SCI and sexual dysfunction

[specepic]

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I have a new pt with Cervical SCI (apparently he had pre-existing but unknown severe central canal stenosis and then we had a motorcycle crash ended up with significant deficits which recovered significantly over several weeks). He was initially treated nonoperatively and then about a year later finally had surgery on the neck

He is able to ambulate independently and has fairly good control of all of his limbs but does have notable spasticity

I was seeing him for consultation of cervical and lumbar pain, but he also mentioned, as we did a spinal cord injury review of systems, that he does have some sexual dysfunction. He reports that when he is close to reaching climax he has intense muscle spasms which sound like his spasticity being provoked

Is this a common phenomenon and if so is there a particular medication that works well for this versus others. I started him on some baclofen for his generalized spasticity and I am scheduling him with a spinal cord injury specialist down in the big city but that may take a while

 

[RangerBob]

It could be worsened/provoked spasticity or maybe autonomic dysreflexia. I wonder if it's the latter. The trouble is a lot of symptoms of AD would be hard for the pt/lay person to differentiate from normal climatic sexual activity. But assuming he's with a partner at these times, the partner could pay attention to whether or not he only has flushing/sweating above the level of injury--that would be a large clue. Also blurry vision wouldn't be the norm for folks during sexual activity, so if he's seeing those things (and a very abnormally high BP if he's willing to check--which I would recommend he do as unsexy as it would be in the moment) then it could be AD.

Trouble is then what would be causing the AD. It sounds like it's when he's close to climaxing, not necessarilly ejaculation (which is a known possible precipitator of AD). But I suppose as things get closer to climax then usually things get more vigorous, meaning he could be putting more pressure on the bladder/causing other noxious stimulus to areas below his level of injury. As awkward as it is, it's good to get a really detailed history--much rougher/more virorous intercourse could certainly precipitate AD on it's own, whereas I wouldn't expect gentle/slow to (at least not until ejaculation).

Does he have any neurogenic bowel/bladder dysfunction? Any sensory deficits? It may seem odd, but one can be an ambulatory tetraplegia with severe AD. Making sure he empties his bladder prior to intercourse, position changes, more lubrication, etc, could help. Might be worthwhile to tell him and his partner to take it real slow one time (like tantric style) and see if that prevents the worsened spasms. #1 rule of AD treatment/prevention is remove the offending stimulus. That's hard to do if the stimulus itself is ejaculation, but if it's the point of near-climax there could be a stimulus at play that is modifiable.

If it is AD and is associated with ejaculation itself, or it's AD due to being near climax but not amenable to environmental changes as above, then Nifedipine is usually the best answer for most:

Sexual function and autonomic dysreflexia in men with spinal cord injuries: how should we treat? - Spinal Cord

Could just be worsened spasms, though usually the things that provoke spasms are the things that provoke AD so I think they're often all on the same spectrum. But with how high one's BP can get during AD, it's something that should be ruled out.

 

[specepic]

It could be worsened/provoked spasticity or maybe autonomic dysreflexia. I wonder if it's the latter. The trouble is a lot of symptoms of AD would be hard for the pt/lay person to differentiate from normal climatic sexual activity. But assuming he's with a partner at these times, the partner could pay attention to whether or not he only has flushing/sweating above the level of injury--that would be a large clue. Also blurry vision wouldn't be the norm for folks during sexual activity, so if he's seeing those things (and a very abnormally high BP if he's willing to check--which I would recommend he do as unsexy as it would be in the moment) then it could be AD.

Trouble is then what would be causing the AD. It sounds like it's when he's close to climaxing, not necessarilly ejaculation (which is a known possible precipitator of AD). But I suppose as things get closer to climax then usually things get more vigorous, meaning he could be putting more pressure on the bladder/causing other noxious stimulus to areas below his level of injury. As awkward as it is, it's good to get a really detailed history--much rougher/more virorous intercourse could certainly precipitate AD on it's own, whereas I wouldn't expect gentle/slow to (at least not until ejaculation).

Does he have any neurogenic bowel/bladder dysfunction? Any sensory deficits? It may seem odd, but one can be an ambulatory tetraplegia with severe AD. Making sure he empties his bladder prior to intercourse, position changes, more lubrication, etc, could help. Might be worthwhile to tell him and his partner to take it real slow one time (like tantric style) and see if that prevents the worsened spasms. #1 rule of AD treatment/prevention is remove the offending stimulus. That's hard to do if the stimulus itself is ejaculation, but if it's the point of near-climax there could be a stimulus at play that is modifiable.

If it is AD and is associated with ejaculation itself, or it's AD due to being near climax but not amenable to environmental changes as above, then Nifedipine is usually the best answer for most:

Sexual function and autonomic dysreflexia in men with spinal cord injuries: how should we treat? - Spinal Cord

Could just be worsened spasms, though usually the things that provoke spasms are the things that provoke AD so I think they're often all on the same spectrum. But with how high one's BP can get during AD, it's something that should be ruled out.

great write up TY