Reinnervating the Penis in Spina Bifida Patients in the United States: Ilioinguinal‐to‐Dorsal‐Penile Neurorrhaphy in Two Cases

Nerve Transfer to Restore Genital Sensation in Women with Low Spinal Lesion: The Female TOMAX Procedure

Background

Women with spinal cord lesions have loss of sensation in the lower body, negatively affecting sexuality in many ways: decreased, lost, or changed genital sensation and difficulties with orgasm. Restoring genital sensation in men with low spinal lesions using a nerve transfer (to maximize sensation, sexuality, and quality of life [TOMAX] procedure) has shown the potential to enhance sexual functioning and satisfaction. This procedure was adapted to a female version, in which the dorsal clitoral nerve was transferred to the ilioinguinal nerve to restore genital sensation. We report the results of the first female TOMAX patients.

Methods

Four patients with spinal lesions below L1 with unilaterally or bilaterally absent genital sensations and normal sensation in the groin were included. All patients underwent both neurological and psychological assessments preoperatively and at 6, 12, and 18 months postoperatively.

Results

The mean patient age was 53.3 years. Three patients experienced sensations in the clitoris and labia minora at 18 months postoperatively, which led to orgasms in 1 patient. One patient gained no sensation in her genitals but had a surprising side effect: she did not have to catheterize herself anymore.

Conclusion

The female TOMAX procedure is a new promising technique for restoring sensation of the genitals in women with low spinal cord lesions.

Erectile Dysfunction: Treatments, Advances and New Therapeutic Strategies

Erectile dysfunction (ED) is the inability to get and maintain an adequate penile erection for satisfactory sexual intercourse. Due to its negative impacts on men's life quality and increase during aging (40% of men between 40 and 70 years), ED has always attracted researchers of different disciplines, from urology, andrology and neuropharmacology to regenerative medicine, and vascular and prosthesis implant surgery. Locally and/or centrally acting drugs are used to treat ED, e.g., phosphodiesterase 5 inhibitors (first in the list) given orally, and phentolamine, prostaglandin E1 and papaverine injected intracavernously. Preclinical data also show that dopamine D4 receptor agonists, oxytocin and α-MSH analogues may have a role in ED treatment. However, since pro-erectile drugs are given on demand and are not always efficacious, new strategies are being tested for long lasting cures of ED. These include regenerative therapies, e.g., stem cells, plasma-enriched platelets and extracorporeal shock wave treatments to cure damaged erectile tissues. Although fascinating, these therapies are laborious, expensive and not easily reproducible. This leaves old vacuum erection devices and penile prostheses as the only way to get an artificial erection and sexual intercourse with intractable ED, with penile prosthesis used only by accurately selected patients.

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.

Male genital sensation after spinal cord injury: a review

Genital sensation (GS) is an essential component of male sexual function. Genital sensory disturbance (GSD) caused by spinal cord injury (SCI) has a severe impact on the patients' sexual function but has garnered little research focus. Under normal conditions, GS encompasses the erection, ejaculation, sexual arousal, and orgasm courses associated with physiological and psychological responses in male sexual activity. However, in SCI patients, the deficiency of GS makes the tactile stimulation of the penis unable to cause sexual arousal, disturbs the normal processes of erection and ejaculation, and decreases sexual desire and satisfaction. To provide an overview of the contemporary conception and management of male GS after SCI, we review the innervation and sexual function of male GS in this article, discuss the effects of GSD following SCI, and summarize the current diagnosis and treatment of GSD in male SCI patients.

Neurological dysfunction of the bladder from myelomeningocele

Myelomeningocele (MMC) affects approximately 2000 infants in the US yearly and causes long-term damage to the genitourinary system. There is a wide spectrum of effects on the bladder and urethral sphincter that do not correlate with the level of the spinal cord defect. The bladder changes can provide a safe storage pressure, often at the expense of continence, or can create a hostile environment leading to increased pressure on the kidneys and eventually to chronic kidney disease. The ultimate goals in management are to maintain a safe system that prevents renal deterioration, while providing social continence and independence in the long term. This review intends to provide an overview of the effects of MMC on the genitourinary system, regardless of intervention, in order to understand the pathophysiology of the disease.

Emerging nonsurgical and surgical techniques to treat erectile dysfunction: A systematic review of treatment options and published outcomes

Erectile dysfunction (ED) is one of the most common causes of morbidity in male patients, with a prevalence of 50-60% in men aged 40-70 years. EDs may be caused by physical or psychological trauma, the former of which may be treatable through surgical intervention. Physical trauma may be further categorized as vasculogenic, neurogenic, or idiopathic in nature. Although many patients do not respond well to nonsurgical treatment options, few opt for surgical intervention. This is likely due to the difficulty of the procedures, as well as relatively low historical success rates. As such, a systematic review of the literature was performed to identify novel surgical interventions for ED. A total of 19 manuscripts were included in this review, representing data of three minimally invasive approaches to ED treatment and seven novel surgical techniques. The data revealed compelling evidence in support of microsurgical treatments for ED - namely, microvascular arterial bypass penile revascularization surgery (MABS) and cavernous nerve graft reconstruction. Nerve grafts varied, with the use of end-to-side ilioinguinal, genitofemoral, and sural grafts, all demonstrating high rates of success. Furthermore, minimally invasive botulinum toxin (BoNT-A) treatment and adipose-derived stem cell (ADSC) therapy have shown extreme promise in rat models; with BoNT-A treatment entering phase II human clinical trials this year. Many of the surgical methods investigated in this review are microsurgical interventions that demonstrate high rates of success in patients with neurogenic or vasculogenic ED. As such, microsurgeons are uniquely trained and positioned to be of value to ED treatment.

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.

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.

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.

Central Somatosensory Networks Respond to a De Novo Innervated Penis: A Proof of Concept in Three Spina Bifida Patients

INTRODUCTION

Spina bifida (SB) causes low spinal lesions, and patients often have absent genital sensation and a highly impaired sex life. TOMAX (TO MAX-imize sensation, sexuality and quality of life) is a surgical procedure whereby the penis is newly innervated using a sensory nerve originally targeting the inguinal area. Most TOMAX-treated SB patients initially experience penile stimulation as inguinal sensation, but eventually, the perception shifts to penis sensation with erotic feelings. The brain mechanisms mediating this perceptual shift, which are completely unknown, could hold relevance for understanding the brain's role in sexual development.

AIM

The aim of this study was to study how a newly perceived penis would be mapped onto the brain after a lifelong disconnection.

METHODS

Three TOMAX-treated SB patients participated in a functional magnetic resonance imagery experiment while glans penis, inguinal area, and index finger were stimulated with a paint brush.

MAIN OUTCOME MEASURE

Brush stimulation-induced activation of the primary somatosensory cortex (SI) and functional connectivity between SI and remote cerebral regions.

RESULTS

Stimulation of the re-innervated side of the glans penis and the intact contralateral inguinal area activated a very similar location on SI. Yet, connectivity analysis identified distinct SI functional networks. In all three subjects, the middle cingulate cortex (MCC) and the parietal operculum-insular cortex (OIC) were functionally connected to SI activity during glans penis stimulation, but not to SI activity induced by inguinal stimulation.

CONCLUSIONS

Investigating central somatosensory network activity to a de novo innervated penis in SB patients is feasible and informative. The consistent involvement of MCC and OIC above and beyond the brain network expected on the basis of inguinal stimulation suggests that these areas mediate the novel penis sensation in these patients. The potential role of MCC and OIC in this process is discussed, along with recommendations for further research.