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

Clinical Predictors of Vibrator-Assisted Ejaculation following Spinal Cord Injury: A Prospective Observational Study

Introduction  Infertility in men with spinal cord injury (SCI) occurs due to combination of factors like erectile dysfunction, ejaculatory failure, and semen abnormalities. Penile vibratory stimulation (PVS) is a known method of treatment for anejaculation. Predicting successful outcome of PVS depends on several clinical factors, which assess the intactness of the neural arc pertaining to the spinal ejaculation pattern generator. This study reports the clinical predictors for successful candidacy for a PVS trial in males with SCI. Methods  Twenty-three males with SCI, satisfying the inclusion criteria, were recruited in this prospective observational study. Participants underwent two trials of PVS with single high-amplitude vibrator. The clinical predictors recorded were neurological level, superficial abdominal reflex, cremasteric reflex, bulbocavernosus reflex, plantar reflex, ankle jerk, knee jerk, lower abdominal sensation, and hip flexor response. In addition, somatic responses during PVS were recorded and corelated. Participants who had successful ejaculation were "responders" and the others were termed as "nonresponders." Binary logistic regression analysis of the clinical parameters was done to compare responders against nonresponders. Results  Of the twenty-three males (mean age 33.2 ± 6.8 years) with paraplegia, all four persons with neurological level above T9 had successful ejaculation with PVS. Among all the clinical parameters in the study, presence of somatic responses showed statistical significance in predicting successful ejaculation ( p -value = 0.02). Conclusion  This study reports that in men with SCI, along with the level of injury, somatic responses and other clinical reflexes, should be considered concurrently to predict the outcome of vibrator assisted ejaculation.

On the therapeutic targets and pharmacological treatments for pain relief following spinal cord injury: A mechanistic review

Spinal cord injury (SCI) is globally considered as one of the most debilitating disorders, which interferes with daily activities and life of the affected patients. Despite many developments in related recognizing and treating procedures, post-SCI neuropathic pain (NP) is still a clinical challenge for clinicians with no distinct treatments. Accordingly, a comprehensive search was conducted in PubMed, Medline, Scopus, Web of Science, and national database (SID and Irandoc). The relevant articles regarding signaling pathways, therapeutic targets and pharmacotherapy of post-SCI pain were also reviewed. Data were collected with no time limitation until November 2020. The present study provides the findings on molecular mechanisms and therapeutic targets, as well as developing the critical signaling pathways to introduce novel neuroprotective treatments of post-SCI pain. From the pathophysiological mechanistic point of view, post-SCI inflammation activates the innate immune system, in which the immune cells elicit secondary injuries. So, targeting the critical signaling pathways for pain management in the SCI population has significant importance in providing new treatments. Indeed, several receptors, ion channels, excitatory neurotransmitters, enzymes, and key signaling pathways could be used as therapeutic targets, with a pivotal role of n-methyl-D-aspartate, gamma-aminobutyric acid, and inflammatory mediators. The current review focuses on conventional therapies, as well as crucial signaling pathways and promising therapeutic targets for post-SCI pain to provide new insights into the clinical treatment of post-SCI pain. The need to develop innovative delivery systems to treat SCI is also considered.

[Neurological complications of coitus: Review of literature]

INTRODUCTION

Sexual activity is composed of different phases (excitation, plateau, resolution). Each phase is associated with cardiovascular, respiratory, muscular and hormonal modification which can have an influence on the nervous system. This impact has been studied many times in literature, but no study has synthetized the complications related to coitus or orgasm.

METHOD

Systematic review of literature on neurological complications, except headache, of coitus based on Medline and Embase.

RESULTS

We screened 1424 articles and selected 46 for this review. 7 (15 %) were clinical or epidemiologic studies, 6 (13 %) were reviews of literature and 33 (72 %) were cases or series of cases reports. 12 articles (26 %) talked about strokes, 10 (22 %) about subarachnoid hemorrhage, 9 (20 %) about reversible cerebral vasoconstriction syndrome. We found 3 (7 %) articles for each of the following complication: intraparenchymal, hematoma and epilepsy. Autonomic hypereflexia was treated in 3 articles (7 %). Only 1 article was included concerning ictus, spinal cord injury, neuralgia and cataplexia. These events can be considered as rare as emergencies related to sexual activity represent only 0.1 % of all emergencies and among these, 12 % are neurological. 31 of the reported cases concerned vascular events (stroke or hemorrhage) and 18 (58 %) of these patients had a patent malformation (aneurism, intracardiac shunt, foramen ovale).

CONCLUSION

This is one of the first review of literature trying to synthetise the neurological complications of coitus. Many articles exist in literature. It is necessary to prevent the occurrence of these complications in a population already at risk of neurological events.

Lifestyle modifications and pharmacological approaches to improve sexual function and satisfaction in men with spinal cord injury: a narrative review

STUDY DESIGN

A narrative review describing various components of sexual dysfunction in men with spinal cord injury (SCI), as well as addressing potential therapeutic approaches.

OBJECTIVES

Restoration of sexual function is considered one of the most important health priorities for individuals with SCI. The purpose of this review is to provide information regarding the factors that are less appreciated when considering changes to sexual function in men with SCI. We also propose therapeutic approaches, with a focus on lifestyle modifications, which have been shown to improve sexual function.

METHODS

A literature search was performed and limited evidence for therapeutic approaches in individuals with SCI was supplemented by consistent findings from the able-bodied population.

RESULTS

We evaluated the less addressed factors known to contribute to sexual dysfunction in men with SCI, including hormonal influences (i.e., testosterone deficiency, thyroid hormone, and cortisol), psychological factors (i.e., pain, fatigue, depression, and body image), and secondary SCI complications (i.e., urinary tract infection, pressure sores, and autonomic dysreflexia). To address these factors beyond standard medical treatments for sexual dysfunction, options include physical activity/exercise, diet, and specific medications for symptom relief (i.e., testosterone replacement therapy and selective serotonin reuptake inhibitors for depression).

CONCLUSIONS

Physical activity's potential application, efficacy across multiple aspects of sexuality, and the lack of side effects, suggests that long-term exercise is a viable solution to directly or indirectly improve sexual function in males with SCI. Diet and supplemental medications may further promote body composition changes, which more broadly affect sexuality.

Dexmedetomidine modulates neuroinflammation and improves outcome via alpha2-adrenergic receptor signaling after rat spinal cord injury

BACKGROUND

Spinal cord injury induces inflammatory responses that include the release of cytokines and the recruitment and activation of macrophages and microglia. Neuroinflammation at the lesion site contributes to secondary tissue injury and permanent locomotor dysfunction. Dexmedetomidine (DEX), a highly selective α2-adrenergic receptor agonist, is anti-inflammatory and neuroprotective in both preclinical and clinical trials. We investigated the effect of DEX on the microglial response, and histological and neurological outcomes in a rat model of cervical spinal cord injury.

METHODS

Anaesthetised rats underwent unilateral (right) C5 spinal cord contusion (75 kdyne) using an impactor device. The locomotor function, injury size, and inflammatory responses were assessed. The effect of DEX was also studied in a microglial cell culture model.

RESULTS

DEX significantly improved the ipsilateral upper-limb motor dysfunction (grooming and paw placement; P<0.0001 and P=0.0012), decreased the injury size (P<0.05), spared white matter (P<0.05), and reduced the number of activated macrophages (P<0.05) at the injury site 4 weeks post-SCI. In DEX-treated rats after injury, tissue RNA expression indicated a significant downregulation of pro-inflammatory markers (e.g. interleukin [IL]-1β, tumour necrosis factor-α, interleukin (IL)-6, and CD11b) and an upregulation of anti-inflammatory and pro-resolving M2 responses (e.g. IL-4, arginase-1, and CD206) (P<0.05). In lipopolysaccharide-stimulated cultured microglia, DEX produced a similar inflammation-modulatory effect as was seen in spinal cord injury. The benefits of DEX on these outcomes were mostly reversed by an α2-adrenergic receptor antagonist.

CONCLUSIONS

DEX significantly improves neurological outcomes and decreases tissue damage after spinal cord injury, which is associated with modulation of neuroinflammation and is partially mediated via α2-adrenergic receptor signaling.

Preservation of Fertility in Testis Cancer Management

The presence of cancer in the testis, as well as the therapies used to treat testis cancer, can impair fertility potential for affected men. Fertility preservation is an important aspect of survivorship care and should be offered to all patients before initiating treatment. The only established means of fertility preservation in men is cryopreservation of sperm. Methods for fertility preservation in prepubertal boys are still experimental. Physicians treating men with testicular cancer should be familiar with the available options. This article outlines testicular cancer and its treatment's effects on fertility, fertility preservation options, and barriers to accessing this specialized care.

Sexual Health in Men With Traumatic Spinal Cord Injuries: A Review and Recommendations for Primary Health-Care Providers

Sexual health has been well established as a salient priority for men following traumatic spinal cord injury; yet, it continues to be under-addressed by health-care providers in both inpatient and community settings. Given that most men with traumatic spinal cord injuries will be followed by community-based primary health-care providers, including family physicians and nurse practitioners, for their long-term health-care needs, these clinicians are well positioned to address ongoing sexual health issues with this population. A scoping review of literature published between 2007 and 2017 inclusive was undertaken to identify what is known about the sexual health of men with spinal cord injuries. Twenty articles met the inclusion criteria. The findings are presented in four themes: (a) patterns and diversity of sexual health concerns; (b) sexual health recovery as an ongoing priority; (c) clinical barriers to addressing sexual health concerns, and (d) recommended interventions and strategies for primary health-care providers. The findings indicate that physiological changes as well as psychological and social factors influence men’s sexual function following spinal cord injury, and that sexual health recovery is an enduring rehabilitation priority. Several barriers including lack of sexual rehabilitation services and consensus around clinician roles, and societal stigmas related to disability and sexuality impede treatment. Attention to sexual health recovery has mainly focused on formal rehabilitation settings; however, many evidence-based clinical strategies and resources are relevant to and adaptable for primary care providers caring for these men in the community.

Promoting Long-Term Health among People with Spinal Cord Injury: What's New?

A key ingredient to successful health promotion is a primary care provider who can offer an informed first response to lifestyle issues, emerging problems and chronic challenges. This article aims to assist family physicians to play their role in promoting the health of people with SCI, by summarizing the latest evidence in the management of spinal cord injury in primary care. This study used a scoping review methodology to survey peer-reviewed journal articles and clinical guidelines published between January 2012 to June 2016. This search strategy identified 153 articles across 20 topics. A prevention framework is used to identify five primary, nine secondary, four tertiary, and two quaternary prevention issues about which family physicians require current information. Major changes in the management of SCI in primary care were noted for 8 of the 20 topics, specifically in the areas of pharmacological management of neuropathic pain and urinary tract infection; screening for bowel and bladder cancer; improvements in wound care; and clarification of dietary fibre recommendations. All of these changes are represented in the 3rd edition of Actionable Nuggets-an innovative tool to assist family physicians to be aware of the best practices in primary care for spinal cord injury.

Women's Sexual Health and Reproductive Function After SCI

Sexual function and to a lesser extent reproduction are often disrupted in women with spinal cord injuries (SCI), who must be educated to better understand their sexual and reproductive health. Women with SCI are sexually active; they can use psychogenic or reflexogenic stimulation to obtain sexual pleasure and orgasm. Treatment should consider a holistic approach using autonomic standards to describe remaining sexual function and to assess both genital function and psychosocial factors. Assessment of genital function should include thoracolumbar dermatomes, vulvar sensitivity (touch, pressure, vibration), and sacral reflexes. Self-exploration should include not only clitoral stimulation, but also stimulation of the vagina (G spot), cervix, and nipples conveyed by different innervation sources. Treatments may consider PDE5 inhibitors and flibanserin on an individual basis, and secondary consequences of SCI should address concerns with spasticity, pain, incontinence, and side effects of medications. Psychosocial issues must be addressed as possible contributors to sexual dysfunctions (eg, lower self-esteem, past sexual history, depression, dating habits). Pregnancy is possible for women with SCI; younger age at the time of injury and at the time of pregnancy being significant predictors of successful pregnancy, along with marital status, motor score, mobility, and occupational scores. Pregnancy may decrease the level of functioning (eg, self-care, ambulation, upper-extremity tasks), may involve complications (eg, decubitus ulcers, weight gain, urological complications), and must be monitored for postural hypotension and autonomic dysreflexia. Taking into consideration the physical and psychosocial determinants of sexuality and childbearing allows women with SCI to achieve positive sexual and reproductive health.

Iatrogenic urological triggers of autonomic dysreflexia: a systematic review

STUDY DESIGN

This is a systematic review.

OBJECTIVE

The objective of this study was to review the literature on iatrogenic urological triggers of autonomic dysreflexia (AD).

SETTING

This study was conducted in an international setting.

METHODS

A systematic review was conducted from PubMed search using AD/ autonomic hyperreflexia and spinal cord injury (SCI). Studies selected for review involved iatrogenic urological triggers of AD in individuals with SCI, including original articles, previous practice guidelines, case reports and literature reviews. Studies that did not report AD or blood pressure (BP) assessments during urological procedures were excluded.

RESULTS

Forty studies were included for analysis and categorized into four groups: (1) urodynamics and cystometry; (2) cystoscopy and transurethral litholapaxy; (3) extracorporeal shock-wave lithotripsy (ESWL); and (4) other procedures. During urodynamics, the incidence of AD ranged from 36.7% to 77.8%. The symptomatic rate ranged from 50% to 65%, with AD symptoms seen predominantly in cervical SCI patients. The studies imply no consensus regarding the relationship between AD, neurogenic detrusor overactivity and detrusor sphincter dyssynergia. Without anesthesia, the majority of individuals develop AD during cystoscopy, transurethral litholapaxy and ESWL. The effectiveness of different anesthesia methods relies on blocking the nociceptive signals from the lower urinary tract (LUT) below the level of the neurological lesion. Other iatrogenic urological triggers were commonly associated with bladder filling.

CONCLUSION

The LUT triggers of episodes of AD are often associated with iatrogenic urological procedures. AD was more prevalent in cervical SCI than in thoracic SCI. To detect this potential life-threatening complication following cervical and high thoracic SCI, routine BP monitoring during urological procedures is highly recommended.

Sexual dysfunction in patients with spinal cord lesions

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