I ORAL PRESENTATIONS

Topic 7: Sexuality and Fertility
Chair: Stefan Zettl, Jens Sonksen

Introduction Lecture:
CAN I, COULD I, SHOULD I, MUST I? … SEXUALITY IN SPINAL CORD INJURED
PATIENTS
Stefan Zettl
Abstract not available

63/7 Sexual dysfunction and sexual health care in Belgian and Dutch
men and women with spinal cord injury.

C Kiekens, P Enzlin, WFJ Brusselmans, MW Post, HJM van Kuppevelt, H
Bongers, FWA van Asbeck.
Physical Medicine & Rehabilitation, University Hospital Pellenberg, K.U.Leuven
(B).

Introduction: Sexual functioning is an important contributor to quality of life.

Objectives: Examine the prevalence of sexual dysfunction in spinal cord injured
patients and how they evaluate provided sexual health care.

Methods: Patients (n=578) that were discharged from 2 Belgian and 3 Dutch
Rehabilitation Centres were sent questionnaires, covering topics as demographic data,
depression (BDI) and quality of the marital relation (DAS). Sexual functioning was
studied by a subscale of the UKU and sexual health care evaluation was performed
with a self-constructed descriptive questionnaire.

Results: 169 patients filled out the questionnaires. At this time we dispose of the
results concerning the 95 Belgian patients. In men, 28% reported decreased libido,
75% problems with erection and 92% problems with ejaculation and orgasm. In
women, 27% reported decreased libido, 9% problems with vaginal lubrication and 50%
problems with orgasm. 54% of the patients would prefer more information about
sexuality. The data of the 74 Dutch patients are currently being analysed and will be
presented at the Congress.

Conclusions: Spinal cord injured patients often have to cope with important changes
in their sexual lives and many are confronted with sexual problems. There is a need for
sexual health care in rehabilitation programmes.

64/7 Female Sexual Outcome After Sacral Neurostimulation Implant in
Spinal Cord Lesioned (Scl) Patients

G. Lombardi, M. Celso, A. Macchiarella, G. Del Popolo
SOD Neuro-Urologia Spinal Cord Lesions Department Florence Italy

Objectives: To investigate if sacral neurostimulation (SNS) improves sexual function in
female incomplete SCL patients.

Methods: We evaluated 12 females, mean age 44.5, with SNS implants to treat lower
urinary tract dysfunction and/or bowel dysfunctions. Prior surgery we assessed sexual
function by anamnesis, a neuro-physical examination, and with the Female Sexual
Function Index (FSFI) questionnaire. 8 weeks after implantation the patients with
sexual dysfunction filled in the FSFI again. We compared the FSFI score pre- and postsurgery
regarding each of the 6 domains, considering a significant increase 60% for
each domain. Patients who achieved remarkable improvement repeated the FSFI
every 6 months.

Results: 9 suffered from 2 sexual diseases. 4 out of 9 reported a significant
improvement in the desire domain. Of those 4, sexual pain disappeared in 2 and 2
reported a notable improvement in sexual arousal. All 4 patients maintained sexual
improvement in follow-up (mean 32.5 months).

Conclusions: SNS may act by afferent pathways at cortical sites, stemming
positive efferent pathways from brain to genital areas. Both a Positron Emission
Tomography scan to identify brain areas activated after sexual stimulation, and genital
biothesiometry detecting changes in threshold sensory (SNS on and off) would clarify
these positive clinical findings.

65/7 The Effect of Sacral Neurostimulation (SNS) on Male Sexual
Function in Spinal Cord Lesioned (SCL) Patients

G. Lombardi, , A. Macchiarella, N.Mondaini, G.Panariello, G. Del Popolo
SOD Neuro-Urologia Spinal Cord Lesions Department Florence Italy

Objectives: To evaluate if SNS improves sexual function in incomplete male SCL
patients.

Methods: We studied 13 males, mean age 46.3, submitted to SNS implants for lower
urinary tract dysfunction (LUTD) and/or bowel dysfunctions. Prior to surgery we
assessed the presence of sexual dysfunction by anamnesis, a neuro-physical
examination, and through the International Index of Erectile Function (IIEF5)
considering erectile dysfunction scores lower than 21. A score of IIEF(5) equal or
greater than 25% after SNS indicated remarkable enhancement. 8 weeks post-2nd
SNS only patients with sexual dysfunction filled out the IIEF(5) again and then only
patients who benefited significantly repeated the questionnaire every 6 months.

Results: We recorded a concomitant erectile impairment in 10 patients. 4 retentionist
patients achieved significant improvement over erectile function. Their IIEF(5)
increased from 14.5 to 21.3, maintaining the median score in the last follow-up (mean
time 29.5 months).

Conclusions: Schurch’s neurophysiological findings during SNS may explain the
clinical benefits of SNS regarding erection by means of the activation of somatosensory
afferent fibres from genitals to brain areas related to sexual function inducing an
improvement in achieving erection, while efferent pathways from brain to genital sites
determined the maintaining of a valid erection.

66/7 Physiologic Studies of Sexual Response in Men with SCIs

M L. Sipski; C J Alexander
University of Miami

We studied men with SCIs to test the hypotheses that the potential for psychogenic
genital arousal is related to the sensory function remaining in the T11-L2 dermatomes
and that an intact sacral reflex arc predicts orgasmic capacity. Subjects included 45
men with SCIs (mean age 37.8) and 16 able-bodied controls (mean age 37.4). A 78-
minute protocol assessed responses to psychogenic and psychogenic plus manual
genital stimulation and a 75-minute protocol assessed preferences and ability to
achieve orgasm. Men with combined T11-L2 International Sensory Scores of 24-32
demonstrated significantly greater increases in penile circumference (p<.01) in
response to psychogenic stimulation than men with lower combined T11-L2 sensory
scores. Orgasm was reported in the lab by 48.9% and historically by 63.6% of men with
SCIs as compared to 100% of able-bodied subjects. Time to orgasm was similar
between SCI (15.8 min) and able-bodied men (16.4 min). Mean BP and HR at orgasm
were 146/80 and 80.9 for SCI men and 157/92 and 90.0 for able-bodied. Men with
complete LMN injuries affecting their sacral segments were significantly less likely than
men with all other levels and degrees of SCI to achieve orgasm (p<.01).

67/7 Phosphodiesterase inhibitors in the treatment of erectile
dysfunction in spinal cord injured men

Previnaire JG, Soler JM, Denys P, Chartier-Kastler E
Centre Bouffard Vercelli, 66290 Cerbère, France

Study Design: Clinical study on the effect of phosphodiesterase inhibitors (sildenafil,
tadalafil, and vardenafil) for erectile dysfunction in male spinal cord injured (SCI)
patients.

Methods: Effects of Sildenafil (Viagra® - 120 patients), Tadalafil (Cialis® - 53
patients), and Vardenafil (Levitra® - 66 patients) were assessed using the International
Index of Erectile Function (IIEF) during clinical trials (all patients) and at home (90
patients).

Results: Without treatment, the intromission was possible but hard to maintain in about
70% of the patients. On phosphodiesterase inhibitors, more than 85% of the SCI
patients achieved an erection of good quality and lasting for more than 10’, allowing
satisfactory sexual intercourse. There was a significant improvement of all aspects of
the IIEF, except for the sexual desire that remained high.

Discussion and Conclusion: Although all these drugs are effective in improving the
sexual function of the SCI patients, they are different in terms of quality of erection,
delay and duration of action, and side effects.

Keywords: spinal cord injury; paraplegia; tetraplegia; sexual function; erection;
ejaculation; phosphodiesterase inhibitors

68/7 The function of epididymis, prostate and seminal vesicles in men
with spinal cord lesion (SCL) and decreased sperm motility rates

J Sønksen, S ELZanaty, J Malm, F Biering-Sørensen, A Giwercman
Department of Urology, Herlev Hospital, Clinic for Para- and Tetraplegia,
Neuroscience Centre, Rigshospitalet, Copenhagen University Hospitals,
Denmark & Scanian Andrology Centre, Fertility Centre, Department of Clinical
Chemistry, Malmö University Hospital, Sweden

Purpose
To evaluate whether decreased sperm motility rates in SCL men is related to
epididymis, prostate and/or seminal vesicle function.

Material and Methods
Thirty SCL men with SCL ranging from C3 to T10 obtained antegrade ejaculation by
vibratory stimulation. Semen analysis and seminal fluid assessment of neutral _-
glucosidase (NAG) (epididymis), zinc and PSA (prostate) and fructose (seminal
vesicles) were performed. Ten fertile men with normal sperm quality were included as
control group.

Results
The sperm motility rates in SCL men were significant lower than in the control group
(28% vs. 66%, p<0.001). There were no statistically significant differences between the
groups in relation to the seminal fluid concentration of NAG, fructose, zinc and PSA.
However, the percentage of motile sperm and seminal fluid concentration of NAG
depended on the level of SCL, with higher fractions in men with SCL at or above T6
compared to SCL below T6 (NAG: 13 mU/ml vs. 9 mU/ml, p=0.02; Percentage motile
sperm: 30% vs. 24%, p>0.05).

Conclusion
No significant differences in the concentration of seminal fluid markers were seen
between groups, but men with SCL at or above T6 seem to have significantly higher
seminal fluid NAG concentrations which might reflect better epididymis function.

69/7 Community Needs of People with Spinal Cord Injury

Lude Peter, Kennedy Paul & Taylor Nicola
The Department of Clinical Psychology, National Spinal Injuries Centre in
association with the Manfred Sauer Foundation, Germany

Study design: Study design: Cross sectional multi community survey.

Objectives: To examine the community needs of people with spinal cord injury (SCI)
across four European countries and to identify areas of unmet needs to provide
information for rehabilitation professionals to foster fuller community integration for
people with SCI.

Setting: United Kingdom, Germany, Austria and Switzerland.

Methods: Self-assessment questionnaires were sent to 1000 people with SCI resident
in the community in UK, Germany, Austria and Switzerland. Questionnaires measured
current needs, community integration, mood, appraisals, coping strategies, hope,
functional independence and perceived manageability.

Results: Occupation, sexual activity and pain relief needs were areas indicative of
highest community needs in all four countries. Most participants were psychologically
well adjusted and socially integrated into the community. Well addressed needs were
skin management, wheelchair needs, and accommodation.

Conclusion: This study has highlighted that the main areas of unmet needs for a
European community sample of people with SCI includes levels of occupation, sexual
activity and pain relief. The findings will be of interest to those involved in rehabilitation
of newly as well as long term injured people and highlights the need to consistently readdress
such issues as part of a person’s long term integration in order to achieve and
maximise effective community reintegration.

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