Electroejaculation in men with spinal cord injury: a step-by-step video demonstration.

OBJECTIVE: To demonstrate the proper technique to perform electroejacuation (EEJ) in men with spinal cord injury (SCI) for the purpose of inducing ejaculation. DESIGN: A video demonstration of the proper technique to perform EEJ in men with SCI using the Seager model 14 electroejaculation machine. SETTING: Major university medical center. PATIENT(S): Men with SCI; institutional review board approval was obtained, and all subjects signed an informed consent form. INTERVENTION(S): Spinal cord injury occurs mostly in young men where the majority suffer from ejaculatory dysfunction. The method of choice to induce ejaculation in penile vibratory stimulation (PVS). PVS is successful in 86% of men with SCI whose level of injury is T10 or rostral. If PVS fails or the level is Caudal to T10, the patient is referred for EEJ. This video will demonstrate the proper technique for successful ejaculation using EEJ. Patients with history of autonomic dysreflexia or their level of injury is T6 or rostral are pretreated with 10-20 mg of nifedipine sublingually 10 minutes before stimulation. The patient is then placed in the lateral decubitus position. The bladder is emptied, and a buffer is instilled. An anoscopy is performed, and a rectal probe is placed. A current is delivered until an antegrade ejaculation is retrieved. A retrograde specimen is collected and examined for sperm identification. Patients with complete SCI (no sensory or motor function is preserved in sacral segments S4-S5) can undergo EEJ without anesthesia. Patients with incomplete SCI (significant nerve sparing or normal sensations) will experience pain during stimulation, and general anesthesia is recommended without the use of muscle relaxing agents. MAIN OUTCOME MEASURE(S): Successful ejaculation after performing EEJ in men with SCI. RESULT(S): Electroejacuation is successful in 95% of men with SCI and in nearly 100% if general anesthesia is used. Outcomes of in vitro fertilization or intracytoplasmic sperm injection after EEJ showed 37.5% pregnancy rate per cycle, 50.0% pregnancy rate per couple, 33.3% live birth rate per cycle, and 43.8% live birth rate per couple. No complications due to EEJ were observed in 953 trials, and none occurred in the patients presented in this video demonstration. CONCLUSION(S): Electroejacuation is a safe and reliable method for induction of ejaculation in men with SCI who fail a trial of PVS.

Proteomic insight of seminal plasma in spinal cord injured men submitted to oral probenecid treatment for improved motility.

OBJECTIVE: To observe the seminal plasma proteomic composition in men with spinal cord injury orally treated with probenecid, in order to observe pathways associated with increased sperm motility. STUDY DESIGN: Prospective study. SETTING: Miami Project to Cure Paralysis - University of Miami/Miller School of Medicine. PARTICIPANTS: Nine men with spinal cord injury, who agreed to participate in the study. INTERVENTION: Oral treatment with probenecid - 500 mg per day for one week, then 500 mg twice daily [1000 mg total] per day for three weeks. OUTCOME MEASURES: Semen analysis as per WHO 2010 guidelines, and seminal plasma proteomics analysis by LC-MS/MS. RESULTS: In total, 783 proteins were identified, of which, 17 were decreased, while 6 were increased after treatment. The results suggest a new pathway that could be treated by the decrease of biglycan after probenecid treatment. CONCLUSION: Oral treatment with probenecid is able to alter the seminal plasma proteome, in pathways that explain decreased innate immune response.

Evaluation of a re-engineered device for penile vibratory stimulation in men with spinal cord injury.

STUDY DESIGN: Cohort study OBJECTIVES: The purpose of this study was to evaluate the performance of a re-engineered device (Ferticare 2.0), which is replacing the previous standard (Ferticare 1.0) for penile vibratory stimulation in men with spinal cord injury. Most men with spinal cord injury are anejaculatory, requiring medical assistance to obtain their semen. Penile vibratory stimulation is generally recognized as the standard of care for semen retrieval in these anejaculatory men. SETTING: Major Research University in Miami, Florida, USA. METHODS: The Ferticare 2.0 device was applied to 15 men with spinal cord injury in a three-step protocol simulating normal use. Step 1: one device (2.5 mm amplitude, 100 Hz) was applied to the glans penis for 2 min. Step 2: If no ejaculation occurred, the amplitude was increased to 4.0 mm (100 Hz) and the device similarly applied. Step 3: If no ejaculation occurred, two devices, each 2.5 mm and 100 Hz were applied to the dorsum and frenulum of the glans penis. Participants at risk for autonomic dysreflexia were pretreated with sublingual nifedipine (20 mg), 15 min prior to stimulation. Blood pressure and other symptoms of autonomic dysreflexia were monitored. Participants answered a questionnaire about their experience with the device. RESULTS: Thirteen of 15 participants ejaculated with the device. No adverse events occurred. All participants commented they would recommend the device to other men with spinal cord injury. CONCLUSIONS: A re-engineered device, the Ferticare 2.0, is safe and effective for inducing ejaculation in men with spinal cord injury.

Effect of a formal oncofertility program on fertility preservation rates-first year experience.

BACKGROUND: A formal fertility preservation program was initiated at our institution in 2016 as part of a multi-disciplinary oncofertility initiative to improve the reproductive needs of oncologic patients. After 1 year of initial experience, we assessed sperm banking rates in men diagnosed with cancer, as well as examined the trends in the use of fertility preservation services. METHODS: We performed a chart review from 2011 to 2017 for men newly diagnosed with cancer, and for all men who underwent fertility preservation during that period of time at our institution. We assessed the rates of sperm banking among patients newly diagnosed with cancer, before and after the implementation of a standardized oncofertility program in 2016. The program includes nursing and physician education regarding indications of fertility preservation. Additionally, we evaluated the overall population undergoing sperm cryopreservation at our institution during the study period. RESULTS: From 2011 to 2016, 30 of 902 oncologic patients underwent sperm banking prior to their treatment (3.3% of total cancer patients). After the program was implemented, 42 of 218 patients underwent fertility preservation between June 2016 and August 2017 (19.3% of total cancer patients). In this group, patients' mean age was 30.14 years old (range, 13-69 years old), with 6 pediatric patients; 36 of the samples (85.7%) were obtained from masturbation. When viable sperm could not be obtained from ejaculation, patients underwent either testicular or epididymal sperm extraction (6 cases). Overall, 98 men used the formal fertility preservation service. Of these, 42 were cancer patients and 56 were non-cancer patients. Of the non-cancer patients, 17 banked sperm after varicocelectomy, 6 prior to vasectomy and 6 because of hypogonadism. CONCLUSIONS: Rate of sperm banking increased nearly six-fold after institution of a formal fertility preservation program, indicating the clinical need for such a program at academic institutions. Oncofertility is a relevant part of the care for oncologic patients, and should be considered as part of counseling before cancer treatment.

Oral probenecid improves sperm motility in men with spinal cord injury.

STUDY DESIGN: Prospective cohort study (twenty men with spinal cord injury [SCI]). OBJECTIVE: Determine if administration of oral probenecid results in improved sperm motility in men with SCI. SETTING: Major university medical center. METHODS: Twenty men with SCI were administered probenecid for 4 weeks (250 mg twice a day for 1 week, followed by 500 mg twice a day for 3 weeks). Semen quality was assessed at three time points: pre-treatment, post-treatment (immediately after the 4-week treatment), and follow-up (4 weeks after the last pill was ingested). RESULT(S): Probenecid was well-tolerated by all subjects. Sperm motility improved in each subject after 4 weeks of oral probenecid. The mean percent of sperm with progressive motility increased from 19% to 26% (P < 0.05). A more striking increase was seen in the mean percent of sperm with rapid linear motility, from 5% to 17%, (P <0.001). This improvement continued into the four week follow up period. Similar improvements were seen in the total motile sperm count (15 million, 28 million, and 27 million at pre-treatment, post-treatment, and follow-up, respectively). Sperm concentration was not significantly different at pre-treatment, post-treatment, and follow-up, (52 million, 53 million and 53 million, respectively). CONCLUSION: This study showed that administration of an oral agent (probenecid) known to interfere with the pannexin-1 cellular membrane channel, can improve sperm motility in men with spinal cord injury. It is the first study to report improved sperm motility after oral medication in men with SCI.

Kikuchi-Fujimoto disease: a clinicopathologic update.

Kikuchi-Fujmoto disease (KFD), also known as "histiocytic necrotizing lymphadenitis", is a rare lymphadenitis of unknown origin, but with an excellent prognosis. It is more common in Asia, but isolated cases are also reported in America, Africa and Europe. The disease can have an acute or subacute course, usually develops in 1 to 3 weeks, with spontaneous resolution in 1-4 months. The main clinical sign is cervical lymphadenopathy, especially in the posterior cervical triangle with bulky and painful lymph nodes, usually affecting only one side; rare cases of generalized lymphadenopathy can be seen. This common clinical presentation can also be accompanied by nausea, vomiting, weight loss, weakness, headache and arthralgia. An extranodal extension of the disease, including involvement of skin, eye, and bone marrow localizations, has been rarely described. Most patients have leukopenia or neutropenia with a relative leukocytosis. At an ultrasound exploration of the affected lymph nodes, a hypoechoic aspect can be seen, with an external, thick and irregular hyperechoic ring. As there are no specific tests for KFD, the final diagnosis is histologically-based from lymph node excisional biopsy. Histological examination shows paracortical foci of coagulative necrosis containing karyorrhectic debris, which are surrounded by numerous CD68+/myeloperoxidase (MPO)+ histiocytes, CD68+/CD123+ plasmacytoid dendritic cells, and a minority of small- to large-sized CD8+lymphocytes and immunoblasts. Differential diagnosis mainly includes systemic lupus erithematous (SLE)-related lymphadenopathy and large cell lymphoma. The histological absence of neutrophils, plasmacells, as well as hematoxylin bodies, is a feature which argues against the diagnosis of SLE. In addition, the absence of auto-antibodies and anti-nuclear antibodies is useful in ruling out an autoimmune disorder. Early diagnosis of KFD is crucial to prevent the patients undergo extensive investigations related to suspected malignant lymphomas or other diseases.

Inhibin B is lower and anti-Müllerian hormone is similar in serum of men with spinal cord injuries compared to controls.

Men with spinal cord injury have a unique semen profile characterized by normal sperm concentration but abnormally low sperm motility and viability. The purpose of our study was to determine if new diagnostic information could be obtained for this population by measuring serum concentrations of inhibin B and anti-Müllerian hormone. These hormones, as well as follicle stimulating hormone, luteinizing hormone, and testosterone, were measured in 30 men with spinal cord injury and 15 age-matched control subjects. Serum concentrations of inhibin B and testosterone were significantly lower in the spinal cord injury group compared to the control group. A statistically significant negative relationship was observed between serum concentrations of inhibin B and follicle stimulating hormone in both the spinal cord injury group and the control group, and between inhibin B and luteinizing hormone in the spinal cord injury group only. A significant positive relationship was also observed between inhibin B and sperm concentration in the spinal cord injury group. Although serum concentrations of inhibin B were significantly lower in the spinal cord injury group than in controls, inhibin B and anti-Müllerian hormone serum concentrations did not provide an additional diagnostic tool for male infertility in this population. This is the first study to determine serum concentrations of inhibin B and anti-Müllerian hormone in men with spinal cord injury.

Involvement of the inflammasome in abnormal semen quality of men with spinal cord injury.

OBJECTIVE: To study the mechanism leading to elevated semen cytokines in men with spinal cord injury (SCI) and to understand if inflammasome pathways are involved in this process. To investigate inflammasome components and end-product cytokines in semen of SCI and control subjects. DESIGN: Prospective study. SETTING: Major university medical center. PATIENT(S): Men with and without SCI (n = 28 per group). INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Seminal plasma concentrations of caspase-1, interleukin (IL) 1ß, and IL-18 were quantified by ELISA. Caspase-1 in sperm fractions and apoptosis-associated speck-like protein containing a caspase activation and recruitment domain (ASC) in seminal plasma and sperm fractions were identified by Western blot. Localization of proteins in sperm was accomplished by immunocytochemistry. RESULT(S): ASC, caspase-1, IL-1ß, and IL-18 concentrations were elevated in the seminal plasma of SCI subjects compared with control subjects. ASC and caspase-1 were elevated in sperm cells of SCI subjects. Immunocytochemistry revealed that ASC was located in the acrosome, equatorial segment, and midpiece, and caspase-1 in the midpiece. CONCLUSION(S): This study provides the first evidence of ASC in human semen and demonstrates the involvement of inflammasome proteins in semen of men with SCI. These findings suggest an immunologic basis for abnormal semen quality in men with SCI.

Semen quality in men who sustained a spinal cord injury during the prepubertal period.

PURPOSE: There are limited reports regarding the semen quality of men who sustained a spinal cord injury during the prepubertal period. We performed a retrospective chart review of 533 subjects with spinal cord injury to identify those injured during the prepubertal period and to characterize the semen quality of this population. To our knowledge this study is the first to formally evaluate semen parameters in this small but important subgroup of spinal cord injured subjects. MATERIALS AND METHODS: A retrospective chart review was performed of all spinal cord injured subjects enrolled in the MFRP (Male Fertility Research Program) from 1991 through 2011. Prepubertal subjects were defined as those who sustained a traumatic spinal cord injury at or before the age of 11.9 years. Data collection included neurological level and completeness of injury, sexual responses, hormone profiles and semen quality. RESULTS: Of 533 subjects 7 met the criteria for this study. Age at injury ranged from 4.4 to 11.9 years. Three subjects, injured before age 9 years, were azoospermic. One subject injured at age 10 years had a subnormal total sperm count, while those injured at age 11.9 years had normal total sperm counts, comparable to those of our subjects who sustained spinal cord injuries as adults. In most ejaculates with sperm, sperm motility was subnormal and comparable to that of subjects injured as adults. CONCLUSIONS: Spinal cord injury before the age of 9 years appears to interfere with spermatogenesis. In subjects injured near the age of 12 years semen quality in adulthood appears to be similar to that of subjects injured as adults.

Comparison of in vitro fertilization/intracytoplasmic sperm injection outcomes in male factor infertility patients with and without spinal cord injuries.

OBJECTIVE: To determine if outcomes after in vitro fertilization with intracytoplasmic sperm injection (IVF/ICSI) using sperm from men with spinal cord injury (SCI group) differ from those of other etiologies of male factor infertility (non-SCI group). In men with SCI, to determine if IVF/ICSI outcomes differ with sperm obtained by penile vibratory stimulation (PVS group) versus electroejaculation (EEJ group). DESIGN: Retrospective analysis. SETTING: University medical center and major infertility center. PATIENT(S): Couples with male factor infertility due to SCI versus other etiologies. INTERVENTION(S): PVS, EEJ, surgical sperm retrieval, and IVF/ICSI. MAIN OUTCOME MEASURE(S): Rates of fertilization, pregnancy, and live birth. RESULT(S): A total of 31 couples in the SCI group underwent 48 cycles of IVF/ICSI, and a total of 297 couples in the non-SCI group underwent 443 cycles of IVF/ICSI. The SCI group had lower fertilization rates but similar pregnancy and live birth rates compared with the non-SCI group. These rates, however, did not differ significantly when the PVS group was compared with the EEJ group. CONCLUSION(S): IVF/ICSI of sperm from men with SCI yield lower fertilization rates but similar pregnancy and live birth outcomes as IVF/ICSI of sperm from men with other etiologies of male factor infertility. Sperm collected by PVS versus EEJ in men with SCI appear to result in similar IVF/ICSI success rates.

Pregnancy outcomes by intravaginal and intrauterine insemination in 82 couples with male factor infertility due to spinal cord injuries.

OBJECTIVE: To report our center's pregnancy rates (PR) by intravaginal insemination (IVI) or intrauterine insemination (IUI) in 82 couples with male partners with spinal cord injuries. DESIGN: Retrospective analysis. SETTING: Major medical center. PATIENT(S): Male patients with spinal cord injuries and their female partners. INTERVENTION(S): Intravaginal insemination and IUI. MAIN OUTCOME MEASURE(S): Pregnancy and live birth outcomes. RESULT(S): Overall, 31 of the 82 couples (37.8% PR) achieved 39 pregnancies. Sperm were obtained by masturbation, penile vibratory stimulation, or electroejaculation in 4 men (4.9%), 42 men (51.2%), and 36 men (43.9%), respectively. Intravaginal insemination, performed mostly at home by selected couples, was undertaken in 45 couples, 17 of whom (37.8% PR) achieved 20 pregnancies. Intrauterine insemination was performed in 57 couples, 14 of whom (24.6% PR) achieved 19 pregnancies, with a cycle fecundity of 7.9%. Eighteen and 21 live births occurred by IVI and IUI, respectively. CONCLUSION(S): The methods of IVI and IUI are reasonable options for this patient population. These methods warrant consideration before proceeding to assisted reproductive technologies (ART).

Semen quality remains stable during the chronic phase of spinal cord injury: a longitudinal study.

PURPOSE: In a longitudinal study we examined changes in semen quality with time during the chronic phase of spinal cord injury. MATERIALS AND METHODS: Included in this study were 87 men with spinal cord injury who underwent 2 or more semen retrieval procedures with a minimum of 3 years between the first and last procedures. Patients were selected from our database of 500 with spinal cord injury who were volunteers enrolled in the Male Fertility Research Program of the Miami Project to Cure Paralysis from January 1, 1991 through April 31, 2009. Semen was collected by masturbation, penile vibratory stimulation or electroejaculation. Semen analysis was done according to WHO criteria. We used a statistical generalized linear mixed model to analyze changes in sperm concentration, total sperm count, total motile sperm count and sperm motility with time. RESULTS: Mean patient age was 30.1 years (range 16 to 48) and mean time after injury at the initial sperm retrieval procedure was 7.1 years (range 1 to 26). Sperm concentration decreased slightly with time but all other parameters were unchanged, including total sperm count, indicating a stable, null pattern in measures with time. CONCLUSIONS: Semen quality does not show clinically significant progressive changes during years after injury in men with spinal cord injury. This information is relevant for urologists who counsel these patients on family planning. Also, routine sperm freezing for fertility preservation is not indicated in this patient population.

Treatment for ejaculatory dysfunction in men with spinal cord injury: an 18-year single center experience.

PURPOSE: In what is to our knowledge the largest study of its kind to date we retrospectively reviewed the records of 3,152 semen retrieval procedures in a total of 500 men with spinal cord injury to make recommendations to the medical field on ejaculatory dysfunction treatment in this specialized patient population. MATERIALS AND METHODS: We retrospectively studied data from 1991 to 2009 in the Miami Project to Cure Paralysis male fertility research program at our institution. We assessed the semen retrieval success rate and semen quality. RESULTS: Of the 500 men 9% could ejaculate by masturbation. Penile vibratory stimulation was successful in 86% of patients with a T10 or rostral injury level. Electroejaculation was successful in most cases of failed penile vibratory stimulation. Sperm were obtained without surgical sperm retrieval, in 97% of patients completing the treatment algorithm. Total motile sperm counts exceeded 5 million in 63% of cases. CONCLUSIONS: Sperm can be easily obtained nonsurgically from most men with spinal cord injury. Sufficient sperm are available for simple insemination procedures. A treatment algorithm based on our experience is presented.

Hyaluronic acid binding and acrosin activity are decreased in sperm from men with spinal cord injury.

In this study, acrosin activity and hyaluronic acid binding were compared in sperm from men with spinal cord injury versus sperm from healthy controls. The results showed statistically significantly lower acrosin activity and statistically significantly lower hyaluronic acid binding in spinal cord injured patients compared with controls, indicating functional impairments that may diminish the capacity of the sperm to fertilize oocytes.

A minority of men with spinal cord injury have normal semen quality--can we learn from them? A case-control study.

OBJECTIVES: To determine factors that may help predict normal semen quality in this unique population of male patients, we examined our large database of men with spinal cord injury (SCI). Most men with SCI have abnormal semen quality; however, a small minority retain normal semen parameters. METHODS: A retrospective analysis was performed on semen retrieval procedures administered between 1991 and 2009 in 500 men with SCI. From those men, we selected subjects who underwent at least 1 penile vibratory stimulation, electroejaculation, or masturbation procedure resulting in antegrade ejaculation (n = 400). Cases were defined as men who, according to World Health Organization criteria, had normal semen volume, sperm concentration, sperm motility. Control subjects (CR) were defined as all remaining subjects. Risk factors for normal semen parameters were evaluated by conditional logistic regression analysis. RESULTS: Of the 400 subjects evaluated, only 30 had normal semen parameters. These 30 CS subjects were matched to 120 CR subjects. Analysis of risk factors revealed that incomplete lesion of the spinal cord (ASIA B to D) was significantly associated with the presence of normal sperm parameters (odds ratio 2.6 [95% confidence interval 1.1-6.1], P = .028). CS subjects were also more likely to be able to collect their samples via masturbation (odds ratio 2.7 [95% confidence interval 1.1-7.1], P = .037). Other risk factors evaluated were not predictive of normal semen parameters. CONCLUSIONS: This retrospective, case-control study, performed on a large group of subjects, showed that completeness of SCI is an important risk factor influencing semen quality.

Safety of a novel treatment to improve sperm motility in men with spinal cord injury.

Seminal plasma of men with spinal cord injury (SCI) contains high concentrations of cytokines. Neutralizing these target cytokines did not damage sperm DNA or sperm viability, indicating that this method may hold promise as a safe therapy for improving sperm motility in men with SCI.

Higher sperm DNA damage in semen from men with spinal cord injuries compared with controls.

Semen from men with spinal cord injuries (SCI) and control subjects was investigated for sperm DNA damage using the sperm chromatin structure assay. Three experiments were performed. In experiment 1, the DNA fragmentation index (DFI) was compared in semen from SCI subjects and control subjects. In experiment 2, the % DFI was determined in repeated ejaculations to examine the effect of anejaculation on DFI. In experiment 3, the DFI was determined in neat vs processed semen to examine the effect of necrospermia or leukocytospermia on DFI. The results of experiment 1 showed a significantly higher mean (+/- SEM) DFI in the semen of SCI subjects (65.2% +/- 6.6%; range, 42.3%-90.8%) compared with control subjects (15.4% +/- 2.9%; range, 5.4%-33.5%; P < .001). In experiment 2, there was a high correlation between the DFIs obtained in the first semen specimens and the DFIs obtained 3 days later in semen of the same SCI subjects (r(s) = .94; P < .02). In experiment 3, the results showed no significant difference between mean DFI in aliquots of neat semen (79.3% +/- 9.9%) vs matched aliquots of semen processed to remove dead sperm and leukocytes in SCI subjects (75.2% +/- 16.1%). The DFI is higher in semen from men with SCI vs controls. The cause of this condition is unknown but does not seem to be due to prolonged anejaculation or to the proximate conditions of necrospermia or leukocytospermia. The relevance of these findings to fertility outcomes with SCI male partners remains to be determined.

Neutralization of cytokine activity at the receptor level improves sperm motility in men with spinal cord injuries.

Men with spinal cord injury (SCI) have a unique semen profile characterized by normal sperm concentrations but abnormally low sperm motility. Previous studies showed that elevated concentrations of cytokines in the seminal plasma of these men contribute to this condition. For example, when elevated concentrations of interlekin-1beta (IL-1beta), IL-6, and tumor necrosis factor-alpha (TNF-alpha) were immunoneutralized in the semen of men with SCI, sperm motility improved. The present study investigated if these cytokines act on sperm cell receptors to inhibit sperm motility. Semen was collected from men with SCI and from healthy non-SCI men. Sperm were separated from the seminal plasma by centrifugation. Eight identical aliquots of 5,000 sperm suspended in 50 microL of seminal plasma were prepared for each subject. Agents were added to the aliquots in order to neutralize IL-1beta, IL-6, and TNF-alpha at the receptor level. In SCI subjects, sperm motility improved in each treatment group compared with the untreated group, but statistical significance was reached only when neutralizing agents to all 3 cytokines were added. Improvement was less pronounced in subjects with close to normal semen cytokine concentrations or close to normal pretreatment sperm motility. In control subjects, IL-1beta, IL-6, and TNF-alpha were within normal values, and addition of receptor blockers to semen had no effect on sperm motility. These data support the hypothesis that cytokines act at the level of the sperm receptor to inhibit sperm motility. These data further support the notion that inactivating semen cytokines leads to improved sperm motility in SCI men. Our goal is to develop this finding into a treatment for low sperm motility in men with SCI.

Application of 2 vibrators salvages ejaculatory failures to 1 vibrator during penile vibratory stimulation in men with spinal cord injuries.

PURPOSE: Penile vibratory stimulation is the treatment of first choice for anejaculation in men with spinal cord injury. Nonresponders to penile vibratory stimulation are usually referred for electroejaculation or surgical sperm retrieval. Compared to penile vibratory stimulation these methods are invasive and usually yield lower total motile sperm, potentially limiting options for assisted reproductive technologies. To avoid these less than ideal options a simple method to salvage penile vibratory stimulation failures would be of benefit to spinal cord injured patients. We investigated the recovery rate when 2 vibrators were used to salvage ejaculatory failures to 1 vibrator in men with spinal cord injury. MATERIALS AND METHODS: A retrospective chart review was performed in 297 spinal cord injured men who underwent a total of 965 trials of penile vibratory stimulation at our center between 1991 and 2006. Only trials with high amplitude vibrators were examined. All men underwent 2 or more penile vibratory stimulation trials using 1 vibrator applied to the dorsum or frenulum of the glans penis. Men failing to ejaculate with 1 vibrator received 1 or more trials in which the glans penis was then sandwiched between 2 vibrators. RESULTS: Of all men 49% and 57% of those whose level of injury was T10 or above responded to penile vibratory stimulation with 1 vibrator. Of failures with 1 vibrator 22% responded to penile vibratory stimulation with 2 vibrators. CONCLUSIONS: Application of 2 vibrators salvaged ejaculatory failures to 1 vibrator during penile vibratory stimulation procedures in men with spinal cord injury. This simple penile vibratory stimulation sandwich method is recommended before referring patients for electroejaculation or surgical sperm retrieval.

Abdominal electrical stimulation rescues failures to penile vibratory stimulation in men with spinal cord injury: a report of two cases.

Most men with spinal cord injury are anejaculatory. To retrieve their semen for insemination, the procedure of penile vibratory stimulation is recommended over electroejaculation. Some men with spinal cord injury, however, cannot ejaculate with penile vibratory stimulation. We present 2 cases in which a simple, over-the-counter abdominal muscle stimulator rescued failures to penile vibratory stimulation. Use of this safe, easy, and inexpensive method may prevent some patients from undergoing more expensive, more invasive sperm retrieval methods such as electroejaculation or surgical sperm retrieval from the testis or epididymis.