The effect of spinal cord level on sexual function in the spina bifida population

Patient Characteristics Associated with Sexual Interest and Activity Among Adults with Spina Bifida

OBJECTIVE

To identify factors associated with sexual interest and activity among adults with spina bifida and to describe the sexual profile of those who were sexually active. Sexual health of adults with spina bifida is often neglected and current knowledge on the topic is limited.

METHODS

An anonymous web-based survey was advertised and administered between March 2018 and September 2018 and participants 16 years and older with spina bifida were included in this study. Respondents were asked about sexual interest, activity, and function using the validated Patient-Reported Outcomes Measurement Information System Sexual Function Profile. Bivariate and multivariable models with ordinal logistic regression were fitted to evaluate predictors of sexual interest and sexual function.

RESULTS

Of the 261 respondents with a self-reported diagnosis of spina bifida (mean age of 38.5 years), 73.2% noted at least a little bit of interest in sexual activity. In multivariate analysis, women were less likely to report higher sexual interest than men (odds ratio (OR) = 0.53, 95% CI 0.31-0.92, P = .03) whereas those with higher physical functioning were more likely to have higher sexual interest (OR = 1.04, confidence interval (CI) 1.01-1.07, P = .03). Just less than half of respondents (46.4%) were sexually active in the past 30 days, and those with a ventriculoperitoneal shunt were less likely to engage in sexual activity compared to those without (OR = 0.36, 95% CI 0.19-0.68; P <.01).

CONCLUSION

The mismatch between sexual interest and sexual activity highlights the importance of exploring issues related to sexual health when counseling adult patients with spina bifida.

Codevelopment of an illustration representative of people living with spina bifida for health educational materials

BACKGROUND

The lack of health education resources specific to people with disabilities contributes to disparities in outcomes. Developing user-centered materials with representative images tailored to people with disabilities could help improve knowledge and outcomes.

OBJECTIVE

As a first step in developing an online sexual health resource for adolescents with physical disabilities, we sought end-user feedback to create illustrated characters for use in educational materials.

METHODS

Two styles of characters were developed by the research team, which included a professional disability artist. Verbal and online survey feedback was obtained at the Spina Bifida Association's Clinical Care Conference. A new image was created incorporating initial feedback. The new image and favored image from the first round were then tested through an online survey advertised on the Spina Bifida Association's Instagram story feed. Open-ended comments were organized by categories and overlapping themes.

RESULTS

Feedback was obtained from 139 audience members and 25 survey respondents from the conference and 156 Instagram survey respondents. Themes included depiction of disability, nondisability diversity, other physical appearance, emotional response, and design style. Most frequently, participants suggested the inclusion of characters with a range of accurately depicted mobility aids and of characters without mobility aids. Participants also wanted a larger, more diverse group of happy, strong people of all ages.

CONCLUSIONS

This work culminated in the codevelopment of an illustration that represents how people impacted by spina bifida view themselves and their community. We anticipate that using these images in educational materials will improve their acceptance and effectiveness.

Sexual activity and function of adult men with spina bifida

OBJECTIVE

Data on sexual function of men with spina bifida (SB) is limited. We aimed to assess sexual activity and erectile dysfunction (ED) in a large international sample of men with SB.

METHODS

Men with SB (≥18yo) were recruited in an international online survey via clinics and social media. We collected data on demographics, ambulation (Hoffer classification), penile rigidity (Erection Hardness Score), sexual activity and ED (International Index of Erectile Function). Non-parametric tests were used.

RESULTS

A total of 162 men (median age 35, 62% shunted, 38% community ambulators) reported sexual desire similar to the general population (p = 0.82), but 55% were dissatisfied with their sex life (Summary Table). Overall, 36% reported full penile rigidity with erections, more commonly with better ambulation (p = 0.01), 69% had ever experienced orgasm and 84% ejaculated. In 44 men (27%) attempting sexual intercourse in the last 4 weeks, 59% had ED (11% severe, 7% moderate, 14% mild-moderate, 27% mild). In this group, 91% of men reporting less than full penile rigidity had ED, compared to 30% with full penile rigidity (p = 0.001). Overall, partnered non-genital contact in the last 3 months was reported by 56%, solo masturbation: 62%, partnered intercourse: 48% (31% vaginal). Of 54 men who used phosphodiesterase type 5 inhibitors (PDE5I), 80% reported improved erections, 56% improved intercourse. Overall, 40% reported non-genital erogenous zones as most pleasurable, especially with poorer ambulation (p = 0.002, chest/nipples: 73%).

COMMENT

Strengths of this study include anonymous, voluntary, online participation maximizing participation of a heterogenous, international population. Whenever available, we compared findings to published values for the general population. Since romantic and sexual activity is a complex intersection of interest, opportunity and ability, a more comprehensive assessment was beyond the study's scope. Future work will focus on the interplay with issues like incontinence.

CONCLUSIONS

ED was frequent among men with SB, especially in men with poorer ambulation. PDE5 inhibitors may be beneficial. Partnered sexual activity was reported by half of the men, although it may not involve penetrative intercourse.

Advances in Fetal Surgical Repair of Open Spina Bifida

Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.

[Guidelines on the urological management of the adult patient with spinal dysraphism (spina bifida)]

INTRODUCTION

Improved life expectancy and prenatal screening have changed the demographics of spina bifida (spinal dysraphism) which has presently become a disease of adulthood. Urinary disorders affect almost all patients with spinal dysraphism and are still the leading cause of mortality in these patients. The aim of this work was to establish recommendations for urological management that take into account the specificities of the spina bifida population.

MATERIALS AND METHODS

National Diagnosis and Management Guidelines (PNDS) were drafted within the framework of the French Rare Diseases Plan at the initiative of the Centre de Référence Maladies Rares Spina Bifida - Dysraphismes of Rennes University Hospital. It is a collaborative work involving experts from different specialties, mainly urologists and rehabilitation physicians. We conducted a systematic search of the literature in French and English in the various fields covered by these recommendations in the MEDLINE database. In accordance with the methodology recommended by the authorities (Guide_methodologique_pnds.pdf, 2006), proposed recommendations were drafted on the basis of this literature review and then submitted to a review group until a consensus was reached.

RESULTS

Bladder dysfunctions induced by spinal dysraphism are multiple and varied and evolve over time. Management must be individually adapted and take into account all the patient's problems, and is therefore necessarily multi-disciplinary. Self-catheterisation is the appropriate micturition method for more than half of the patients and must sometimes be combined with treatments aimed at suppressing any neurogenic detrusor overactivity (NDO) or compliance alteration (anticholinergics, intra-detrusor botulinum toxin). Resort to surgery is sometimes necessary either after failure of non-invasive treatments (e.g. bladder augmentation in case of NDO resistant to pharmacological treatment), or as a first line treatment in the absence of other non-invasive alternatives (e.g. aponeurotic suburethral tape or artificial urinary sphincter for sphincter insufficiency; urinary diversion by ileal conduit if self-catheterisation is impossible).

CONCLUSION

Spinal dysraphism is a complex pathology with multiple neurological, orthopedic, gastrointestinal and urological involvement. The management of bladder and bowel dysfunctions must continue throughout the life of these patients and must be integrated into a multidisciplinary context.

Discrepancies in Educational Needs for Transition in Adolescents and Young Adults with Spina Bifida in South Korea: Use of the Borich Needs Assessment Model

PURPOSE

Transition is an important goal for ensuring that adolescents and young adults (AYAs) with spina bifida (SB) lead autonomous lives. This study aimed to identify the educational needs of AYAs with SB based on the discrepancies between perceived importance and proficiency levels during the transition process.

DESIGN AND METHODS

A cross-sectional study was conducted through face-to-face and online surveys from Jan-Dec 2020 of AYAs aged 13-25 years who had previously been diagnosed with SB. The survey consisted of 37 transition-related questions, of which 11 pertained to healthcare environments and 26 pertained to transition education needs SPSS and Excel were used for statistical analysis. Transition educational needs were analyzed by the Borich Needs Assessment Model. Higher the mean weighted discrepancy scores, lower the proficiency as compared to the perceived importance, indicating that the educational needs were high.

RESULTS

Overall, 108 responses were analyzed, and 56 (51.9%) AYAs were diagnosed with lipomyelomeningocele. The highest ranked educational needs were for "Health insurance system", "SB related urinary system diseases management", "SB related nervous system symptoms", and "Self-catheterization management". "The demands for 'SB related work life", "Urinary incontinence management", and "Constipation management" were significantly higher in young adults than adolescents.

CONCLUSIONS

During the transition process, activities perceived as important by AYAs with SB may differ from the activities that they can actually perform proficiently. It is important to assess their needs based on these discrepancies.

PRACTICE IMPLICATIONS

Transition education programs are needed that consider the individual educational needs and developmental stage-specific characteristics of AYAs with SB.

Promoting Healthy Sexuality for Children and Adolescents With Disabilities

This clinical report updates a 2006 report from the American Academy of Pediatrics titled "Sexuality of Children and Adolescents With Developmental Disabilities." The development of a healthy sexuality best occurs through appropriate education, absence of coercion and violence, and developmental acquisition of skills to navigate feelings, desires, relationships, and social pressures. Pediatric health care providers are important resources for anticipatory guidance and education for all children and youth as they understand their changing bodies, feelings, and behaviors. Yet, youth with disabilities and their families report inadequate education and guidance from pediatricians regarding sexual health development. In the decade since the original clinical report was published, there have been many advancements in the understanding and care of children and youth with disabilities, in part because of an increased prevalence and breadth of autism spectrum disorder as well as an increased longevity of individuals with medically complex and severely disabling conditions. During this same time frame, sexual education in US public schools has diminished, and there is emerging evidence that the attitudes and beliefs of all youth (with and without disability) about sex and sexuality are being formed through media rather than formal education or parent and/or health care provider sources. This report aims to provide the pediatric health care provider with resources and tools for clinical practice to address the sexual development of children and youth with disabilities. The report emphasizes strategies to promote competence in achieving a healthy sexuality regardless of physical, cognitive, or socioemotional limitations.

Sexuality of Female Spina Bifida Patients: Predictors of a Satisfactory Sexual Function

OBJECTIVE

 To assess the sexual function of women with spina bifida (SB), and to verify the factors that influence their sexual function.

METHODS

 A cross-sectional study in which a validated female-specific questionnaire was applied to 140 SB female patients from four different cities (Porto Alegre, Brazil; and Barcelona, Madrid, and Málaga, Spain) between 2019 and 2020. The questionnaires collected data on the clinical characteristics of SB, and female sexual function was assessed using the 6-item version of the Female Sexual Function Index (FSFI-6) validated to Portuguese and Spanish.

RESULTS

 Half of the patients had had sexual activity at least once in the life, but most (57.1%) did not use any contraception method. Sexual dysfunction was present in most (84.3%) patients, and all sexual function domains were impaired compared those of non-neurogenic women. The presence of urinary and fecal incontinence significantly affected the quality of their sexual activity based on the FSFI-6.

CONCLUSION

 The specific clinical aspects of the SB patients, such as urinary and fecal incontinence, should be properly addressed by their doctors, since they are associated with reduced sexual activity and lower FSFI-6 scores in the overall or specific domains. There is also a need to improve gynecological care among sexually-active SB patients, since most do not use any contraceptive methods and are at risk of inadvertent pregnancy.

The impact of neurogenic bladder bowel dysfunction in the sexuality of female spina bifida patients

INTRODUCTION

The sexual life of Spina Bifida (SB) women may be affected by their physical impairments. Data has consistently associated symptoms such as urinary and fecal incontinence with negative effects on social and intimate life.

OBJECTIVE

To analyze the female spina bifida patient sexual life and assess which factors - including bladder bowel dysfunction and bladder augmentation - influenced in the sexual function of patients in a multi-center cross-sectional study.

STUDY DESIGN

A cross-sectional survey with validated female-specific questionnaire was applied in 140 spina bifida female patients from four different cities (Porto Alegre/Brazil; Barcelona, Madrid and Málaga/Spain) between 2019 and 2020. Questionnaires collected data on spina bifida clinical characteristics and sexuality, which was assessed using the 6-item version of the Female Sexual Function Index (FSFI-6) in the Portuguese and Spanish validated versions. Female sexual dysfunction was defined as a FSFI-6 total score ≤19.

RESULTS

Sexual dysfunction was present in most (84.3%) patients with a median overall FSFI-6 total score of 14.5 (range 4-26), being all sex domains impaired. Bladder augmentation, type of spina bifida, spinal cord level, hydrocephalus, use of wheelchair and psychological disorder were not statistically associated with differences among rates of sexual activity or female sexual dysfunction. The presence of urinary incontinence (UI) showed both significant lower sexual intercourse and higher dysfunction rates (Summary Table). Urinary and fecal incontinence were significantly associated with worst scores in all domains, except for pain.

DISCUSSION

Urinary incontinence status was the most relevant factor since it impaired either female sexual dysfunction and sexual activity rates, as well as the FSFI-6 overall and specific domains. These findings are consistent with previous studies who also observed that desire, arousal and lubrication domains had negative effects from urinary loss on SB patients. Fecal incontinence status did not influenced in sexual activity of female sexual dysfunction rates, nevertheless it promoted lower scores in the overall and specific sexual domains.

CONCLUSION

Spina bifida is a complex condition that demands proper care to achieve a satisfactory sexual life, specially regarding neurogenic bladder and bowel dysfunction. Clinical aspects in the SB patient, such as urinary and fecal incontinence, should be properly addressed by pediatric urologists since they are associated with female sexual dysfunction and reduced sexual activity, as well as lower FSFI-6 scores in the overall and specific domains. There is also a need to improve communication about sexuality, because only 18.6% of the patients considered it that had received sufficient sex information from physicians.

Sexual Function and Dysfunction in Individuals with Spina Bifida: A Systematic Review

OBJECTIVE

To conduct a systematic review of self-reported experiences of sexual function and dysfunction in individuals with spina bifida (SB).

MATERIALS AND METHODS

Medline, Embase, and Web of Science were systematically searched. Studies included contained self-reported data from SB patients on one or more of the following sexual function domains: Genital sensitivity, orgasm, erectile function, ejaculation, lubrication, and/or dyspareunia. Two authors independently assessed eligibility, extracted data, and cross-checked results, with disagreements resolved by consensus. Studies included contained self-reported data from SB patients on one or more of the following sexual function domains: Genital sensitivity, orgasm, erectile function, ejaculation, lubrication, and/or dyspareunia.

RESULTS

Systematic search yielded 23 studies representing 1441 patients (816 males, 625 females). Eight utilized questionnaires validated in non-SB adults; the remainder used semi-structured interviews and non-validated instruments. Eleven assessed dysfunctions in both sexes, 10 in males, and 2 in females. Erectile function and orgasm were the most commonly assessed outcomes in males and females respectively. 12%-88% of males experienced erectile dysfunction; a majority (51%-90%) reported normal ejaculatory function. Many females were unable to experience orgasm (28%-63%).

CONCLUSION

Males with SB report significant erectile and ejaculatory dysfunction. Both sexes report impaired orgasms and genital sensitivity. SB-specific instruments assessing sexual dysfunction are needed in order to improve multidisciplinary care for this population.

Sexual Function of Men and Women With Spina Bifida: A Scoping Literature Review

INTRODUCTION

As most adults with spina bifida are either sexually active or interested in becoming sexually active, providers should understand how spina bifida impacts sexual function and options for treatment.

OBJECTIVES

The objective of this study is to summarize the current literature describing how features of spina bifida impact sexual function in men and women, effective available treatment options for sexual dysfunction, and to identify research gaps.

METHODS

Searches were conducted in PubMed, CINAHL Complete, PsychInfo, Cochrane Central, Scopus, and Web of Science Core Collection databases using keywords related to spina bifida and sexual function. 34 primary research studies were included.

RESULTS

Most men (56-96%) can achieve an erection, although it may be insufficient for penetration. Although 50-88% ejaculate, it is often dripping, retrograde, or insensate. Twenty percent to 67% achieve orgasm. Generally, men with lower lesions and intact sacral reflexes have better outcomes, although some men with all levels of lesion report good function. Sildenafil is efficacious at treating erectile dysfunction for most men. The "TO-MAXimize sensation, sexuality, and quality of life" procedure may improve sexual function in selected men with low-level lesions. Female sexual function and treatment is less well understood. Women may experience decreased arousal, difficulties with orgasm, and pain. No treatment has been studied in women. Bowel and bladder incontinence during intercourse appears to be bothersome to men and women. Although both men and women have diminished sexual satisfaction, their sexual desire appears to be least impacted. Present studies are limited by studies' small, heterogeneous populations, the misuse of validated questionnaires in the sexually inactive population, and the lack of a validated questionnaire specific to people with spina bifida.

CONCLUSIONS

Spina bifida impacts the sexual function of both men and women. Future studies should seek a better understanding of female sexual function and treatment, use validated questionnaires appropriately, and ultimately create a validated sexual function questionnaire specific to this population. Streur CS, Corona L, Smith JE, et al. Sexual Function of Men and Women With Spina Bifida: A Scoping Literature Review. Sex Med Rev 2021;9:244-266.

Erectile Functional Restoration With Genital Branch of Genitofemoral Nerve to Pelvic Nerve Transfer After Spinal Root Transection in Rats

OBJECTIVE

To investigate the feasibility of erectile function restoration by the genitofemoral nerve to pelvic nerve transfer in rats.

METHODS

Thirty-six male rats were included in this study. Rats in the nerve transfer group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection and then bilateral genitofemoral nerve to pelvic nerve transfer, rats in the nerve resection group (n = 12) were subjected to pelvic nerve, sacral roots, and L6 roots transection without nerve transfer, and rats in the control group (n = 12) served as controls. After reinnervation, intracavernous pressure (ICP) assessment was performed. Fluoro-Gold was injected into the corpus cavernosum. Immediately before euthanasia, transferred nerves were stimulated to test penile intracavernous pressure. The L6, S1, and L1-2 spinal cord segments were used for retrogradely labeled neurons. Regenerative nerve morphologic examination assessment was performed.

RESULTS

Genitofemoral nerve stimulation induced an increase in ICP in the nerve transfer group. The mean ICP in this group was (33.8 ± 9.4 mm Hg), which is higher than the mean value in the nerve resection group (3.9 ± 1.0 mm Hg) but lower than that in the control group (69.8 ± 12.2 mm Hg; P < .05). The formation of new neural pathways was confirmed by the appearance of Fluoro-Gold labeled neurons in the L-1 and L-2 spinal cord segments in the nerve transfer group. Regenerative nerve morphologic examination showed good axonal regeneration after genitofemoral nerve transfer.

CONCLUSION

Nerve regeneration can be obtained by genitofemoral nerve to pelvic nerve transfer, and erectile function can be restored.

Fetal spina bifida: What we tell the parents

Worldwide, about 150 000 infants are born with spina bifida yearly, making this condition one of the most common fetal central nervous system anomalies compatible with life. Over the last decade, major changes have been introduced in the prenatal diagnosis and management of spina bifida. In this review, we provide a brief summary of the current management of fetal spina bifida and present essential information that should be provided to expecting parents when their fetus has been diagnosed with spina bifida. This information is focused around common parental questions, as encountered in our typical clinical practice, to facilitate knowledge translation.

Let's Talk About Sex: Special Considerations in Reproductive Care and Sexual Education in Young Women With Spina Bifida

Medical advances in the last several decades have allowed an increasing number of children with spina bifida to reach adolescence and adulthood. As they reach puberty, girls with spina bifida face unique social and health challenges to their sexuality, such as orthopedic restrictions, continence, and pelvic floor disorders. Recent research efforts have focused on better understanding female sexual desires, dysfunctions, and activity and the role of the physician in educating this vulnerable population. This article aims to summarize current literature on sexual function, knowledge gaps, and the importance of tailored sexual education from providers in women with spina bifida.

"I Tell Them What I Can Feel and How Far My Legs Can Bend": Optimizing Sexual Satisfaction for Women With Spina Bifida

BACKGROUND

There is a high reported rate of sexual dysfunction among women with spina bifida, but little is known about the etiology of this or how sexual satisfaction could be improved.

AIM

To identify, through the words of women with spina bifida, perceived causes of diminished sexual satisfaction and recommendations to optimize partnered sexual encounters.

METHODS

In this qualitative study, we conducted semi-structured individual interviews with 22 women with spina bifida (median age 26.5 years, range 16-52 years) who have had a romantic partner. Using Grounded Theory, interviews were independently coded by 3 reviewers. Disagreements were resolved by consensus.

OUTCOMES

We identified overlapping themes of issues women experienced during sexual intimacy and strategies they learned to improve sexual encounters.

RESULTS

7 salient themes emerged from the data: (i) fear of rejection with resulting difficulty setting boundaries and the risk of coercion; (ii) conflict between spontaneity and self-care in sexual encounters; (iii) worry about incontinence during sex; (iv) trial and error in learning optimal sexual positions; (v) decreased genital sensation; (vi) safety considerations; and (vii) sharing advice with other women with spina bifida.

CLINICAL IMPLICATIONS

As sexual satisfaction is influenced by physical features as well as psychological, interpersonal, and sociocultural factors, optimizing sexual satisfaction of women with spina bifida is best managed with a holistic approach utilizing a biopsychosocial model.

STRENGTHS & LIMITATIONS

The sample included women with a diverse range of functional impairments. Women were forthright with their comments and thematic saturation was reached. Recruitment was primarily from a single Midwestern institution, which may have limited sampled perspectives.

CONCLUSION

While women with spina bifida encounter challenges during sexual encounters, strategies focused on improving communication with partners and addressing specific physical considerations can potentially enhance their sexual experiences. Streur CS, Schafer CL, Garcia VP, et al. "I Tell Them What I Can Feel and How Far My Legs Can Bend": Optimizing Sexual Satisfaction for Women With Spina Bifida. J Sex Med 2020;17;1694-1704.

Sexual health and education guidelines for the care of people with spina bifida

Sexual development is not only comprised of the changes to a person's body during puberty; it is a part of social development and should be considered in the context of basic and routine human desires for connectedness and intimacy, beliefs, values and aspirations. As is true for everyone, it is important that individuals with spina bifida have opportunities to acquire developmentally appropriate, relevant and accurate sexual health knowledge. Those with spina bifida need to be able to negotiate sexual desire, intimacy and sexual expression. They also need education about their sexual health and how to limit the negative outcomes of sexual activity related to sexually transmitted infections, unplanned pregnancy or sexual coercion, violence, abuse or exploitation. This article discusses the Spina Bifida Sexual Health and Education Healthcare Guidelines from the 2018 Spina Bifida Association's Fourth Edition of the Guidelines for the Care of People with Spina Bifida using the World Health Organization's framing of sexual health and reviews the literature on sexual health and education for individuals with spina bifida.

"If Everyone Else Is Having This Talk With Their Doctor, Why Am I Not Having This Talk With Mine?": The Experiences of Sexuality and Sexual Health Education of Young Women With Spina Bifida

INTRODUCTION

Women with spina bifida are sexually active, but most never discuss this topic with providers.

AIM

To determine what women with spina bifida understand about their sexual health, how they learned about it, what questions they have, and their experiences with their sexuality.

METHODS

For this qualitative study, women with spina bifida ages 16 and older without marked developmental delay were individually interviewed. 25 women with spina bifida participated (mean age 27.1 years, range 16-52). Interviews were independently coded for themes by 3 reviewers, using Grounded Theory, with disagreements resolved by consensus.

MAIN OUTCOME MEASURES

We identified overlapping themes regarding the women's perception and experience of their sexuality and sexual health education.

RESULTS

17 of the 25 (68%) participants had been or were currently sexually active. 5 themes emerged regarding their understanding of their sexuality and their sexual experiences: (i) being perceived as asexual, (ii) sources for sex education, (iii) need for spina bifida-specific sex education, (iv) impact of spina bifida-specific features on sexual encounters, and (v) perceived relationship between low sexual self-confidence and risk for sexual assault.

CLINICAL IMPLICATIONS

Women with spina bifida are sexual beings, but they are perceived as asexual by providers, which prevents them from getting adequate sexual health education and leaves them with misconceptions and unanswered questions, as well as vulnerable to sexual abuse.

STRENGTH & LIMITATIONS

The strengths of this study include the diversity of women interviewed, including their age, severity of disability, and experiences with their sexuality, as well as the ability to reach thematic saturation. The limitation of this study is that most women received treatment at a single Midwestern tertiary referral center in the United States.

CONCLUSION

Including sexual health discussions in the usual care of women with spina bifida is critical to enhancing their sexual confidence and experience and preventing sexual abuse. Streur CS, Schafer CL, Garcia VP, et al. "If Everyone Else Is Having This Talk With Their Doctor, Why Am I Not Having This Talk With Mine?": The Experiences of Sexuality and Sexual Health Education of Young Women With Spina Bifida. J Sex Med 2019;16:853-859.

An Exploratory Electrical Stimulation Protocol in the Management of an Infant With Spina Bifida: A Case Report

An infant with myelomeningocele and underdevelopment of the thoracic spinal cord was treated with 2 protocols of electrical stimulation: functional electrical stimulation and transcutaneous spinal cord electrical stimulation. The protocols were incorporated into the infant’s outpatient early intervention home programs. Prior to initiation of electrical stimulation treatment at age 6 months, the infant exhibited complete loss of sensation below the level of T8 and muscular paralysis below the level of T10. The unexpected emergence of somatosensory responses and spontaneous movements in the trunk and lower extremities are described, focusing on the electrical stimulation protocols. Spinal cord electrical stimulation protocols were not previously described in the medical literature regarding the management of children with spina bifida. Both functional and spinal cord electrical stimulation protocols used with this infant proved safe and well tolerated. The experience gained over 12 months of treatment is the subject of this case report.

Gap analysis of service needs for adults with neurodevelopmental disorders

In Florida, the Agency for Persons with Disabilities provides waivers for adults with the following types of disabilities: intellectual disability, autism spectrum disorder, cerebral palsy, spina bifida, Down syndrome, and Prader-Willi syndrome. This review examined the peer-reviewed literature to indicate and assess the common needs for individuals with intellectual and developmental disabilities. Current models of service delivery, the efficacy of these services, and remaining gaps in the need fulfillment of individuals within the six diagnostic categorizations of interest were examined. Severity level within each diagnostic category was plotted on a matrix according to whether the needs of individuals were minimal, moderate, severe, or universal. The study found that sexual health education, socialization, and adult-focused medical care are universal needs among the six conditions. The study indicates that health-care professionals must work toward addressing the many unmet needs in comprehensive life span care services for adult individuals with neurodevelopmental disorders.

Sexual dysfunction and infertility in the male spina bifida patient

Spina bifida is a congenital neural tube defect with many neurological implications, as well as decreased sexual function and infertility. Few studies have directly investigated infertility in men with spina bifida. Infertility in this special patient population is primarily the result of spermatogenic defects and/or failure of sperm transport due to erectile or ejaculatory dysfunction. The severity of sexual and reproductive dysfunction seems to correlate with higher level of spina cord lesion and presence of hydrocephalus. Phosphodiesterase 5 inhibitors (PDE5is) have been shown to be effective for erectile dysfunction in some men with spina bifida. Surgical sperm retrieval from the genitourinary tract and rectal probe electroejaculation can serve as methods for collecting sperm from those with ejaculatory dysfunction or retrograde ejaculation. Assisted reproductive technology such as intracytoplasmic sperm injection allows isolated sperm from men with infertility to achieve fertilization. Since most spina bifida patients are surviving into adolescence and adulthood due to improved medical and surgical advancements, it is paramount for healthcare professionals to address issues related their sexual and reproductive function.

"I Don't Know What I'm Doing… I Hope I'm Not Just an Idiot": The Need to Train Pediatric Urologists to Discuss Sexual and Reproductive Health Care With Young Women With Spina Bifida

INTRODUCTION

Although pediatric urologists have taken responsibility for initiating discussions on sexual and reproductive health with spina bifida patients, research shows that very few girls and women with spina bifida have ever discussed this topic with any physician.

AIM

We sought to better understand pediatric urologists' gaps in knowledge and training needs in the sexual and reproductive health education of women with spina bifida with the goal of creating a tool kit to equip providers to have these discussions.

METHODS

In this qualitative study, pediatric urologists were interviewed separately about their current practices, perceived barriers, knowledge gaps, and recommendations for the tool kit until thematic saturation was reached. The interviews were recorded and transcribed verbatim, then analyzed using grounded theory by 3 independent reviewers.

MAIN OUTCOME MEASURES

To evaluate the perspectives and practices of pediatric urologists, we identified the overlapping themes of the interviews. Consensus on themes was reached.

RESULTS

10 Pediatric urologists participated in the study, including 5 men and 5 women, of whom 4 were fellows and 6 were attending physicians (mean years of practice 18, range 6-31 years). The mean number of patients followed up in the respective spina bifida clinics or by the provider was 434 (range 24-1,500). The following themes regarding pediatric urologists' experience providing sexual and reproductive health education to women with spina bifida emerged. Pediatric urologists': (i) lack of formal training; (ii) knowledge gaps such as spina bifida sexuality, fertility, and pregnancy experience; (iii) barriers to having sexual and reproductive health conversations such as lack of comfort and lack of time; (iv) facilitators of these conversations such as a long-term relationship with the patient and the patient's own initiative; (v) desire to learn and provide competent care; and (vi) recommendations for a web-based tool kit that would include content to address the knowledge gaps and training about how to start sexual and reproductive health conversations.

CLINICAL IMPLICATIONS

These findings can provide the beginning concepts for the development of training on providing sexual and reproductive health education for pediatric urologists' care for women with spina bifida.

STRENGTHS & LIMITATIONS

This study gives the perspectives of 10 pediatric urologists with a diversity of backgrounds, but all of whom care for a large number of spina bifida patients. This does not give the perspectives of the spina bifida women themselves, which will be evaluated in the next phase of the study.

CONCLUSION

Pediatric urologists are not trained and do not feel prepared to provide sexual and reproductive health education for girls and women with spina bifida. However, they do see it as their scope of practice and wish to acquire competence in this area. Streur CS, Schafer CL, Garcia VP, et al. "I Don't Know What I'm Doing… I Hope I'm Not Just an Idiot": The Need to Train Pediatric Urologists to Discuss Sexual and Reproductive Health Care With Young Women With Spina Bifida. J Sex Med 2018;15:1403-1413.

A cross-sectional study of sexual function and fertility status in adults with congenital genitourinary abnormalities in a U.S. tertiary care centre

INTRODUCTION

We aimed to evaluate sexual function, sexual knowledge, and fertility status in adult patients with congenital genitourinary abnormalities (CGUA).

METHODS

Adult patients with CGUA who were referred to a single transitional urology clinic between 2014 and 2017 were prospectively recruited to participate in the study. Questionnaires about general demographics, bowel and bladder continence, fertility, and sexuality were gathered. Validated questionnaires, including the Sexual Health Inventory for Men (SHIM) and Brief Index of Sexual Functioning for Women (BISF-W), were also collected.

RESULTS

A total of 167 adults with CGUA were referred to our clinic within the defined time frame. Sixty patients (25 males, 35 females) with a mean age of 25.4 years (range 18-75) met inclusion criteria and responded to questionnaires pertaining to sexuality and fertility. Forty-five (75%) responded to the fertility questionnaire; 26 (58%) had never heard of assisted reproductive technologies, and only one had received prior fertility counselling. Fifty-eight participants (97%) responded to the sexuality questionnaire; 21 (36%) reported a history of sexual activity, with 12 (21%) being currently sexually active. Twenty (34%) wanted to learn more about sexuality and/or fertility. The SHIM response rate was 44%, and only three females (9%) completed the BISF-W in its entirety.

CONCLUSIONS

Adults with CGUA desire more sexuality and fertility education, yet they are uncomfortable completing current questionnaires. Our sexuality and fertility questionnaires are too challenging for this patient population to complete despite assistance. Thus, modifications are urgently needed. Additionally, medical providers should discuss sexual and reproductive health with these patients earlier and in more detail.

Complications of Delivery Among Mothers With Spina Bifida

OBJECTIVE

To determine rates and types of peripartum morbidity among delivering women with spina bifida (SB) compared to those without SB. The rates of pregnancy and delivery among women with SB have been significantly increasing. Current knowledge of peripartum outcomes for these women is limited.

METHODS

Using 2004-2013 National Inpatient Sample data, we identified all hospitalizations for delivery, distinguishing between women with and without SB. Using a code-based algorithm, we determined whether a complication occurred during the hospitalization. We then fit a series of multivariable logistic models to examine for associations between a complication occurrence during vaginal or cesarean delivery and a woman's SB status.

RESULTS

We identified 38,319,814 weighted admissions for delivery, 9516 of which were made by women with SB. Women with SB had a significantly higher rate of cesarean delivery than women without this diagnosis (53% vs 32%, P < .001). The 46.7% of women with SB who delivered vaginally did not have significantly increased odds of a complication associated with their delivery compared to women without SB [odds ratio 1.15, 95% confidence interval 0.99-1.34, P = .066]. However, women with SB who underwent a cesarean delivery did have higher odds of morbidity compared to those without (odds ratio 1.49, 95% confidence interval 1.25-1.78, P < .001). Common complications included preterm delivery, urinary tract infection, hematologic event, and blood transfusion.

CONCLUSION

Compared to women without SB, those with SB deliver more frequently by cesarean section and have higher odds of morbidity associated with cesarean delivery, but not vaginal delivery.

Spina Bifida Health-care Guidelines for Men's Health

Spina bifida has traditionally been regarded as a pediatric health issue with little regard to adult consequences of the disorder. The congenital neurologic and urologic anomalies, as well as sequelae of bladder management, can have a profound impact on adult male sexual function. Abnormalities in testicular descent, development, and function; fertility; penile sensation; erectile function; ejaculatory function; and orgasmic function are common. Prostate cancer has been diagnosed in men with spina bifida, but little data are available to guide screening, diagnosis, and treatment efforts. The Spina Bifida Association has supported development of guidelines for health care providers to address male health issues in individuals with spina bifida throughout their lives.

Sexual function and qualify of life in women with spina bifida: Are the women with spina bifida satisfied with their sexual activity?

AIMS

As the life expectancy of persons with spina bifida increases, sexual life in adulthood presents a considerable challenge for this population. The purpose of this study was to evaluate the sexual function of young women with spina bifida and its impact on their quality of life (QOL).

METHODS

To assess sexual function and QOL by using self-administered questionnaires (Female Sexual Function Index [FSFI] and 36-Item Short Form Health Survey) in young women with spina bifida, we collected data from 44 young women with spina bifida between June 2013 and October 2013 at the spina bifida clinic of our hospital.

RESULTS

Sexual dysfunction was noted in 55.5% of women with spina bifida who had sexual activity in the previous month. In sexually active women, the diagnosis, ventriculoperitoneal shunt in situ, mobility, and clean intermittent catheterization did not show a significant difference between each subdomain (desire, arousal, lubrication, orgasm, satisfaction, and pain) and the total FSFI score. However, women who did not have urinary incontinence experienced better sexual function in terms of lubrication and pain scores (P = 0.033 and P = 0.026, respectively). Both the physical and mental composites of QOL were positively weakly correlated with the arousal score of FSFI (r = 0.455, P = 0.044 and r = 0.507, P = 0.023, respectively).

CONCLUSIONS

More than half of sexually active women with spina bifida experience sexual dysfunction. Therefore, health-care providers should pay attention to the symptoms and their management.

Neuropathic bladders: Investigation and treatment through their lifetime

The child with a neuropathic bladder requires lifelong dedicated care. Just as each patient presents with unique physiology, each phase of their life presents varying challenges. The primary concern for our patients is their renal health, but continence and independence also play significant roles. Most patients can be managed conservatively, but a myriad of surgical options are also available, reinforcing our emphasis on individualized care. Appropriate pre-surgical planning is required to ensure the right patient receives the best operation for his/her wants and needs. Furthermore, the numerous potential complications must be understood and long-term followup and surveillance is required. This review outlines the basic pathophysiology, investigations, and treatments, with a focus on the changing needs throughout their lives.

Fertility and sexual dysfunction issues in adults with genitourinary congenital anomalies

PURPOSE OF REVIEW

As growing numbers of adolescents with a history of congenital genitourinary anomalies successfully enter adulthood, their spectrum of urologic concerns broadens to include sexual function and reproduction.

RECENT FINDINGS

In hypospadias repair, preoperative testosterone was found to reduce rates of postoperative complications of urethrocutaneous fistula formation and meatal stenosis. Following hypospadias correction, dissatisfaction with surgical outcomes has been observed to correlate with psychological outcomes, rather than objective measurements such as location of meatus degree of curvature. In women with a congenital absence of a vagina, sigmoid vaginoplasty and dilation yield similar sexual outcomes, however, vaginoplasty was associated with a 20% rate of reoperation. Ilioinguinal-to-dorsal neurorrhaphy for restoration of penile sensation in myelomeningocele has shown success in a small pilot study. Both sexual activity and paternity rates are higher in women, compared with men who are born with bladder exstrophy.

SUMMARY

The extent and complexity of issues related to sexual function and fertility in the population of patients with a history of genitourinary malformation requires a thoughtful approach to timely surgical management and consistent care through their transition from childhood to adulthood.

Fertility treatment in spinal cord injury and other neurologic disease

Infertility in individuals with neurologic disorders is complex in etiology and manifestation. Its management therefore often requires a multimodal approach. This review addresses the implications of spinal cord injury (SCI) and other neurologic disease on fertility, including the high prevalence of sexual dysfunction, ejaculation disorders and compromised semen parameters. Available treatment approaches discussed include assisted ejaculation techniques and assisted reproductive technology including surgical sperm retrieval and intracytoplasmic sperm injection (ICSI).