Epidural Stimulation

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Authors: Dominik Zbogar and Sharon Jang | Reviewer: Susan Harkema | Published: 14 February 2022 | Updated: ~

Key Points

  • Epidural stimulation is a treatment that sends electrical signals to the spinal cord.
  • Epidural stimulation requires a surgical procedure to implant electrodes close to the spinal cord.
  • One of the ways epidural stimulation works is by replacing the signals that would normally be sent from the brain to the spinal cord before spinal cord injury (SCI).
  • Epidural stimulation affects numerous systems. Stimulation aimed at activating leg muscles may potentially also affect bowel, bladder, sexual, and cardiovascular function.
  • Studies of epidural stimulation in spinal cord injury (SCI) generally do not include a comparison group without stimulation. The benefits of epidural stimulation that have been reported have been in small numbers of participants. So, while reports thus far are encouraging, more research is necessary.
  • Because it is in the research and development phase, epidural stimulation for spinal cord injury is not part of standard care nor is it a readily available treatment.

Neuromodulation is a general term for any treatment that changes or improves nerve pathways. Different types of neuromodulation can work at different sites along the nervous system (e.g., brain, nerves, spinal cord) and may or may not be invasive (i.e., involve surgery). Epidural stimulation (also known as epidural spinal cord stimulation or direct spinal cord stimulation) is a type of invasive neuromodulation that stimulates the spinal cord using electrical currents. This is done by placing an electrode on the dura (the protective covering around the spinal cord).

To read more about other types of neuromodulation used in SCI, access these SCIRE Community articles: Functional Electrical Stimulation (FES), Transcutaneous Electrical Nerve Stimulation (TENS), sacral nerve stimulation, and intrathecal Baclofen.

Watch our neuromodulation series videos! Our experts explainexperimental to more commonplace applications, and individuals with SCI describe how neuromodulation has affected their lives.

What is “an Epidural”?

Epi- is a prefix and means “upon”, and the dura (full name: dura mater) is a protective covering of the spinal cord. So epidural means “upon the dura”, and in the context of epidural stimulation, this is where the electrodes that stimulate the spinal cord are placed. Yes, it is also possible to have sub-dural (under the dura) or endo-dural (within the dura) electrode placement. And, there are more layers between the dura and the spinal cord, not to mention the spinal cord itself where electrodes could be placed in what is called intraspinal microstimulation. The benefit of being beneath the dura and closer to the spinal cord is that there is a more direct stimulation. Having the electrode closer to the spinal cord allows more precision with the signal going more directly to the neurons.

The drawback is that more complications can arise with closer placement because the electrodes are in the spinal cord tissue. Such placement is currently rare, experimental, or non-existent but that will change as the technology advances. Intraspinal microstimulation has been tested in animal models and is in the process of being translated to humans.

You are probably familiar with the term “epidural” already, as it is often mentioned in relation to childbirth. If a new mother says she had an epidural, what she usually means is that she had pain medication injected into the epidural space for the purpose of managing pain during birth.

We specifically discuss epidural spinal cord stimulation in this article. Spinal cord stimulation can also be applied transcutaneously. This type of spinal cord stimulation is non-invasive as the stimulating electrodes are placed on the skin. With transcutaneous stimulation, the signal has to travel a greater distance through muscle, fat, and other tissues, which means the ability to be precise with stimulation is hampered. However, it does allow for more flexibility in electrode placement and does not require surgery. There is research published or underway investigating the impact of transcutaneous stimulation in some of the areas discussed above, including hand, leg, and cardiovascular function.

Normally, input from your senses travels in the form of electrical signals through the nerves, up the spinal cord, and reaches the brain. The brain then tells the muscles or organs what to do by sending electrical signals back down the spinal cord. After a spinal cord injury, this pathway is disrupted, preventing electrical signals from traveling below the level of injury to reach where they need to go. However, the nerves, muscles, and organs can still respond below the injury to electrical signals.

Epidural stimulation works by helping the network of nerves in the spinal cord below the injury function better and take advantage of any leftover signals from the spinal cord. To do so, the stimulation must be fine-tuned to make sure the amount of stimulation is optimal for each person and a specific function, such as moving the legs.

Recent studies of the role of epidural stimulation on standing and walking have noted unexpected beneficial changes in some participants’ bowel, bladder, sexual, and temperature regulation function. This highlights both the potential for epidural stimulation to improve quality of life in multiple ways and that much research remains to be done to understand how epidural stimulation affects the body.


There may still be spared connections in the spinal cord with a complete injury.

How can someone with a complete injury regain movement control with epidural stimulation?

Being assessed with a complete injury implies that there is no spared function below the injury. However, scientists are finding that this may not be the case. Studies have found that even with a complete loss of sensory and motor function, there may be some inactive connections that are still intact across the injury site. These remaining pathways may be important for regaining movement or other functions. Another hypothesis is that epidural stimulation in combination with training may encourage stronger connections across the level of injury. Although these pathways may provide some substitution for the injured ones, they are not as effective as non-injured pathways across the injury level.

When it is decided that an individual will receive epidural stimulation, a health professional, such as a neurosurgeon, will perform an assessment of the spinal cord using magnetic resonance imaging (MRI) to determine the best place to implant the electrodes.

In most of the studies mentioned in this article, the electrodes were placed between the T9-L1 levels, though researchers are investigating the impact of epidural stimulation on hand function.


Xray image of wires connecting power and signal to electrodes (red circle) placed on a spinal cord.

There are two possible procedures. One approach is to have two surgeries. During the initial surgery, a hollow needle is inserted through the skin into the epidural space, guided using fluoroscopy, a type of X-ray that allows the surgeon to see where the needle is in real time. Potential spots on the spinal cord are tested using a stimulator. A clinician will look to see if stimulation over those areas of the spinal cord leads to a desired response. Once found, the electrode array is properly positioned over the dura and the surgery is completed. This begins a trial period where the response to epidural stimulation is monitored. During this time the electrode array is attached to an electrical generator and power supply, which is worn on a belt outside of the body. When it is shown that things are working as desired, the generator is implanted underneath the skin in the abdomen or buttocks. The generator can be rechargeable or non-rechargeable. A remote control allows one to turn the generator on or off and control the frequency and intensity of stimulation.

The second method is to only have one surgery and no trial period. This is possible due to increased knowledge in how to stimulate the spinal cord. Soon after surgery, the individual will be taught how and when to use the epidural stimulation system at home. If needed, the frequency (how often) and intensity (how strong) of the stimulation will be adjusted at follow-up appointments with the physician. In other cases, many practice sessions of learning the right way to stimulate may be needed before a person can stimulate at home.

If the epidural stimulation is used for leg control, movement training, standing, and stepping will be required to learn how to coordinate and control movement during stimulation. This is required for the recovery of voluntary movements, standing and/or walking.

Epidural stimulation can be used in all people with SCI, regardless of the level or completeness of injury. However, certain situations can make it an unsafe treatment in some. It is important to speak to a health professional about your health history before beginning any new treatment.

Epidural stimulation should not be used in the following situations:

  • By people with implanted medical devices like cardiac pacemakers
  • By people who are unable to follow instructions or provide accurate feedback
  • By people with an active infection
  • By people with psychological or psychiatric conditions (e.g., depression, schizophrenia, substance abuse)
  • By people who are unable to form clots (anticoagulopathy)
  • Near areas of spinal stenosis (narrowing of the spinal canal)

Epidural stimulation should be used with caution in the following situations:

  • By children or pregnant women
  • By people who require frequent imaging tests like ultrasound or MRI (some epidural stimulation systems are compatible)
  • By people using anticoagulant medications (blood thinners)

Epidural stimulation is generally well-tolerated, but there is a risk of experiencing negative effects.

The most common risks and side effects of epidural stimulation include:

  • Technical difficulties with equipment, such as malfunction or shifting of the electrodes that may require surgery to fix
  • Unpleasant sensations of jolting, tingling, burning, stinging, etc. (from improper remote settings)

Other less common risks and side effects of epidural stimulation include:

  • Damage to the nervous system
  • Leakage of cerebrospinal fluid
  • Increased pain or discomfort
  • Broken bones
  • Masses/lumps growing around the site of the implanted electrode

Risks specific to the surgery which involves the removal of part of the vertebral bone (laminectomy) include:

  • bleeding and/or infection at the surgical site
  • spinal deformity and instability

Proper training on how to use the equipment and using the stimulation according to the directions of your health provider can help decrease the risks of experiencing these side effects.

Neuromodulation methods to manage bladder function have usually involved stimulation of the sacral nerves (which are outside of the spinal cord), not with epidural spinal cord stimulation. This is reflected in the fact that almost no research exists regarding the effects of epidural stimulation on bowel and bladder function in the previous century.

New information on epidural stimulation relating to bladder function is coming. In the last several years, several studies (weak evidence) from a very small group of participants of participants (who were AIS A or B) have found consistent improvements in bladder function. Participants in these reports were fitted with epidural stimulators for reactivation of paralyzed leg muscles for walking and reported additional benefits of improvements in bladder and/or bowel function. However, other studies have shown small changes to bladder function and no changes to bowel function. Negative changes, such as decreased control over the bladder, have even been noticed by some participants in another study. These findings suggest that epidural stimulation may improve quality of life by safely increasing the required time between catheterizations. Fewer catheterizations and reduced pressure in the bladder would preserve lower and upper urinary tract health. More research is required, especially with respect to bowel function. It must be noted that walk training alone has been shown to improve bladder and bowel function. Epidural stimulation may provide additional improvement to bladder function in comparison to walk training alone. Neuromodulation methods to manage bladder function have usually involved stimulation of the sacral nerves (which are outside of the spinal cord), not with epidural spinal cord stimulation. This is reflected in the fact that almost no research exists regarding the effects of epidural stimulation on bowel and bladder function in the previous century.

For more information, visit our pages on Bowel and Bladder Changes After SCI!

Why does walk/stand training alone have a beneficial effect on bladder, bowel, and sexual function?

Relationships between the leg movement and nerves in the low back regions have been identified.

Some evidence suggests that walk/step training alone can create improvements in bladder/bowel function. Researchers hypothesize that the sensory information created through walking or standing provides stimulation to the nerves in the low back region, which contains the nerves to stimulate bowel, bladder, and sexual function. Research has shown that bending and straightening the legs can be enhanced by how full the bladder is and the voiding of urine.

One of the consequences of SCI is the loss of muscle mass below the injury and a tendency to accumulate fat inside the abdomen (abdominal fat or visceral fat) and under the skin (subcutaneous fat). These changes and lower physical activity after SCI increase the risk for several diseases.

A single (weak-evidence) study measured body composition in four young males with complete injuries. Participants underwent 80 sessions of stand and step training without epidural stimulation, followed by another 160 sessions of stand/step training with epidural stimulation. This involved one hour of standing and one hour of stepping five days a week. After all, training was complete, all four participants had a small reduction in their body fat, and all participants but one experienced an increase in their fat free body mass (i.e., the weight of their bones, muscles, organs, and water in the body) in comparison to their initial values prior to stimulation. While all participants experienced a reduction of fat, the amount of fat loss was minimal, ranging from 0.8 to 2.4 kg over a period of a year.

The first use of epidural stimulation was as a treatment for chronic pain in the 1960s. Since then, it has been widely used for chronic pain management in persons without SCI. However, it is important to recognize that the chronic pain experienced by those without SCI is different from the chronic neuropathic pain experienced after SCI. This may explain, to some extent, why epidural stimulation has not been as successful in pain treatment for SCI. The mechanism by which electrical stimulation of the spinal cord can help with pain relief is unclear. Some research suggests that special nerve cells that block pain signals to the brain may be activated by epidural stimulation.

There are a few studies focused on the role of epidural stimulation in managing pain after SCI. A number of other studies included a mix of different people with and without SCI. Because chronic neuropathic pain after SCI may not be the same as the chronic pain others experience, studies that do not separate mixed groups raise questions about the validity of findings. The number of individuals with SCI in these studies is often small, most were published in the 1980s and 1990s and so are quite dated, and the research is classified as weak evidence.

The results of this body of research show that some people may receive some pain reduction. Those who saw the most reduction in pain were individuals with an incomplete SCI. Also, satisfaction with pain reduction drops off over time. One study showed only 18% were satisfied 3 years after implantation. A different study looking at the long-term use of epidural stimulation for pain reduction found seven of nine individuals stopped using this method.

In the only recent study in this area, one woman with complete paraplegia (weak evidence) experienced a reduction in neuropathic pain frequency and intensity, and a reduction in average pain from 7 to 4 out of 10, with 0 being no pain and 10 being the worst imaginable pain. This improvement remained up to three months later after implantation of the epidural stimulation device.

It should be noted that the studies for pain place electrodes in different parts of the spinal cord compared to the more recent studies for voluntary movement, standing and stepping.

Refer to our article on Pain After SCI for more information!

Using epidural stimulation to improve respiratory function is useful because it contracts the diaphragm and other muscles that help with breathing. Also, these muscles are stimulated in a way that imitates a natural pattern of breathing, reducing muscle fatigue. More common methods of improving respiratory function do not use epidural stimulation, but rather, directly stimulate the nerves that innervate the respiratory muscles. While such methods significantly improve quality of life and function in numerous ways, they are not without issues, including muscle fatigue from directly stimulating the nerves.

To date, most research into using epidural stimulation to improve respiratory function has been done in animals. Recently, research has been done in humans and weak evidence suggests that epidural stimulation may:

  • help produce a cough strong enough to clear secretions independently.
  • reduce frequency of respiratory tract infections.
  • reduce the time required caregiver support.
  • help individuals project their voice better and communicate more effectively.

Long term use of epidural stimulation shows that improvements remain over years and that minimal supervision is needed, making it suitable for use in the community.

Refer to our article on Respiratory Changes After SCI for more information!

The impact of epidural stimulation on sexual function has been a secondary focus in research studies looking at standing and walking. Currently, there are reports from one male and two females.

After a training program of walk training with epidural stimulation, one young adult male reported stronger, more frequent erections and the ability to reach full orgasm occasionally, which was not possible before epidural stimulation. However, this study looked at the effects of walk training and epidural stimulation together, which took place after several months of walk training without stimulation. Because the researchers did not describe what the individual’s sexual function was like after walk training, it is difficult to say how much benefit is attributed to epidural stimulation versus walk training.

In another study with two middle-aged females 5-10 years post-injury, one reported no change in sexual function and the other reported the ability to experience orgasms with epidural stimulation, which was not possible since her injury.

Refer to our article on Sexual Health After SCI for more information!

Botulinum toxin (Botox) injections and surgically implanted intrathecal Baclofen pumps are the most common ways to manage spasticity. Baclofen pumps are not without issues, however. Many individuals do not qualify for this treatment if they have seizures or blood pressure instability, and pumps require regular refilling.

Research in the 80s and 90s on the use of epidural stimulation for spasticity did not report very positive findings. It was noted that greater benefits were found in those with incomplete injury compared to those who were complete. Another paper concluded that (weak evidence) the beneficial effects of epidural stimulation on spasticity may subside for most users over a short period of time. This, combined with the potential for equipment failure and adverse events, suggested that epidural stimulation was not a feasible approach for ongoing management of spasticity.

More recently, positive results with epidural stimulation have been observed (weak evidence). This is likely due to improvements in technology, electrode placement, and stimulation parameters. Positive findings show that participants:

  • reported fewer spasms over 2 years
  • reported a reduction in severe spasms over 2 years
  • reported a reduction in spasticity
  • reported an improvement in spasticity over 1 year
  • were able to stop or reduce the dose of antispastic medication

For more information, visit our page on Botulinum Toxin and Spasticity!

In a study with a single participant (weak evidence) investigating walking, an individual implanted with an epidural stimulator also reported improvement in body temperature control, however details were not provided. More research is required to understand the role of epidural stimulation for temperature regulation.

In severe SCI, individuals may suffer from chronic low blood pressure and orthostatic hypotension (fall in blood pressure when moving to more upright postures). These conditions can have significant effects on health and quality of life. Some recent studies have looked at how epidural stimulation affects cardiovascular function to improve orthostatic hypotension. Overall, they show (weak evidence) that epidural stimulation immediately increases blood pressure in individuals with low blood pressure while not affecting those who have normal blood pressure. They also showed that there is a training effect with repeated stimulation. This means that after consistently using stimulation for a while, normal blood pressure can occur even without stimulation when moving from lying to sitting.

Moreover, researchers are starting to believe that changes in orthostatic hypotension and blood pressure can promote changes in the immune system (Bloom et al., 2020). In the body, the blood helps to circulate immune cells so they are able to fight infections in various areas. One case study found that after 97 sessions of epidural stimulation, the participant had fewer precursors for inflammation and more precursors for immune responses. Although these changes are exciting, researchers are still unsure why this happens, and whether these effects occur with all people who are implanted with an epidural stimulator.

Refer to our article on Orthostatic Hypotension for more information!

For individuals with tetraplegia, even some recovery of hand function can mean a big improvement in quality of life. Research into using epidural stimulation to improve hand function consists of one case study (weak evidence) involving two young adult males who sustained motor complete cervical spinal cord injury over 18 months prior.

The researchers reported improvements in voluntary movement and hand function with training while using epidural stimulation implanted in the neck. Training involved grasping and moving a handgrip while receiving stimulation. For 2 months, one man engaged in weekly sessions while the other trained daily for seven days. One participant was tested for a longer time as a permanent electrode was implanted, while the other participant only received a temporary implant. Both participants increased hand strength over the course of one session. Additional sessions brought additional gradual improvements in hand strength as well as hand control (i.e., the ability to move the hand precisely). These improvements carried over to everyday activities, such as feeding, bathing, dressing, grooming, transferring in and out of bed and moving in bed. Notably, these improvements were maintained when participants were not using epidural stimulation.

Being able to control your trunk (or torso) is important for performing everyday activities such as picking things up or reaching for items. One study found that using epidural stimulation can increase the amount of distance you are able to lean forward. The improvement in forward reach occurred immediately when the stimulation was turned on. The two participants in this study were also able to reach more side to side as well, but the improvement was minor.

Learning to make voluntary movements

Voluntary movements (i.e., being able to move your body when you want to) of affected limbs can occur with the use of epidural stimulation. Researchers are still unsure of the right training regimen to optimize results. For example, one study found that many sessions of step training with epidural stimulation are required for participants to slowly regain voluntary movement of the leg and foot with epidural stimulation when lying down. However, another study found that participants were able to voluntarily move their legs with stimulation and no stand training.

Voluntary movements (i.e., being able to move your body when you want to) of affected limbs can occur with the use of epidural stimulation. Researchers are still unsure of the right training regimen to optimize results. For example, one study found that many sessions of step and stand training with epidural stimulation are required for participants to slowly regain voluntary movement of the leg and foot with epidural stimulation when lying down. However, another study found that participants were able to voluntarily move their legs with stimulation and no stand training though the amount each participant was able to move their legs with epidural stimulation varied greatly. For example, one participant was able to voluntarily move their leg without any stimulation after over 500 hours of stand training with epidural stimulation while another participant from the same study was not able to voluntarily move their leg without stimulation after training. Overall, more than 25 people can move some or all of their leg joints voluntarily from the first time they receive epidural stimulation.

More recently, research shows that some with epidural stimulators can produce voluntary movements without stimulation on and without any intensive training program. In one study, participants did not do a consistent intensive training program, although many of them attended out-patient therapy or did therapy at home. Over the period of a year, 3 of 7 participants were able to voluntarily bend their knee, and bend and straighten their hips. Additionally, of those 3 participants, 2 were able to point their toes up and down. While the number of people able to make voluntary movements without stimulation is small, many more studies are underway.

Recent research indicates that epidural stimulation can influence walking function in individuals with limited or no motor function. While these findings are exciting, researchers are still learning how to use stimulation effectively to produce walking motions. Before being able to walk again, people must be able to make voluntary movements and be able to stand.

Learning to stand

Some studies have also found that with extensive practice (e.g., 80 sessions), independent standing (i.e., standing without the help of another person, but holding onto a bar) may be achieved without epidural stimulation. Gaining the ability to stand may also occur with stand training combined with epidural stimulation. However, the findings with regard to the effect of stand training with epidural stimulation have been mixed. For example, one study showed that stand training for 5 days a week over a 4 month period with epidural stimulation resulted in independent standing for up to 10 minutes in an individual with a complete C7 injury, while another study has suggested that independent standing for 1.5 minutes can be achieved with epidural stimulation and 2 weeks of non-step specific training in an individual with complete T6 injury.

Learning to walk

Earlier research has found that epidural stimulation can help with the development of walking-like movements, but these movements do not resemble “normal” walking. Instead, they resemble slight up and down movements of the leg. Recent studies have shown that with 10 months of practicing activities while lying down on the back and on the side, in addition to standing and stepping training, people are able to take a step without assistance from another person or body weight support. While some individuals in these studies have been able to regain some walking function, they are walking at a very slow pace, ranging from 0.19 meters per second to 0.22 meters per second. This is much slower than the 0.66 meters per second required for community walking. For example, of the 4 participants in one study, two were able to walk on the ground with a walker, one was only able to walk on a treadmill, and one was able to walk on the ground while holding the hands of another person. These differences in walking abilities gained by participants were not expected.

In late 2018, one researcher demonstrated that constant epidural stimulation was interfering with proprioception, or the body’s ability to know where your limbs are in space, which ultimately hinders the walking relearning process. The solution to this problem involves activating the stimulation in a specific sequence, rather than having it continuously on. With this method and a year’s worth of training, participants were able to begin walking with an assistive device (such as a walker or poles) without stimulation. However, these individuals had to intensively practice standing and walking with stimulation for many months to produce these results. In these studies, one case of injury was reported where a participant sustained a hip fracture during walking with a body weight support. Further studies on how to individualize therapy will be necessary as the response to treatment in these studies varied greatly from person to person depending on the frequency and intensity of the stimulation.

Is it the training or the epidural stimulation?

Most of the stand/walk training conducted in the studies is with the use of a body weight support treadmill.


Arm and leg movement and blood pressure have been seen to improve with epidural stimulation, but the role of rehabilitation in these recoveries is unclear. Rehabilitation techniques can have an effect on regaining motor function. For example, step/walk training alone can help improve the ability to make voluntary movements, walking and blood pressure among individuals with incomplete injuries.  In much of the current research, epidural stimulation is paired with extensive training (typically around 80 sessions) before and after the epidural stimulator is implanted. Furthermore, these studies do not compare the effects of epidural stimulation to a control group who receives a fake stimulation (a placebo) which would help to see if stimulation truly has an effect. Without this comparison, we are unable to clearly understand the extent of recovery that is attributable to epidural stimulation versus the effects of training. However, evidence now shows that voluntary movement and cardiovascular function can be improved from the first time epidural stimulation is used, if the stimulation parameters are specific for the function and person, which supports the role of epidural stimulation in improving function.

Access to new medical treatment for those requiring it cannot come soon enough. Experimental therapies are typically expensive and not covered by health care. Rigorous and sufficient testing is required before treatments become standard practice and receive health care coverage. Epidural stimulation for improving function in SCI is a unique example because epidural stimulation technology has been used widely to treat intractable back pain in individuals without SCI. The benefit of this is that, if/when epidural stimulation for individuals with SCI is shown to be safe and effective, the move from experimental clinical practice could happen relatively quickly as a number of hurdles from regulatory bodies have already been overcome. That said, current barriers to accessing epidural stimulation noted in a survey study of doctors include a lack of strong evidence research showing benefits, a lack of guidelines for the right stimulation settings, and an inability to determine who will benefit from it.

In Canada, the cost for an institution to install an epidural stimulation system for back pain in those without spinal cord injury, which is a common procedure, was $21,595 CAD. The cost incurred by a Canadian citizen undergoing implantation in Canada is $0 as it is covered by publicly funded health care.

 

In the United States, the cost for an institution to install an epidural stimulation system for back pain in those without spinal cord injury ranged between $32,882 USD (Medicare) and $57,896 USD (Blue Cross Blue Shield). The cost incurred for American citizens in the US will vary widely depending on their insurance coverage.

In contrast, for individuals with SCI, an epidural stimulation system is reported to cost over $100,000 USD in Thailand, and higher in other countries. Prospective clients should be aware that the epidural stimulation offered by these clinics may not be the same as that in the research reported in this article.

The recommended course for those wishing to try epidural stimulation is to register in a clinical trial. Regardless, persons interested in pursuing surgery at a private clinic or registering for clinical trials will find it useful to refer to the clinical trial guidelines published by ICORD (https://icord.org/research/iccp-clinical-trials-information/) for information on what they should be aware of when considering having an epidural stimulator implanted. Research studies that involve epidural stimulation can be found by searching the clinicaltrials.gov database.

Overall, there is evidence that epidural stimulation can improve function and health after SCI in numerous ways. However, because of the invasive nature of epidural stimulator implantation, research in this area involves few participants, no control groups, and no randomization, so it is classified as weak evidence. It is therefore important to keep in mind that while these recent reports are encouraging, more rigorous studies with more participants are needed to confirm the benefits and risks of this treatment to determine its place in SCI symptom management.

Epidural stimulation is not “plug and play” technology. Each implanted device needs to be tailored to the spine of the recipient. Some individuals respond to certain stimulation settings while others may respond better to other settings. Furthermore, over time, the need to change stimulation settings or even reposition the implant to maintain effectiveness may be required. Extensive physical training appears to be required for epidural stimulation to be most effective in improving standing or walking. The additional benefit of epidural stimulation to walk training is not always clear from the literature.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.


Parts of this page have been adapted from the SCIRE Project (Professional) “Spasticity”, “Bladder Management”, and “Pain Management” chapters:

Hsieh JTC, Connolly SJ, McIntyre A, Townson AF, Short C, Mills P, Vu V, Benton B, Wolfe DL (2016). Spasticity Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Curt A, Mehta S, Sakakibara BM, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0.

Available from: scireproject.com/evidence/rehabilitation-evidence/spasticity/

Hsieh J, McIntyre A, Iruthayarajah J, Loh E, Ethans K, Mehta S, Wolfe D, Teasell R. (2014). Bladder Management Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0: p 1-196.

Available from: scireproject.com/evidence/rehabilitation-evidence/bladder-management/

Mehta S, Teasell RW, Loh E, Short C, Wolfe DL, Benton B, Hsieh JTC (2016). Pain Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Loh E, McIntyre A, Querée M, editors. Spinal Cord Injury Rehabilitation Evidence. Version 6.0: p 1-92.

Available from: scireproject.com/evidence/rehabilitation-evidence/pain-management/


Evidence for “What is epidural stimulation” is based on the following studies:

International Neuromodulation Society. (2010). Neuromodulation: An Emerging Field.

Toossi, A., Everaert, D. G., Azar, A., Dennison, C. R., & Mushahwar, V. K. (2017). Mechanically Stable Intraspinal Microstimulation Implants for Human Translation. Annals of Biomedical Engineering, 45(3), 681–694. Retrieved from http://link.springer.com/10.1007/s10439-016-1709-0

Evidence for “How does epidural stimulation work?” is based on the following studies:

Evidence for “How are epidural stimulation electrodes implanted?” is based on the following studies:

Lu, D. C., Edgerton, V. R., Modaber, M., AuYong, N., Morikawa, E., Zdunowski, S., … Gerasimenko, Y. (2016a). Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabilitation & Neural Repair, 30(10), 951–962. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27198185

Lu, D. C., Edgerton, V. R., Modaber, M., AuYong, N., Morikawa, E., Zdunowski, S., … Gerasimenko, Y. (2016b). Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabilitation & Neural Repair, 30(10), 951–962.

Evidence for “Are there restrictions or precautions for using epidural stimulation?” is based on the following studies:

Moore, D. M., & McCrory, C. (2016). Spinal cord stimulation. BJA Education, 16(8), 258–263. Retrieved from https://linkinghub.elsevier.com/retrieve/pii/S2058534917300975

Wolter, T. (2014). Spinal cord stimulation for neuropathic pain: current perspectives. Journal of Pain Research, 7, 651–663.

Evidence for “Are there risks and side effects of epidural stimulation?” is based on the following studies:

Eldabe, S., Buchser, E., & Duarte, R. V. (2015). Complications of Spinal Cord Stimulation and Peripheral Nerve Stimulation Techniques: A Review of the Literature. Pain Medicine, 17(2), pnv025. Retrieved from https://academic.oup.com/painmedicine/article-lookup/doi/10.1093/pm/pnv025

Taccola, G., Barber, S., Horner, P. J., Bazo, H. A. C., & Sayenko, D. (2020). Complications of epidural spinal stimulation: lessons from the past and alternatives for the future. Spinal Cord, 58(10), 1049–1059. Retrieved from http://dx.doi.org/10.1038/s41393-020-0505-8

Evidence for “Epidural stimulation and bladder and bowel function” is based on the following studies:

Herrity, A. N., Williams, C. S., Angeli, C. A., Harkema, S. J., & Hubscher, C. H. (2018). Lumbosacral spinal cord epidural stimulation improves voiding function after human spinal cord injury. Scientific Reports, 8(1), 1–11. Retrieved from http://dx.doi.org/10.1038/s41598-018-26602-2

Herrity, April N., Aslan, S. C., Ugiliweneza, B., Mohamed, A. Z., Hubscher, C. H., & Harkema, S. J. (2021). Improvements in Bladder Function Following Activity-Based Recovery Training With Epidural Stimulation After Chronic Spinal Cord Injury. Frontiers in Systems Neuroscience, 14(January), 1–14.

Hubscher, C. H., Herrity, A. N., Williams, C. S., Montgomery, L. R., Willhite, A. M., Angeli, C. A., & Harkema, S. J. (2018). Improvements in bladder, bowel and sexual outcomes following task-specific locomotor training in human spinal cord injury. Plos One, 1–26.

Darrow, D., Balser, D., Netoff, T. I., Krassioukov, A., Phillips, A., Parr, A., & Samadani, U. (2019). Epidural Spinal Cord Stimulation Facilitates Immediate Restoration of Dormant Motor and Autonomic Supraspinal Pathways after Chronic Neurologically Complete Spinal Cord Injury. Journal of Neurotrauma, 2336, neu.2018.6006. Retrieved from https://www.liebertpub.com/doi/10.1089/neu.2018.6006

Beck, L., Veith, D., Linde, M., Gill, M., Calvert, J., Grahn, P., … Zhao, K. (2020). Impact of long-term epidural electrical stimulation enabled task-specific training on secondary conditions of chronic paraplegia in two humans. Journal of Spinal Cord Medicine, 0(0), 1–6. Retrieved from https://doi.org/10.1080/10790268.2020.1739894

Evidence for “Epidural stimulation and body composition” is based on the following studies:

Terson de Paleville, D. G. L., Harkema, S. J., & Angeli, C. A. (2019). Epidural stimulation with locomotor training improves body composition in individuals with cervical or upper thoracic motor complete spinal cord injury: A series of case studies. The Journal of Spinal Cord Medicine, 42(1), 32–38.

Evidence for “Epidural stimulation and pain” is based on the following studies:

Guan, Y. (2012). Spinal cord stimulation: neurophysiological and neurochemical mechanisms of action. Current Pain and Headache Reports, 16(3), 217–225.

Marchand, S. (2015). Spinal cord stimulation analgesia. PAIN, 156(3), 364–365.

Tasker, R. R., DeCarvalho, G. T., & Dolan, E. J. (1992). Intractable pain of spinal cord origin: clinical features and implications for surgery. Journal of Neurosurgery.

Cioni, B., Meglio, M., Pentimalli, L., & Visocchi, M. (1995). Spinal cord stimulation in the treatment of paraplegic pain. Journal of Neurosurgery, 82(1), 35–39.

Warms, C. A., Turner, J. A., Marshall, H. M., & Cardenas, D. D. (2002). Treatments for chronic pain associated with spinal cord injuries: many are tried, few are helpful. Clinical Journal of Pain, 18(3), 154–163.

Reck, T. A., & Landmann, G. (2017). Successful spinal cord stimulation for neuropathic below-level spinal cord injury pain following complete paraplegia: a case report. Spinal Cord Series and Cases, 3, 17049.

Evidence for “Epidural stimulation and respiratory function” is based on the following studies:

Hachmann, J. T., Grahn, P. J., Calvert, J. S., Drubach, D. I., Lee, K. H., & Lavrov, I. A. (2017). Electrical Neuromodulation of the Respiratory System After Spinal Cord Injury. Mayo Clinic Proceedings, 92(9), 1401–1414. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/28781176

DiMarco, A. F., Kowalski, K. E., Geertman, R. T., & Hromyak, D. R. (2006). Spinal cord stimulation: a new method to produce an effective cough in patients with spinal cord injury. American Journal of Respiratory and Critical Care Medicine, 173(12), 1386–1389.

DiMarco, A. F., Kowalski, K. E., Geertman, R. T., & Hromyak, D. R. (2009). Lower thoracic spinal cord stimulation to restore cough in patients with spinal cord injury: results of a National Institutes of Health-sponsored clinical trial. Part I: methodology and effectiveness of expiratory muscle activation. Archives of Physical Medicine & Rehabilitation, 90(5), 717–725.

Harkema, S. J., Wang, S., Angeli, C. A., Chen, Y., Boakye, M., Ugiliweneza, B., & Hirsch, G. A. (2018). Normalization of Blood Pressure With Spinal Cord Epidural Stimulation After Severe Spinal Cord Injury. Frontiers in Human Neuroscience, 12, 83.

DiMarco, A. F., Kowalski, K. E., Hromyak, D. R., & Geertman, R. T. (2014). Long-term follow-up of spinal cord stimulation to restore cough in subjects with spinal cord injury. The Journal of Spinal Cord Medicine, 37(4), 380–388.

Evidence for “Epidural stimulation and sexual function” is based on the following studies:

Harkema, S., Gerasimenko, Y., Hodes, J., Burdick, J., Angeli, C., Chen, Y., … Edgerton, V. R. (2011). Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: A case study. The Lancet, 377(9781), 1938–1947.

Darrow, D., Balser, D., Netoff, T. I., Krassioukov, A., Phillips, A., Parr, A., & Samadani, U. (2019). Epidural Spinal Cord Stimulation Facilitates Immediate Restoration of Dormant Motor and Autonomic Supraspinal Pathways after Chronic Neurologically Complete Spinal Cord Injury. Journal of Neurotrauma, 2336, neu.2018.6006. Retrieved from https://www.liebertpub.com/doi/10.1089/neu.2018.600

Evidence for “Epidural stimulation and spasticity” is based on the following studies:

Nagel, S. J., Wilson, S., Johnson, M. D., Machado, A., Frizon, L., Chardon, M. K., … Howard, M. A. 3rd. (2017). Spinal Cord Stimulation for Spasticity: Historical Approaches, Current Status, and Future Directions. Neuromodulation: Journal of the International Neuromodulation Society, 20(4), 307–321.

Dekopov, A. V., Shabalov, V. A., Tomsky, A. A., Hit, M. V., & Salova, E. M. (2015). Chronic spinal cord stimulation in the treatment of cerebral and spinal spasticity. Stereotactic and Functional Neurosurgery.

Dimitrijevic, M. R., Illis, L. S., Nakajima, K., Sharkey, P. C., & Sherwood, A. M. (1986). Spinal cord stimulation for the control of spasticity in patients with chronic spinal cord injury: II. Neurophysiologic observations. Central Nervous System Trauma, 3(2), 145–152. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med2&AN=3490313

Midha, M., & Schmitt, J. K. (1998). Epidural spinal cord stimulation for the control of spasticity in spinal cord injury patients lacks long-term efficacy and is not cost-effective. Spinal Cord, 36(3), 190–192. Retrieved from https://www.nature.com/articles/3100532

Barolat, G., Singh-Sahni, K., Staas, W. E. J., Shatin, D., Ketcik, B., & Allen, K. (1995). Epidural spinal cord stimulation in the management of spasms in spinal cord injury: a prospective study. Stereotactic & Functional Neurosurgery, 64(3), 153–164.

Dekopov, A. V., Shabalov, V. A., Tomsky, A. A., Hit, M. V., & Salova, E. M. (2015). Chronic spinal cord stimulation in the treatment of cerebral and spinal spasticity. Stereotactic and Functional Neurosurgery.

Pinter, M. M., Gerstenbrand, F., & Dimitrijevic, M. R. (2000). Epidural electrical stimulation of posterior structures of the human lumbosacral cord: 3. Control Of spasticity. Spinal Cord, 38(9), 524–531. Retrieved from https://www.nature.com/articles/3101040

Evidence for “Epidural stimulation and temperature regulation” is based on the following studies:

Edgerton, V. R., & Harkema, S. (2011). Epidural stimulation of the spinal cord in spinal cord injury: current status and future challenges. Expert Review of Neurotherapeutics, 11(10), 1351–1353. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med7&AN=21955190

Harkema, S. J., Gerasimenko, Y., Hodes, J., Burdick, J., Angeli, C., Chen, Y., … Edgerton, V. R. (2011). Supplementary index: Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: A case study. The Lancet, 377(9781), 1938–1947. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21601270

Evidence for “Epidural stimulation and cardiovascular function” is based on the following studies:

Bloom, O., Wecht, J. M., Legg Ditterline, B. E., Wang, S., Ovechkin, A. V., Angeli, C. A., … Harkema, S. J. (2020). Prolonged Targeted Cardiovascular Epidural Stimulation Improves Immunological Molecular Profile: A Case Report in Chronic Severe Spinal Cord Injury. Frontiers in Systems Neuroscience, 14(October), 1–11.

Evidence for “Epidural stimulation and hand function” is based on the following study:

Lu, D. C., Edgerton, V. R., Modaber, M., AuYong, N., Morikawa, E., Zdunowski, S., … Gerasimenko, Y. (2016a). Engaging Cervical Spinal Cord Networks to Reenable Volitional Control of Hand Function in Tetraplegic Patients. Neurorehabilitation & Neural Repair, 30(10), 951–962. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/27198185

Evidence for “Epidural stimulation and movement: trunk control” is based on the following studies:

Evidence for “Epidural stimulation and movement: voluntary movements” is based on the following studies:

Rejc, E., Angeli, C. A., Bryant, N., & Harkema, S. J. (2017). Effects of Stand and Step Training with Epidural Stimulation on Motor Function for Standing in Chronic Complete Paraplegics. Journal of Neurotrauma, 34, 1787–18023. Retrieved from www.liebertpub.com

Angeli, C. A., Edgerton, V. R., Gerasimenko, Y. P., & Harkema, S. J. (2014). Altering spinal cord excitability enables voluntary movements after chronic complete paralysis in humans. Brain, 137(Pt 5), 1394–1409. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999714/

Peña Pino, I., Hoover, C., Venkatesh, S., Ahmadi, A., Sturtevant, D., Patrick, N., Freeman, D., Parr, A., Samadani, U., Balser, D., Krassioukov, A., Phillips, A., Netoff, T. I., & Darrow, D. (2020). Long-Term Spinal Cord Stimulation After Chronic Complete Spinal Cord Injury Enables Volitional Movement in the Absence of Stimulation. Frontiers in systems neuroscience14, 35. https://doi.org/10.3389/fnsys.2020.00035

Evidence for “Epidural stimulation and movement: walking and standing” is based on the following studies:

Grahn, P. J., Lavrov, I. A., Sayenko, D. G., Straaten, M. G. Van, Gill, M. L., Strommen, J. A., … Lee, K. H. (2017). Enabling Task-Specific Volitional Motor Functions via Spinal Cord Neuromodulation in a Human with Paraplegia. Mayo Clinic Proceedings, 92(4), 544–554. Retrieved from http://dx.doi.org/10.1016/j.mayocp.2017.02.014

Harkema, S. J., Gerasimenko, Y., Hodes, J., Burdick, J., Angeli, C., Chen, Y., … Edgerton, V. R. (2011). Supplementary index: Effect of epidural stimulation of the lumbosacral spinal cord on voluntary movement, standing, and assisted stepping after motor complete paraplegia: A case study. The Lancet, 377(9781), 1938–1947. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/21601270

Rejc, E., Angeli, C. A., Atkinson, D., & Harkema, S. J. (2017). Motor recovery after activity-based training with spinal cord epidural stimulation in a chronic motor complete paraplegic. Scientific Reports, 7(1), 13476. Retrieved from www.nature.com/scientificreports

Rejc, E., Angeli, C., & Harkema, S. (2015). Effects of Lumbosacral Spinal Cord Epidural Stimulation for Standing after Chronic Complete Paralysis in Humans. PLoS ONE [Electronic Resource], 10(7), e0133998. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med8&AN=26207623

Grahn, P. J., Lavrov, I. A., Sayenko, D. G., Straaten, M. G. Van, Gill, M. L., Strommen, J. A., … Lee, K. H. (2017). Enabling Task-Specific Volitional Motor Functions via Spinal Cord Neuromodulation in a Human with Paraplegia. Mayo Clinic Proceedings, 92(4), 544–554. Retrieved from http://dx.doi.org/10.1016/j.mayocp.2017.02.014

Gill, M. L., Grahn, P. J., Calvert, J. S., Linde, M. B., Lavrov, I. A., Strommen, J. A., … Zhao, K. D. (2018). Neuromodulation of lumbosacral spinal networks enables independent stepping after complete paraplegia. Nature Medicine, 24(11), 1677–1682. Retrieved from https://doi.org/10.1038/s41591-018-0175-7

Angeli, C. A., Boakye, M., Morton, R. A., Vogt, J., Benton, K., Chen, Y., … Harkema, S. J. (2018). Recovery of Over-Ground Walking after Chronic Motor Complete Spinal Cord Injury. New England Journal of Medicine, 379(13), 1244–1250. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=medl&AN=30247091

van de Port, I. G., Kwakkel, G., & Lindeman, E. (2008). Community ambulation in patients with chronic stroke: How is it related to gait speed? Journal of Rehabilitation Medicine, 40(1), 23–27.

Wagner, F. B., Mignardot, J.-B., Le Goff-Mignardot, C. G., Demesmaeker, R., Komi, S., Capogrosso, M., … Courtine, G. (2018). Targeted neurotechnology restores walking in humans with spinal cord injury. Nature, 563(7729), 65–71. Retrieved from http://www.nature.com/articles/s41586-018-0649-2

Angeli, C. A., Edgerton, V. R., Gerasimenko, Y. P., & Harkema, S. J. (2014). Altering spinal cord excitability enables voluntary movements after chronic complete paralysis in humans. Brain, 137(Pt 5), 1394–1409. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3999714/

Carhart, M. R., He, J., Herman, R., D’Luzansky, S., & Willis, W. T. (2004). Epidural spinal-cord stimulation facilitates recovery of functional walking following incomplete spinal-cord injury. IEEE Transactions on Neural Systems & Rehabilitation Engineering, 12(1), 32–42. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&CSC=Y&NEWS=N&PAGE=fulltext&D=med5&AN=15068185

Harkema, S. J., Wang, S., Angeli, C. A., Chen, Y., Boakye, M., Ugiliweneza, B., & Hirsch, G. A. (2018). Normalization of Blood Pressure With Spinal Cord Epidural Stimulation After Severe Spinal Cord Injury. Frontiers in Human Neuroscience, 12, 83.

Legg Ditterline, B. E., Aslan, S. C., Wang, S., Ugiliweneza, B., Hirsch, G. A., Wecht, J. M., & Harkema, S. (2020). Restoration of autonomic cardiovascular regulation in spinal cord injury with epidural stimulation: a case series. Clinical Autonomic Research, (0123456789), 2–5. Retrieved from https://doi.org/10.1007/s10286-020-00693-2

Evidence for “Costs and availability of epidural stimulation” is based on the following studies:

Solinsky, R., Specker-Sullivan, L., & Wexler, A. (2020). Current barriers and ethical considerations for clinical implementation of epidural stimulation for functional improvement after spinal cord injury. Journal of Spinal Cord Medicine, 43(5), 653–656.

Kumar, K., & Bishop, S. (2009). Financial impact of spinal cord stimulation on the healthcare budget: a comparative analysis of costs in Canada and the United States. Journal of Neurosurgery: Spine.

Image credits
  1. Image by SCIRE Community Team
  2. Image by SCIRE Community Team
  3. Image by SCIRE Community Team
  4. Image by SCIRE Community Team
  5. Adapted from image made by Mysid Inkscape, based on plate 770 from Gray’s Anatomy (1918, public domain).
  6. Pregnant woman holding tummy. [CC BY-SA 4.0 (https://creativecommons.org/licenses/by-sa/4.0)] via Google Images.
  7. Edited from Nervous system, Musculature. ©Servier Medical Art. CC BY 3.0.
  8. Neurons ©NIH Image Gallery. CC BY-NC 2.0.
  9. Image by SCIRE Community
  10. bladder by fauzan akbar from the Noun Project
  11. Large Intestine by BomSymbols from the Noun Project
  12. Feet by Matt Brooks from the Noun Project
  13. hip by priyanka from the Noun Project
  14. visceral fat by Olena Panasovska from the Noun Project
  15. Lightning by FLPLF from the Noun Project
  16. Lungs by dDara from the Noun Project
  17. Love by Jake Dunham from the Noun Project
  18. Male by Centis MENANT from the Noun Project
  19. Female by Centis MENANT from the Noun Project
  20. Image by SCIRE Community
  21. Temperature by Adrien Coquet from the Noun Project
  22. Heart by Nick Bluth from the Noun Project
  23. Image by SCIRE Community
  24. Hand by Sergey Demushkin from the Noun Project
  25. Torso by Ronald Vermeijs from the Noun Project
  26. Yoga posture by Gan Khoon Lay from the Noun Project
  27. Standing by Rafo Barbosa from the Noun Project
  28. Walking by Samy Menai from the Noun Project
  29. Image by SCIRE Community
  30. Canada by Yohann Berger from the Noun Project
  31. United States of America by Yohann Berger from the Noun Project

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.

Sexual Health After Spinal Cord Injury

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Author: SCIRE Community Team | Reviewers: Lesley Houle, Rachel Nicoletti | Published: 12 June 2018 | Updated: ~

Sexual health changes are common after spinal cord injury (SCI). This page provides an overview of changes to sexual function after SCI and options for management.

Key Points

  • Sexual health is an important part of health and well-being after SCI.
  • People with SCI may experience changes to sexual desire, sensation, arousal, and orgasm because of the injury.
  • Other changes related to the injury, such as changes to bladder and bowel control, movement, self-image, and life roles may also affect sexual health after SCI.
  • People with SCI may experience changes to sexual desire, sensation, arousal, and orgasm because of the injury.
  • There are a number of treatments and techniques that may be used to help improve sexual arousal and satisfaction after SCI, including medications, physical treatments, and adaptive devices.
A man behind a woman on a wheelchair looking into the horizon as the sun sets

Your emotional, mental, and social wellbeing can be linked to your sexual health.1

Sexual health means being healthy and well in all parts of life related to sexuality. Sexual health is more than just being physically healthy; it also means feeling emotionally, mentally and socially well as a sexual being.

Having good sexual health means that we are able to be sexual beings and take part in sexual activities that are healthy and meaningful to each of us with our own unique needs, values, and life circumstances.

 

What is “sexuality”?

Sexuality describes who we are as sexual beings. It includes all the ways that we may experience and express ourselves sexually, including through aspects of our identities (such as gender identity), our physical features and functions, how we relate to others, our roles in relationships and society, and our sexual thoughts, values, beliefs and behaviours.

Sexual health after spinal cord injury

Sexual health and intimacy are important parts of living a fulfilling life and this continues to be true after SCI. In most cases, injury to the spinal cord will affect a person’s physical sexual functions in some way. Although being sexual may not be the same as it was before the injury, people with SCI continue to be sexual beings and can still have satisfying sexual and intimate lives after injury.

Watch a SCIRE video introducing sexual health after SCI.

We often think that “sex” means sexual intercourse involving penetration. However, this is only one small part of what sex is. “Sex” describes any activity that you find pleasurable and sexually satisfying. Sex means different things to different people and can include a wide range of activities, such as intimacy, kissing, touching, masturbation, oral sex, using sex toys and many other activities, as long as they feel like “sex” to you.

How is sex different after SCI?

Many people find that the beliefs they had about sex and the ways that they had sex before their injury may not be those that work best afterwards. Some things that might be different about sex after SCI may include:

  • Sex might require more planning instead of being entirely “spontaneous”
    A couple in wheelchairs leaning towards each other and holding hands

    After SCI, you may explore different ways to satisfy your sex life.2

  • Activities that you enjoyed before your injury (such as penetrative sex) may be less important than they were before
  • Body parts other than the genitals may be more pleasurable when touched (such as the lips, nipples, or areas of skin near the level of injury)
  • Different sexual positions may work better after injury
  • You may have a different role in your sexual relationships than you did before
  • Communicating with your partner may be more important for satisfying sex than it was before

Everyone is different and will experience their sexuality differently after injury. Being open to different ideas about what sex is can be a helpful way to find what works best and is most satisfying for you after injury.

To help understand changes to sexual function after SCI, it can be helpful to understand how the sex organs work when the spinal cord is not injured.

The male reproductive system

Labeled diagram showing the male reproductive system

The male reproductive system.3

The testicles (testes) are the main male sex glands, located within a sac called the scrotum underneath the penis. The testes create sperm and hormones, which then travel through connecting tubes towards the penis. The prostate gland and seminal vesicles are glands that make fluids that mix with sperm to make semen.

The penis is a shaft that has several columns of spongy tissue. These tissues contain blood vessels that can fill up with blood to make the penis firmer (an erection). The urethra is a tube that travels through the prostate gland and penis to expel semen during ejaculation. It also passes urine from the bladder.

The female reproductive system

Labeled diagram of female reproductive system

The female reproductive system.4

The ovaries are the main female sex glands. They are located within the abdomen and produce egg cells. The Fallopian tubes connect the ovaries to the uterus. The uterus (or womb) is where fertilized eggs develop into a fetus. It connects below to the inner part of the vagina through the cervix (the ‘neck’ of the uterus).

The vagina then extends from the cervix to the outside of the pelvis (the vulva), which is surrounded by the inner and outer vaginal lips (the labia). The opening to the urethra, where urine is expelled, is between the opening to the vagina and the clitoris.The clitoris is a small, button-like organ which is sensitive to sexual touch. It is located at the top of the inner labia above the urethra and opening to the vagina.

Sexual arousal

Sexual arousal describes how the mind and body become sexually excited and prepare the body for sex. In men, sexual arousal causes increased circulation to the penis, which fills the spongy tissues with blood and causes an erection. In women, sexual arousal involves developing lubrication in the vagina and increased circulation to the vagina and clitoris.

Sexual arousal happens in two ways

Sexual arousal happens in response to sexual thought or touch. These two ways of getting aroused have different pathways through the nervous system.

Arousal from thoughts (Psychogenic arousal)A cartoon outline of two people putting their heads together with their eyes closed

Becoming aroused by sexual thoughts is called psychogenic arousal (‘psychogenic’ means ‘originating in the mind’). This type of arousal happens when a person sees, hears, or imagines something sexual. This causes nerve signals from the brain to travel down the spinal cord and through nerves in the thoracic and lumbar spinal cord (from T11 to L2) to the sex organs.

Arousal from touch (Reflex arousal)

When arousal happens in response to sexual touch, it is called reflex arousal. Sexual touch causes nerve signals to travel to the spinal cord and back without travelling to the brain first. This leads to automatic (reflex) arousal of the sex organs. Reflex arousal involves nerves in the sacral spinal cord (from S2 to S4).

 

Orgasm

Orgasm is the peak of sexual excitement. It involves a sudden release of sexual tension caused by sexual activity, which is accompanied by rhythmic movement of muscles in the pelvis and feelings of pleasure.

In men, orgasm is often accompanied by ejaculation. Ejaculation involves coordinated movements along the reproductive glands and tubes that send semen out of the penis. The muscles at the neck of the bladder also close to prevent semen from accidentally entering the bladder. In women, orgasm is accompanied by rhythmic muscle tensing in the vagina and uterus.

When the spinal cord is injured, some or all of the nerve signals that would normally allow the brain and sex organs to communicate with one another cannot get through. This can affect sexual responses in many different ways.

Changes to sensation

Most people will have some loss of feeling in the genitals and nearby skin after injury. Some people experience sensations that are less intense and others may not be able to feel their genitals at all. In some cases, pain or other unusual sensations may be felt in response to touch which was previously pleasurable.

While there is typically reduced feeling below the injury, some people notice that areas at or above the level of injury (such as the nipples, lips or ears) may be more sensitive to sexual touch after injury.

Changes to erection

Most men experience changes to their ability to get an erection and maintain it during sex. This is called erectile dysfunction. The type of erectile dysfunction that a person has depends on where the injury is on the spinal cord.

 

  • Men with injuries at T10 and above typically lose the ability to get an erection from sexual thoughts (a psychogenic erection). However, they are usually able to get an erection through touch (a reflex erection). Sometimes reflex erections may happen in non-sexual situations (such as while inserting a catheter).
  • Men with injuries from L3 to S1 may be able to have both psychogenic and reflex erections, although these responses may be poorly coordinated during sex.
  • Men with injuries from S2 to S4 typically lose the ability to have reflex erections; however, they may be able to have psychogenic erections.

 

Listen to Cory’s experience with erections after spinal cord injury.

Male gender symbol with the arrow arched downwardMost men with SCI can get an erection in some form. However, erections are rarely the same as they were before the injury. Most men find that their erections are unreliable and can often be inadequate for penetrative sexual activity. It may also be difficult to keep the erection during sex. There are many different options for treating erectile dysfunction after SCI, which are explained below.

Changes to ejaculation

Cartoon depiction of three spermMost men with SCI also experience changes to their ability to ejaculate. They may experience an inability to ejaculate during sex, unpredictable ejaculation, or a condition called retrograde ejaculation. Retrograde ejaculation is when semen is propelled into the bladder during ejaculation because the bladder neck muscles do not close at the right time. Retrograde ejaculation is most common in people with injuries from T11 to L3. Many men with SCI require medical assistance to obtain sperm to have biological children. For some men with injuries above T6, ejaculation can also trigger autonomic dysreflexia.

Changes to female arousal

In women, SCI may lead to reduced arousal responses (such as reduced vaginal lubrication). These changes depend on where the injury is on the spinal cord.

  • Women with injuries at T10 and above may lose the ability to become aroused from sexual thoughts (psychogenic arousal), but may still be able to experience arousal from touch (reflex arousal).
  • Women with injuries from L3 to S1 may retain both psychogenic and reflex arousal.
  • Women with injuries from S2 to S4 may lose reflex arousal, but may still have psychogenic arousal.

In addition, women with SCI may also experience spasms of the vaginal muscles related to spasticity. This can cause difficulties with penetration. Treatments and techniques for improving genital arousal responses in women are outlined below.

Changes to female orgasm

Women may experience a change in their ability to orgasm following SCI. This typically involves greater difficulties in having an orgasm or an inability to have an orgasm at all. Having an orgasm may also feel different after SCI.

Changes to sexual desire

Many people experience changes to sexual desire (sometimes called libido) after an SCI. This can happen for several reasons, related to both physical changes from the injury and other life changes. For example, hormonal changes, emotional distress, and reduced sexual sensation may affect sexual desire.

Changes to self-image

A woman looking at her reflection in the mirror

Changes to your body following SCI can affect your sexual self-esteem.9

Self-image describes how a person sees themselves and believes that others see them. Self-image may affect how sexually attractive a person feels and their confidence in becoming sexual after an injury. It is also an important aspect of one’s willingness to engage in social activities like dating or becoming intimate with a new partner. For some people, it takes time to adjust to the physical and life changes after an SCI and become comfortable in their own skin. Other people may find that assistance from mental health providers or peers can help them regain their self-confidence to be sexual and participate fully in intimate relationships.

 

Watch a SCIRE YouTube video about sexual self-esteem after SCI.

 

Changes to relationships

Spinal cord injury affects all aspects of life and this can cause changes to relationships as well. For example, partners may take on greater caregiving responsibilities and there may be changes in working and family roles within the partnership. While every couple is different, most people do experience some changes to their relationships which can have an impact on their sexual health.

 

Changes to fertility

A woman sitting on a couch and holding her pregnant belly

Pregnancy is still possible after a SCI.10

Fertility is a male’s capacity to cause a pregnancy in a fertile female and a female’s ability to become pregnant from a fertile male. Men may have difficulty ejaculating during sex and often require medical interventions to obtain sperm. Sperm may also be lower quality following SCI because of a number of changes to the body. However, there are many medical interventions that may assist with fertility in men after SCI.

Women’s fertility is typically not affected by an SCI and they can usually become pregnant after injury. Immediately after the injury, women may experience a temporary loss in menstruation (having a period), but can still become pregnant.

This page does not discuss fertility treatments, for more information, please see SCISexualHealth.ca.

The function of the sex organs is only one part of sexual health. There are many other important considerations that may affect sexual health after SCI.

Bladder and bowel changes

Loss of bowel and bladder control is often one of the biggest concerns related to sex after SCI. People with SCI may experience bladder or bowel accidents during sex or have medical equipment such as an indwelling catheter. This can lead to anxiety or feeling self-conscious about being sexual with a partner.

Bladder and bowel changes can be managed in a number of different ways. The most important is to maintain a regular routine of bowel and bladder care to reduce the likelihood of having an accident. It may also help to:

  • Discuss the topic openly with partners before sex (outside of the bedroom)
  • Empty the bladder and bowel before sexual activity
  • Maintain good bowel and bladder hygiene
  • Prepare for potential accidents ahead of time by using waterproof sheets and having towels and wipes on hand to manage if an accident happens

Condoms can also be worn over an indwelling catheter that is folded back over the penis; please see the ‘Contraception’ page on SCISexualHealth.ca for more information.

Please see our articles on Bladder Changes After SCI and Bowel Changes After SCI for more information.

 

Listen to Cory describe how he manages bowel, bladder, and sex.

Hear about Cory’s initial concerns with positioning during the his recovery.

 

Positioning and movement for sexual activity

A silhouette of two people in bed with a heart aboveAssuming positions for sex may be more challenging after an SCI because of changes in movement control and flexibility. It may also be hard to get into certain positions because of reduced flexibility caused by spasticity and joint contractures. It may help to:

  • Try out different positions to find out which positions work best
  • Try out different places to have sex, such as in a wheelchair
  • Use assistive devices, such as bolsters, slings, and other devices to help with movement and positioning

For a guide to assistive sexual devices, please see the pleasureABLE Sexual Device Manual for Persons with Disabilities.

Autonomic dysreflexia

Autonomic dysreflexia is a serious medical emergency that can affect people with SCI at T6 and above. This condition involves a sudden rise in blood pressure, which may be accompanied by heart rate changes, headaches, sweating, and other symptoms. It typically occurs in response to strong stimulation below the level of injury, even if there is no feeling in the area.

Autonomic dysreflexia may happen during sexual activity and ejaculation or as a result of sexual health treatments. If you are prone to autonomic dysreflexia, it is important to be able to recognize it when it happens and know how to treat it right away.

Please see our article on Autonomic Dysreflexia Emergency Treatments for more information.

A pile of different pills and capsules.

Certain medications can contribute to sexual dysfunction as a side effect.12

Medications

Some medications that are used to treat other symptoms of SCI may have sexual side effects. One of the most common is Baclofen, a medication that is used to treat spasticity, which can make it more difficult to have an erection. Other medications, such as some antidepressant medications, may reduce sexual desire. If you suspect that your medications may be affecting your sexual health, speak to your health providers for more information.

Skin care

Care needs to be taken to avoid injuring the skin during sexual activity. Excessive rubbing, pressure or other forces to the skin during sexual activity can lead to pressure injuries. Care should be taken to avoid irritating or damaging the skin and any changes in skin condition should be noted and cared for as soon as possible.

Please see our article on Pressure Injuries for more information.

Erections lasting for hours (Priapism)

Priapism is an erection that lasts for more than two hours. If an erection is maintained for a long time, there will not be adequate blood circulation, which can damage the penis. Priapism is a medical emergency requiring immediate treatment from a doctor. It may happen as a side effect of treatment for erectile dysfunction, such as medications, penile rings, or injections. If you or your partner experiences an erection that lasts more than two hours, seek medical attention immediately.

Birth control and safe sex

Birth control pills in a pink package

Birth control is an important consideration in women who are sexually active.13

Following an SCI, most women are still able to become pregnant, even if menstruation is temporarily stopped (which may last up to 6 months after injury). Men may also be able to cause a pregnancy after SCI. It is important that individuals who could potentially become pregnant use birth control according to their doctor’s instructions.

In addition, your risk of contracting a sexually transmitted infection (an STI) is the same after injury as it was before the injury, so it is important to engage in safe sex practices.

A sexual health assessment is typically done with a health provider such as a nurse, physician, or other health provider specializing in the care of people with SCI. Depending on your location and the services available to you, this may take place at a doctor’s office, rehabilitation centre, or specialized sexual health service.

General health and sexual health history

A review of your health and medical history, including information about your SCI, functional abilities (such as hand function) and other health conditions (including spasticity, mental health, and bladder and bowel changes), as well as your medications and other current medical treatments. Your health providers will also ask you about your current and previous sexual history and current sexual abilities and concerns.

Physical exam

A man lying down on a bed with a healthcare provider performing a physical assessment beside him

A physical exam may be used for accurate diagnosis of your sexual condition.14

Although most often not required, a sexual physical exam may include:

  • Testing for movement control and muscle tone in the genitals and anus (such as the ability to squeeze the anus or control the pelvic floor muscles)
  • Testing for sensation in the pelvic region
  • Testing reflexes in the genital region, which may involve squeezing parts of the genitals and observing the reactions

Erectile dysfunction medications

A box and blister pack of blue Viagra pills

Sildenafil (Viagra).15

Several medications are used to treat erectile dysfunction after SCI. The most common medications are called Phosphodiesterase 5 inhibitors (PDE5i), such as Sildenafil (Viagra), Vardenafil (Levitra), and Tadalafil (Cialis). These medications work by opening the blood vessels and increasing blood flow in the penis. This helps maintain an erection during sexual activity.

There is strong evidence that phosphodiesterase 5 inhibitors are safe and effective for treating erectile dysfunction after SCI. In general, men who are able to have reflex erections respond better to these medications.

Injectable erectile dysfunction medications

Medications that are injected through a small needle directly into the penis (called intracavernosal injections) are another common treatment. The most common medication used is Alprostadil (Caverject). The needle injects the medication into the sides of the penis to allow the blood vessels of the penis to relax and fill up with blood.

There is moderate evidence that injectable medications are effective for treating erectile dysfunction following SCI. However, there may be an increased risk of priapism, a prolonged erection that can cause damage to the penis.

Vacuum devices

Vacuum devices (sometimes called ‘pumps’) are a non-drug treatment option for getting an erection. With these devices, the penis is inserted into a cylindrical device, where a handheld pump creates a vacuum by drawing air out of the cylindrical device. This causes a change in pressure that draws blood into the penis to cause an erection.

Penile (penis) rings may help to maintain an erection from a vacuum device. A ring can be placed around the base of the penis to limit blood flow away from the penis and keeping it firm. Care should be taken when using these devices and they should not be left on for more than 30 minutes because they can cause tissue damage, especially if there is reduced sensation.

A penile vacuum device with a clear chamber and pump on one end

Vacuum devices are a non-invasive method to treat erectile dysfunction.16

Vacuum devices are commonly used for managing erectile dysfunction after SCI, as they are non-invasive and non-drug treatment options. They may also assist with maintaining a person’s ability to have an erection over time. There is weak evidence that vacuum devices and penile rings are effective to assist with the treatment of erectile dysfunction after SCI. However, it is important that these devices are medically approved and used carefully.

Surgical implants (Penile prostheses)

Surgical implants to the penis, also known as penile prostheses, are a permanent surgical procedure that involves inserting a flexible or inflatable implant into the areas of the penis that would normally become firm during an erection. They will then remain in place, holding the penis erect. Inflatable prostheses can be inflated to fill up only when needed.

A penile prosthesis containing cylinders attached to a reservoir and pump

Penile prostheses are a permanent method to treat erectile dysfunction.17

Implants are typically only used if other treatments fail because they are permanent and once implanted, other methods will not work. There is weak evidence that surgical implants may be effective for improving erectile dysfunction after SCI.

Pelvic floor exercises (Perineal muscle training)

The pelvic floor muscles (also called the perineal muscles) are a group of muscles which are located in the pelvic region. They support the internal organs from below and play a role in bladder, bowel, and sexual function. There is weak evidence that pelvic floor exercise may help improve erectile dysfunction in men with SCI who retain some ability to control these muscles.

Vibration

Vibration sensation applied to the penis from a commercial mechanical vibrator, such as the FertiCare device, may assist men with SCI in achieving ejaculation. This is sometimes called vibrostimulation, and is a frequently used technique to obtain sperm for fertility. There is weak evidence that vibration may assist with ejaculation in men with injuries above T10. These devices may also be used for sexual pleasure by some men.

Electroejaculation

A cartoon sperm in a test tubeElectroejaculation is another procedure which can be used for ejaculation to collect sperm. This procedure involves the insertion of an electrical probe into the rectum, which is placed close to the prostate gland and seminal vesicles. Electrical currents are then used to stimulate the nerves to cause a reflex ejaculation. There is weak evidence that this treatment can cause ejaculation in men that are unable to ejaculate through vibrostimulation.

Experimental treatments for improving sensation and pleasure

There are a few experimental treatments that have shown promise in improving sexual sensation following SCI that are not currently available for treatment.

An experimental microsurgery procedure where nerves in the groin were connected to those from the penis has been shown to improve sensation of the penis in some individuals with SCI.

Sensory substitution training is an experimental technique in which stroking motions of the penis were connected to stroking of the tongue, so that the brain would be able to use the intact sense to substitute for one that is lost. In one study, this type of training improved sexual pleasure in men with SCI.

Clitoris stimulation

A cylindrical vibrator

A vibrator may be used to enhance sexual stimulation.19

The clitoris is very sensitive to touch and can be stimulated manually or with a vibrator to assist with sexual arousal. There is moderate evidence that clitoral stimulation using a mechanical vibrator and stimulation with the hands both increased the sexual response of women with SCI and were both effective. There is some evidence that stimulation of other areas such as the cervix or nipples may also result in orgasm, but more research is needed.

Vacuum devices

Vacuum devices are a relatively new technology for women with SCI, in which a small cup can be placed over the clitoris and a small amount of suction is applied to increase blood to flow and arousal. There is moderate evidence that a vacuum suction device for the clitoris was effective for improving sensory stimulation and increasing lubrication in women with SCI. However, further studies are needed to confirm these results.

Medications to assist with sexual response

Sildenafil (Viagra) has been studied as a way to improve sexual responses in women with SCI with some remaining genital sensation. However, there is moderate evidence from one study that this medication was not effective for improving sexual arousal in women with SCI.

Pelvic floor exercises (Perineal muscle training)

Although it has been proposed that pelvic floor exercises may help with sexual function in women with some control in these muscles, it has not yet been studied in people with SCI.

For people of all genders, there are many other tips and techniques that may be recommended by health providers and peers to improve sexual satisfaction and participation. However, because these techniques have not been scientifically studied, we do not know how effective they are.

Assistive devices

Sexual assistive devices and sex toys, such as hands-free vibrators or positioning products like bolsters and slings, may assist with enabling different activities and enjoyment during sexual activity. For a guide to assistive sexual devices, please see the pleasureABLE Sexual Device Manual for Persons with Disabilities.

Counselling and talk therapies

A healthcare professional providing education to a man who sits in front of her

Healthcare providers can support you through sexual health counselling.20

Many people experience mental distress and anxiety related to changes to their sexual health. For many people, this can be one of the biggest barriers to being sexual after SCI. It may be helpful to speak to a mental health professional, sexual health clinician, or peer about your concerns and feelings.

Sexual exploration

Because the body responds differently to sex than it did before, many people find that exploration is an important way to find what feels and works best after SCI. For example, exploring other areas of arousal (such as the lips, neck, ears, or nipples) on your own or with a partner may help find new ways to experience sexual pleasure. Often, people find that the areas of skin near the level of injury are sensitive to sexual stimulation.

In addition, experimenting with different positions during sexual activity may also help during sex. Some people find that it is easier to get an erection in certain positions over others and that increasing time spent on foreplay may assist with achieving arousal. Talking to your partner about your needs and what feels best during sex can be an important part of your sexual life after SCI.

Sexual health is an important part of living well after SCI. SCI may affect many aspects of sexual function, such as sensation, arousal, and orgasm. However, people with SCI can still have fulfilling sexual lives after injury.

Several medical treatments have been shown to assist with physical arousal responses in men and women, such as medications and vacuum devices. Many other ways of enhancing sexual health may also be recommended, such as trying out different positions, activities, and sexual devices.

For a review of how we assess evidence at SCIRE Community and advice on making decisions, please see SCIRE Community Evidence.

Parts of this page have been adapted from the SCIRE Project (Professional) “Sexual and Reproductive Health” Chapter:

Elliott S, McBride K (2014). Sexual and Reproductive Health Following Spinal Cord Injury. In Eng JJ, Teasell RW, Miller WC, Wolfe DL, Townson AF, Hsieh JTC, Connolly SJ, Noonan VK, Loh E, McIntyre A, editors. Spinal Cord Injury Rehabilitation Evidence. Version 5.0. Vancouver: p 1- 84.

Available from: https://scireproject.com/evidence/rehabilitation-evidence/sexual-and-reproductive-health/

Evidence for ‘What medical treatments are available for men?’ is based on the following studies:

Erectile dysfunction medications

Derry FA, Dinsmore WW, Fraser M, Gardner BP, Glass CA, Maytom MC, et al. Efficacy and safety of oral sildenafil (viagra) in men with erectile dysfunction caused by spinal cord injury. Neurology 1998;51:1629-1633.

Giuliano F, Hultling C, El Masry WS, Smith MD, Osterloh IH, Orr M, et al. Randomized trial of sildenafil for the treatment of erectile dysfunction in spinal cord injury. Sildenafil Study Group. Ann Neurol 1999;46:15-21.

Hultling C, Giuliano F, Quirk F, Pena B, Mishra A, Smith MD. Quality of life in patients with spinal cord injury receiving Viagra (sildenafil citrate) for the treatment of erectile dysfunction. Spinal Cord 2000;38:363-370.

Del Popolo G, Li Marzi V, Mondaini N, Lombardi G. Time/duration effectiveness of sildenafil versus tadalafil in the treatment of erectile dysfunction in male spinal cord-injured patients. Spinal Cord 2004;42:643-648.

Giuliano F, Rubio-Aurioles E, Kennelly M, Montorsi F, Kim ED, Finkbeiner AE, et al. Efficacy and safety of vardenafil in men with erectile dysfunction caused by spinal cord injury. Neurology 2006;66:210-216.

Tuzgen S, Karamehmetoglu SS, Karacan I, Tanriverdi T. Use of sildenafil in the treatment of erectile dysfunction in patients with spinal cord injury. Neurosurg 2006;16:40-43.

Giuliano F, Sanchez-Ramos A, Löchner-Ernst D, Del Popolo G, Cruz N, Leriche A, et al. Efficacy and safety of tadalafil in men with erectile dysfunction following spinal cord injury. Arch Neurol. 2007;64:1584-1592.

Ergin S, Gunduz B, Ugurlu H, Sivrioglu K, Oncel S, Gok H, Erhan B, Levendoglu F, Senocak O. A placebo-controlled, multicenter, randomized, double-blind, flexible-dose, two-way crossover study to evaluate the efficacy and safety of sildenafil in men with traumatic spinal cord injury and erectile dysfunction. J Spinal Cord Med. 2008;31:522-31.

Khorrami MH, Javid A, Moshtaghi D, Nourimahdavi K, Mortazavi A, Zia HR. Sildenafil efficacy in erectile dysfunction secondary to spinal cord injury depends on the level of cord injuries. Int J Androl 2010;33:861-4.

Injectable erectile dysfunction medications (Intracavernosal injections)

Renganathan R, Suranjan B, Kurien T. Comparison of transdermal nitroglycerin and intracavernous injection of papaverine in the treatment of erectile dysfunction in patients with spinal cord lesions. Spinal Cord1997;35:99-103

Vacuum Devices and Penile rings

Moemen MN, Fahmy I, AbdelAal M, Kamel I, Mansour M, Arafa MM. Erectile dysfunction in spinal cord-injured men: Different treatment options. Int J Impotence Res 2008;20:181-187.

Denil J, Ohl DA, Smythe C. Vacuum erection device in spinal cord injured men: Patient and partner satisfaction. Arch Phys Med Rehabil 1996;77:750-753.

Chancellor MB, Rivas DA, Panzer DE, Freedman MK, Staas WE,Jr. Prospective comparison of topical minoxidil to vacuum constriction device and intracorporeal papaverine injection in treatment of erectile dysfunction due to spinal cord injury. Urology 1994;43:365-369.

Heller L, Keren O, Aloni R, Davidoff G. An open trial of vacuum penile tumescence: constriction therapy for neurological impotence. Paraplegia 1992;30:550-553.

Zasler ND, Katz PG. Synergist erection system in the management of impotence secondary to spinal cord injury. Arch Phys Med Rehabil 1989;70:712-716.

Surgical implants (Penile prosthesis)

Kim YD, Yang SO, Lee JK, Jung TY, Shim HB. Usefulness of a malleable penile prosthesis in patients with a spinal cord injury. Int J Urol 2008;15:919-923.

Zermann DH, Kutzenberger J, Sauerwein D, Schubert J, Loeffler U. Penile prosthetic surgery in neurologically impaired patients: Long-term followup. J Urol 2006;175:1041-1044.

Gross AJ, Sauerwein DH, Kutzenberger J, Ringert R-H. Penile prostheses in paraplegic men. Brit J Urol 1996;78:262-264.

Pelvic floor exercises (Perineal muscle training)

Courtois FJ, Mathieu C, Charvier KF, Leduc B, Bélanger M. Sexual rehabilitation for men with spinal cord injury: preliminary report on a behavioral strategy. Sex Disabil 2001;19:149-157.

Vibration

Beretta G, Chelo E, Zanollo A. Reproductive aspects in spinal cord injured males. Paraplegia 1989;27:113-118.

Sonksen J, Biering-Sorensen F, Kristensen JK. Ejaculation induced by penile vibratory stimulation in men with spinal cord injuries. The importance of the vibratory amplitude. Paraplegia 1994;32:651-660.

Le Chapelain L, Nguyen Van Tam P, Dehail P, Berjon JJ, Barat M, Mazaux JM, et al. Ejaculatory stimulation, quality of semen and reproductive aspects in spinal cord injured men. Spinal Cord 1998;36:132-136.

Brackett NL, Kafetsoulis A, Ibrahim E, Aballa TC, Lynne CM. Application of 2 vibrators salvages ejaculatory failures to 1 vibrator during penile vibratory stimulation in men with spinal cord injuries. J Urol 2007b;177:660-663.

Sonksen J, Fode M, Lochner-Ernst D, Ohl DA. Vibratory ejaculation in 140 spinal cord injured men and home insemination of their partners. Spinal Cord 2012;50:63-66.

Electroejaculation

Brindley GS. The fertility of men with spinal injuries. Paraplegia 1984;22:337-348.

Halstead LS, VerVoort S, Seager SW. Rectal probe electrostimulation in the treatment of anejaculatory spinal cord injured men. Paraplegia 1987;25:120-129.

Ohl DA, Bennett CJ, McCabe M, Menge AC, McGuire EJ. Predictors of success in electroejaculation of spinal cord injured men. J Urol 1989;142:1483-1486.

Lochner-Ernst D, Mandalka B, Kramer G, Stohrer M. Conservative and surgical semen retrieval in patients with spinal cord injury. Spinal Cord 1997;35:463-468.

Le Chapelain L, Nguyen Van Tam P, Dehail P, Berjon JJ, Barat M, Mazaux JM, et al. Ejaculatory stimulation, quality of semen and reproductive aspects in spinal cord injured men. Spinal Cord 1998;36:132-136.

Kolettis PN, Lambert MC, Hammond KR, Kretzer PA, Steinkampf MP, Lloyd LK. Fertility outcomes after electroejaculation in men with spinal cord injury. Fertil Steril 2002;78:429-431.

Experimental treatments for improving sensation and pleasure

Overgoor ML, de Jong TP, Cohen-Kettenis PT, Edens MA, Kon M. Increased sexual health after restored genital sensation in male patients with spina bifida or a spinal cord injury: the TOMAX procedure. J Urol 2013;189:626-632.

Borisoff JF, Elliott SL, Hocaloski S, Birch GE. The development of a sensory substitution system for the sexual rehabilitation of men with chronic spinal cord injury. J Sex Med. 2010 Nov;7(11):3647-58.

Evidence for ‘What medical treatments are available for women?’ is based on the following studies:

Clitoral stimulation

Sipski ML, Alexander CJ, Gómez-Martín O, Grossbard M, Rosen R. Effect of vibratory stimulation on sexual response in women with spinal cord injury. J Rehabil Res Devel 2005;42:609-616.

Whipple B, Richards E, Tepper M, Komisaruk BR. Sexual response in women with complete spinal cord injury. Sex Disab 1996;14:191-201.

Courtois F, Alexander M, McLain ABJ. Women’s Sexual Health and Reproductive Function After SCI.Top Spinal Cord Inj Rehabil. 2017 Winter;23(1):20-30.

Vacuum devices

Alexander M, Bashir K, Alexander C, Marson L, Rosen R. Randomized Trial of Clitoral Vacuum Suction Versus Vibratory Stimulation in Neurogenic Female Orgasmic Dysfunction. Arch Phys Med Rehabil. 2018 Feb;99(2):299-305.

Medications to assist with sexual response

Alexander MS, Rosen RC, Steinberg S, Symonds T, Haughie S, Hultling C. Sildenafil in women with sexual arousal disorder following spinal cord injury. Spinal Cord 2011;49:273-279.

Sipski ML, Rosen RC, Alexander CJ, Hamer RM. Sildenafil effects on sexual and cardiovascular responses in women with spinal cord injury. Urology 2000;55:812-815.

Pelvic floor exercises (Perineal muscle training)

Courtois F, Alexander M, McLain ABJ. Women’s Sexual Health and Reproductive Function After SCI.Top Spinal Cord Inj Rehabil. 2017 Winter;23(1):20-30.

Other references

Alexander CJ, Sipski ML, Findley TW. Sexual activities, desire, and satisfaction in males pre- and post-spinal cord injury. Arch Sex Behav 1993;22:217-228.

Alexander M, Courtois F, Elliott S, Tepper M. Improving sexual satisfaction in persons with spinal cord injuries: Collective wisdom. Top Spinal Cord Inj Rehabil. 2017;23(1):57-70.

Alexander MS, Rosen RC, Steinberg S, Symonds T, Haughie S, Hultling C. Sildenafil in women with sexual arousal disorder following spinal cord injury. Spinal Cord 2011;49:273-279.

Anderson KD. Targeting recovery: Priorities of the spinal cord-injured population. J Neurotrauma 2004;21:1371-1383.

Axel SJ. Spinal cord injured women’s concerns: Menstruation and pregnancy. Rehabil Nurs 1982;7:10-15.

Baker ER, Cardenas DD, Benedetti TJ. Risks associated with pregnancy in spinal cord-injured women. Obstet Gynecol 1992;80:425-428.

Brackett NL, Lynne CM, Aballa TC, Ferrell SM. Sperm motility from the vas deferens of spinal cord injured men is higher than from the ejaculate. J Urol 2000;164:712-715.

Denys P, Mane M, Azouvi P, Chartier-Kaster E, Thiebault J-B, Bussel B. Side effects of chronic baclofen on erection and ejaculation in patients with spinal cord lesions. Arch Phys Med Rehabil 1998;79;494-496.

Dunzendorfer, U. (ed.) Sildenafil. Basel: Springer Science & Business Media; 2004.

Jackson AB, Wadley V. A multicenter study of women’s self-reported reproductive health after spinal cord injury. Arch Phys Med Rehabil 1999;80:1420-1428.

Jones ML, Leslie DP, Bilsky G, Bowman B. Effects of intrathecal baclofen on perceived sexual functioning in men with spinal cord injury. J Spinal Cord Med 2008;31:97-102.

Lombardi G, Mondaini N, Macchiarella A, Del Popolo G. Female sexual dysfunction and hormonal status in spinal cord injured patients. J Androl 2007; 28(5):722-76.

Ohl DA, Bennett CJ, McCabe M, Menge AC, McGuire EJ. Predictors of success in electroejaculation of spinal cord injured men. J Urol 1989;142:1483-1486.

Rutkowski SB, Middleton JW, Truman G, Hagen DL, Ryan JP. The influence of bladder management on fertility in spinal cord injured males. Paraplegia 1995;33:263-266.

Sexual health and its linkages to reproductive health: an operational approach. Geneva: World Health Organization; 2017. Licence: CC BY-NC-SA 3.0 IGO.

Skrowonski E, Hartman K. Obstetric management following tramautic tetraplegia: case series and literature review. Aust NZJ Obstet Gynaecol 2008;45:485-491.

Sramkova T, Skrivanova K, Dolan I, Zamecnik L, Sramkova K, Kriz J, Muzik V, Fajtova R. Women’s Sex Life After Spinal Cord Injury. Sex Med. 2017 Dec;5(4):e255-e259.

Image credits:

  1. BeachWheelchairGPEIBLS_6945x_EDT ©Government of Prince Edward Island, CC BY-NC-ND 2.0
  2. Love Life ©amslerPIX, CC BY-NC 2.0
  3. Modified from: Male anatomy blank ©Tsaitgaist, CC-BY-SA-3.0 and Male anatomy ©alt.sex FAQalt, GFDL
  4. Modified from: Female anatomy with g-spot ©Tsaitgaist, CC BY-SA 3.0 or GFDL
  5. Closeness ©Mark S Waterhouse, CC BY 3.0 US
  6. Fireworks ©Alex Muravev, CC BY 3.0 US
  7. Impotent ©Stephen Plaster, CC BY 3.0 US
  8. Sperm ©Alejandro Capellan, CC BY 3.0 US
  9. Image by SCIRE Community Team
  10. 000068750037 ©Alagich Katya, CC BY 2.0
  11. Make love ©matias porta lezcano, CC BY 3.0 US
  12. Assorted Medications ©NIAID, CC BY 2.0
  13. Not 100% Effective © Nate Grigg, CC BY 2.0
  14. Image by SCIRE Community Team
  15. Viagra ©Tim Reckmann, CC BY 2.0
  16. Air based penis pump ©Bjoernnielsen, CC BY-SA 4.0
  17. Prótesis de pene inflable ©Eduardo García Cruz, CC BY 2.0
  18. Sperm ©Hare Krishna, CC BY 3.0 US
  19. Penis-shaped vibrator ©Mekitin, CC0 1.0
  20. Image by SCIRE Community Team

 

Disclaimer: This document does not provide medical advice. This information is provided for educational purposes only. Consult a qualified health professional for further information or specific medical advice. The SCIRE Project, its partners and collaborators disclaim any liability to any party for any loss or damage by errors or omissions in this publication.