-based studies be performed to ascertain the benefits of performance of routine procedures in patients with SCIs.

Sexual responsiveness in women with spinal cord injuries: differential effects of anxiety-eliciting stimulation.

Sexual dysfunction is a common problem in women after spinal cord injuries (SCIs). Recently, the use of anxiety-provoking stimulation has been explored as a means of improving sexual responses in able-bodied sexually functional and dysfunctional women. In this laboratory-based study, we assessed the sexual and autonomic responses of women with SCIs with varying degrees of preservation of sympathetic innervation to their genitals to respond to anxiety-provoking audiovisual (AV) stimulation. Subjects were 45 women with SCIs and 11 able-bodied women. For purposes of analysis, SCI subjects were grouped on the basis of the degree of preservation of sensation in the T11-L2 dermatomes. Results revealed that women with low sensory scores in these dermatomes achieved higher vaginal pulse amplitude (VPA) responses to audiovisual erotic stimulation after anxiety preexposure than after neutral preexposure; however, women with SCIs and the greatest degree of preservation of sensory function in the T11-L2 dermatomes, as well as able-bodied controls, did not. Moreover, these same 2 groups of subjects had a decrease in VPA responses during baseline periods in which an anxiety-provoking video sequence was shown, but not during the neutral sequence. It is concluded that these findings are due to the proximity of sensory and autonomic neurologic elements in the spinal cord. Moreover, they demonstrate the differential effects of sympathetic stimulation on genital sexual arousal.

Disorders of orgasm in women.

INTRODUCTION: Orgasm is a sensation of intense pleasure creating an altered consciousness state accompanied by pelvic striated circumvaginal musculature and uterine/anal contractions and myotonia that resolves sexually-induced vasocongestion and induces well-being/contentment. In 1,749 randomly-sampled U.S. women, 24% reported an orgasmic dysfunction. AIM: To provide recommendations/guidelines concerning state-of-the-art knowledge for management of orgasmic disorders in women. METHODS: An International Consultation in collaboration with the major urology and sexual medicine associations assembled over 200 multidisciplinary experts from 60 countries into 17 committees. Committee members established specific objectives and scopes for various male and female sexual medicine topics. The recommendations concerning state-of-the-art knowledge in the respective sexual medicine topic represent the opinion of experts from five continents developed in a process over a 2-year period. Concerning the Disorders of Orgasm in Women Committee, there were four experts from two countries. MAIN OUTCOME MEASURE: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation and debate. RESULTS: Female Orgasmic Disorder, the second most frequently reported women's sexual problem is considered to be the persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase that causes marked distress or interpersonal difficulty (DSM-IV). Empirical treatment outcome research is available for cognitive behavioral and pharmacological approaches. Cognitive-behavioral therapy for anorgasmia promotes attitude and sexually-relevant thought changes and anxiety reduction using behavioral exercises such as directed masturbation, sensate focus, and systematic desensitization treatments as well as sex education, communication skills training, and Kegel exercises. To date there are no pharmacological agents trials (i.e., bupropion, granisetron, and sildenafil) proven to be beneficial beyond placebo in enhancing orgasmic function in women diagnosed with Female Orgasmic Disorder. CONCLUSIONS: More research is needed in understanding management of women with orgasmic dysfunction.

Women's orgasm.

An orgasm in the human female is a variable, transient peak sensation of intense pleasure, creating an altered state of consciousness, usually with an initiation accompanied by involuntary, rhythmic contractions of the pelvic striated circumvaginal musculature, often with concomitant uterine and anal contractions, and myotonia that resolves the sexually induced vasocongestion and myotonia, generally with an induction of well-being and contentment. Women's orgasms can be induced by erotic stimulation of a variety of genital and nongenital sites. As of yet, no definitive explanations for what triggers orgasm have emerged. Studies of brain imaging indicate increased activation at orgasm, compared to pre-orgasm, in the paraventricular nucleus of the hypothalamus, periaqueductal gray of the midbrain, hippocampus, and the cerebellum. Psychosocial factors commonly discussed in relation to female orgasmic ability include age, education, social class, religion, personality, and relationship issues. Findings from surveys and clinical reports suggest that orgasm problems are the second most frequently reported sexual problems in women. Cognitive-behavioral therapy for anorgasmia focuses on promoting changes in attitudes and sexually relevant thoughts, decreasing anxiety, and increasing orgasmic ability and satisfaction. To date there are no pharmacological agents proven to be beneficial beyond placebo in enhancing orgasmic function in women.

From the bench to the body: key issues associated with research aimed at a cure for SCI.

Significant advances have been made in the study of neuroprotection and neural regeneration following spinal cord injury (SCI). However, there is wide variability in the animal models used for these studies. Moreover, there is no consensus on which outcome measures are best used to document recovery in animals. On top of these issues, the transfer of research from the laboratory into clinical trials is also hampered by a lack of sensitive outcome measures to document the recovery of function in humans with SCIs. This paper identifies specific issues related to the transfer of research findings from animals into humans. In the laboratory, these issues include the choice of animal model and outcome measures selected; and in humans, the standardization of medical treatment and other therapies, patient selection, and the outcome measures chosen. In the transfer of research from animals into humans, safety and feasibility issues must also be considered.

Efficacy and safety of sildenafil citrate (Viagra) in men with erectile dysfunction and spinal cord injury: a review.

Spinal cord injury (SCI) affects a substantial number of men who are young, active, and otherwise healthy. Erectile dysfunction (ED) is a common consequence of SCI. Since its approval, sildenafil citrate (Viagra) has been shown to effectively treat ED of various etiologies. We review the evidence for the efficacy and safety of sildenafil treatment of ED in men with SCI. A literature search identified 2 randomized controlled trials and 4 prospective case series that evaluated sildenafil treatment for ED from SCI. Efficacy was evaluated using an assessment of global efficacy and a more specific assessment of erectile function. For general efficacy, the proportion of patients who reported improved erections and ability to have intercourse was as high as 94%. Up to 72% of intercourse attempts were successful. For measures of erectile function, 5 of the 6 studies showed statistically significant improvements among sildenafil-treated versus placebo-treated patients. Erectile response rates were generally higher in patients with incomplete versus complete SCI and in patients with upper versus lower motor neuron lesions. Nevertheless, a substantial proportion of patients with complete lesions, regardless of level or lower motor neuron lesions, also benefited from sildenafil. Sildenafil was well tolerated. Incidence rates and types of adverse events that occurred in these studies were similar to those published previously. Symptoms of autonomic dysreflexia were not reported in any study. Existing evidence suggests that oral sildenafil is a highly effective and well-tolerated treatment for ED associated with SCI.

Central nervous system based neurogenic female sexual dysfunction: current status and future trends.

The amount of information available regarding the impact of various central nervous system disorders on female sexual function has greatly increased. In this article, the most recent information regarding brain and spinal cord disorders in human females is reviewed. Evidence from women with spinal cord injuries (SCIs) supports findings in able-bodied females that the sympathetic nervous system provides regulation of psychogenic sexual arousal. In women with SCIs, the ability to achieve orgasm persists in approximately 50%; however, there is a relative inability to achieve orgasm with complete disruption of the sacral reflex arc. These natural effects of injury should be considered when educating patients about neurogenic sexual dysfunction and when developing treatment protocols. Published research protocols aimed at improving sexual responsiveness and future possibilities for treatment of neurogenic sexual dysfunction are also discussed.

Neurogenic bladder, neurogenic bowel, and sexual dysfunction in people with spinal cord injury.

The purpose of this article is to review the literature related to the effects of spinal cord injuries on genitourinary, gastrointestinal, and sexual function. These important areas of function are profoundly affected by spinal cord injuries, with the effects of injury being dependent on the specific level and degree of neurologic dysfunction. Our ability to manage neurogenic bladder dysfunctions and neurogenic bowel dysfunctions has improved over the past few years; however, in general the techniques used have not significantly changed. In contrast, a significant amount of new information has been made available regarding the effects of specific neurologic injuries on sexual response, particularly female sexual response. Moreover, techniques to remediate erectile dysfunction and infertility in the male have vastly improved the fertility potential of men with spinal cord injuries. Further research is warranted in all of these areas.

Mothers with spinal cord injuries: impact on marital, family, and children's adjustment.

OBJECTIVE: To evaluate how mothers with spinal cord injury (SCI) adjust to parenting, their marriages, and their families, and how their children adjust to their mothers' disability. DESIGN: Randomized control study of mothers with SCI and their children, matched to able-bodied mothers and their children on key demographic variables. SETTING: Subjects were selected from 7 regional Spinal Cord Injury Model Systems from across the United States. PARTICIPANTS: A total of 310 volunteers (experimental: 88 mothers with SCI, 46 partners, 31 children; matched controls: 84 able-bodied mothers, 33 partners, 28 children). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Children's adjustment, gender role identity; self-esteem; children's attitude toward mother and father; dyadic and family adjustment; parenting stress; and satisfaction. RESULTS: No significant differences were found between mothers with SCI and able-bodied mothers. Moreover, there were no significant differences between children raised in families with mothers with SCI and children raised in families with able-bodied mothers. Also, no significant differences were found in dyadic or family functioning with mothers with SCI or able-bodied mothers. CONCLUSIONS: SCI in mothers does not appear to affect their children adversely in terms of individual adjustment, attitudes toward their parents, self-esteem, gender roles, and family functioning. Our results may challenge health care providers, social policy-makers, and the general public to end negative stereotyping of children, couples, and families with a disabled mother and wife.