Female Sexuality Issues in Women With Spinal Cord Injury Chronic Illness

Sexual health is not restricted to the mere physical -- genital function. Sexuality comprises different facets. At the basic, instinctual level, it is the feeling of maleness or femaleness; and, how this sexuality and personality impacts and is impacted by society. (Sipski, Alexander, & Rosen, 1996) Finally, it includes such things as the right to be a sexual person following neurological injury, the opportunity to have knowledge about sexual changes and to make informed choices about appropriate options. This work involves a review of the literature associated with female sexuality following injury to the spinal cord.

Before delving into the sexual ramifications, it bears recognizing the anatomical and functional features of the Spinal Cord. The spinal cord enables the brain to communicate with every physical facets of the body -- independent action, and reaction to stimuli. When a spinal cord injury occurs, this communication between the central and afferent nervous system may be severed, resulting in a loss of function. Spinal cord injuries (SCI) occur when a traumatic event damages cells within the spinal cord. (Sipski & Alexander, 1997) The trauma may also independently (or as a consequence) sever the neuronal processes that relay signals to and from, and up and down, the spinal cord. The most common types of SCI include contusions (bruising) and compressions (pressure). Other types of injuries include nerve fiber lacerations, and central cord syndrome (damage to the cortico-spinal tracts of the cervical region of the spinal cord). Severe SCI often causes paralysis (loss of control over voluntary movement and muscles of the body) and loss of sensation and reflex function below the point of injury, including involuntary activities like breathing and bowel and bladder control. Occasionally, pain or sensitivity to stimuli, muscle spasms, and sexual dysfunction develop over time. SCI patients are also prone to develop secondary medical problems, such as bladder infections, lung infections, and bedsores.

Damage to the spinal cord due to an injury can be permanent and currently there is no cure. New research proves that spinal cord repair and regeneration is possible. More and more researchers around the world are confident that a cure for paralysis could be as close as ten years away. (Ducharme & Gill, 1997)

There two common manifestations of SCI: Paraplegia and Quadriplegia. Paraplegia is the loss of sensation and movement in legs and the trunk (or a part of it). Paraplegia results from an injury to the spinal cord below the neck. Quadriplegia (also called Tetraplegia) is the paralysis of all four limbs (from the neck down) resulting from injury to the neck. Fractures or compression of the vertebrae, which cause permanent damage to the spinal cord, may lead to loss of sensation, movement, pain management, bladder and bowel control, and sexual function. The most common causes of spinal cord injury are car and other motor vehicle collisions (54.7%), falls (17.7%), and other medical conditions and sports injuries (27.6%). SCI are caused by sudden impact that results in crushing the spine and the cord. (CureParalysis.org, 1997)

In the event of a complete spinal cord injury, for both men and women there is loss of genital sensation resulting from stimulation. Despite the physical problems, erotic sexual feelings continue to exist. Many people shift their source of eroticism so that the brain receives sexual signals from parts of the body other than the genitals. The brain learns to react sexually to pleasurable touching in other areas of the body. For example, the ear lobes and the back of the neck can be erogenous areas. This experience will be different than before but can be as fulfilling. In others the feelings in these newly discovered erogenous zones are less intense or more diffuse. For women, spinal cord injuries can affect vaginal lubrication. Women lubricate variably -- from physical stimulation or sexual thoughts. If vaginal lubrication is unsatisfactory, then a water-soluble lubricant can be recommended. Sildenafil may be of value in women with SCI by increasing blood flow to the perineum and increasing vaginal lubrication. (Crenshaw & Goldberg, 1996)

In the case of incomplete injuries, a clear picture is difficult to form. Factors such as location of the injury and the amount of sensation and motor functioning can be important in predicting changes to sexual response. A general indication of possible normal sexual function is the ability to control bladder and bowel movement.

Lesions of the spinal cord that result in paralysis of certain areas of the body, along with the corresponding loss of sensation. Complete injuries result in total loss of sensation and function below the injury level. Incomplete injuries result in partial loss. Complete injuries do not necessarily mean the severing of the cord. The cord, a continuation of the brain, is like a coaxial cable. It measures about one inch in diameter. From the spinal cord, nerves extend out to the muscles, skin and bones to control movement, receive sensations and regulate bodily excretions and secretions. (Barker, Barasi, & Neal, 2003)

The ligaments link and support the bones. The spinal cord, like the brain, is surrounded by the meninges, which are layers of tissue that have some fluid between them and protect the spine. There are main components of the spinal cord: The cervical spine consists of seven vertebrae. Joints in this region allow the head to move on the neck and turn sideways, nod and tilt. The cervical spine is the most mobile region of the spine, which is why the majority of spinal injuries occur in the neck. The thoracic spine has twelve vertebrae. These bones form the spine for the chest and upper abdomen and each one has a pair of ribs attached. Larger and stronger, thoracic vertebrae carry more weight. The rib cage region means that the thoracic spine is much less mobile than the cervical spine. Five lumbar vertebrae form the lumbar spine. The lumbar region takes the most weight. Hence these vertebrae are the biggest and strongest bones.

The sacrum is shaped like a triangle, and is five vertebrae fused into a single bone. The sacrum is the rear part of the pelvis. The coccyx (tailbone) is also triangular in shape. The final four vertebrae are fused into one.

Fractures can occur to almost any vertebra. Simple fractures are breaks that are commonly only a chip, or a crack in the bone. Simple fractures do not usually require treatment. They are stable and will not potentially injure the spinal cord. In wedge or compression fractures, the spine is compressed. The front part of the bone is compressed but the rear part stays intact forming the wedge. These injuries often need an operation and no treatment other than pain relief and rest is needed. Burst fractures result from a vertical shearing force. The bones are overloaded and one or more vertebral bodies bursts open. These fractures are not stable and require treatment.

The largest problem with cervical spine injury is damage to the spinal cord. The closer the injury to the brain, the greater the consequences of spinal injury. An injury to the spinal cord at the top of the cervical spine is likely to be fatal. These nerves control breathing. Injury at C4 results in breathing difficulties and quadriplegia. If the spinal cord at C5 is injured, the patient has partial shoulder and elbow movement, but is otherwise paralyzed. The patient with cord damage at C6 will be able to use shoulders and elbows and have partial wrist movement but no use of their hands and their legs. Injury at C7 allows shoulder, elbow, wrist and some hand movement.

Damage at T1 (thoracic spine) will affect hand movements as well but injury lower down will result in paraplegia. The lower the injury the more sensation around the torso will be retained.

The spinal cord ends at the level of L1 or L2. Cord injury with paraplegia can still occur at L1 or L2 but below this level there is more room in the spinal canal for the nerves. Nerve injury is therefore rare and isolated to individual or small groups of nerves. This can still be severely debilitating. (Vaccaro, 2003)

Injuries to the sacrum and coccyx are rare. The sacrum forms the rear of the pelvis and is therefore well protected. In pelvic trauma, the sacrum may become dislocated from the bones it is joined to but is rarely broken. Injuries to the coccyx bone are almost exclusively a result of falling directly onto the buttocks, or as a result of giving birth.

There are different treatment modalities (despite the fact that spinal cord problems are difficult to heal): The most common investigation for suspected spinal injury is X-ray. While x-rays do not show cord injury, they do indicate any bony damage. CT (Computerized Tomography) Scans are used to support and give further detail to the x-ray findings, assisting diagnosis and treatment plans. Magnetic Resonance Imaging (MRI) Scans are another form of scanning that provides doctors with additional information the injury has had on the spinal cord. Hard collars are used to immobilize a patient's neck. Patients given a collar by ambulance personnel or on arrival at hospital do not necessarily have a broken neck. These collars are placed as a precaution in all patients until exams show the absence of spinal injury. Other (more comfortable) collars are used to support the neck during recovery these collars are more comfortable. (Quencer & Hawighorst, 2001)

Surgery is often required to stabilize a fracture. There are several systems in use by surgeons but the operation may involve inserting metal plates and screws to support the injured spinal column. (Johnston, 2001) Bed Rest and traction devices are non-invasive options that allow the fracture time to heal. Better Practice Guidelines are available on a number of health related issues. These guidelines are compiled with the assistance of expert advice and research on the topics under scrutiny.

Among males, erectile and ejaculatory functions are activities that require the interaction between the vascular, nervous and endocrine systems. An erection is controlled by a reflex arc that is mediated in the sacral spinal cord. Ejaculation signals the culmination of the male sexual act and is primarily controlled by the sympathetic nervous system. Similar to the sympathetic innervation of the bladder, these fibers originate in the thoraco-lumbar spinal cord and travel into the sympathetic chain. These fascicles then travel through the splanchnic nerves into the hypogastric plexus. After synapsing in the inferior mesenteric ganglion, postganglionic fibers travel through the hypogastric nerves to supply the vas deferens, seminal vesicles and ejaculatory ducts in the prostate. (Bancroft, 1989)

Adaptation to an SCI is a gradual process that extends over a prolonged period of time. Successful sexual adjustment is influenced by many factors such as age at time of injury, quality of social supports, physical health, gender and severity of the injury. It is suggested to the sufferer to achieve as quick a closure as is possible so the quality of life can be nurtured and developed. Attempts to recapture the past sexual proclivities and habits are general detrimental. The patients are counseled to learn new sexual abilities.

The effect of spinal cord injury on sexual response is depends on the degree of completeness or incompleteness of the patient's injury and whether the neurological damage affecting the individual's sacral spinal segments is an upper or lower motor neuron injury. Whether a spinal cord injury is considered complete or incomplete is determined by whether they have voluntary rectal contraction and whether they have the ability to perceive sensation around their rectum.

Previous research suggested that female sexual function would be affected similarly to male sexual function in that psychogenic and reflex lubrication will be maintained in a comparable fashion to males, depending on the level and degree of the woman's spinal cord injury. Recent laboratory-based research performed supports the hypothesis that women with complete spinal cord injuries and upper motor neuron injuries affecting the sacral spinal segments will maintain the capacity for reflex lubrication while losing the capacity for psychogenic lubrication (Sipski, Rosen, & Alexander, 1995).

Also, in women with incomplete injuries and upper motor neuron injuries, research indicates the preservation of the ability to perceive pinprick sensation in the T11-L2 dermatomes may be able to be used as a predictor for the ability of psychogenic lubrication. Similar to male sexual functions, females with spinal cord injury have been shown to have the capacity to achieve orgasm approximately 50% of the time, and this has not been found to be related to the degree of injury. This has also recently been confirmed via laboratory-based research (Cooper, 1995) Lesions of the orbital parts of the frontal lobes may remove moral-ethical restraints and lead to indiscriminate sexual behavior, and that superior frontal lesions may be associated with a general loss of initiative which reduces all impulsivity, including sexual. During the acute rehabilitation phase, a sensitive discussion regarding sexuality is appropriate. The person with SCI may inquire about issues such as dating, attractiveness, relationships, parenthood and physical appearance. Other topics of interest may include erections, lubrications, sensation, orgasm, ejaculation and fertility. Many individuals will inquire about sexuality as it related to bladder and bowel function. Even if the patient does not initiate discussions about these topics, it is important for members of the rehabilitation team to provide basic information.

Women with spinal cord injuries suffer from temporary loss of their menstrual periods after their injuries lasting about four to six months. Resumption of periods occurs similar to their previous fashion. Menstrual pain is still present after spinal cord injury and there is generally not a decrease in the ability of a woman with a spinal cord injury to conceive. For this reason, the need to use birth control must be emphasized with women who have spinal cord injuries.

For those women who become pregnant after spinal cord injury are liable to suffer potential complications associated with pregnancy and spinal cord injuries. These can include anemia, problems with transfers due to weight gain, urinary tract infections, pressure sores, and, most significantly, autonomic dysreflexia, which frequently occurs during labor in women with injuries above the level of T6. This is often confused with preeclampsia. There is an increased risk of caesarean section in women with spinal cord injuries; however, more recent works have not shown this increased incidence.

The issue of birth control can give rise to problems for women with SCI. Condoms provide contraception as well as diminish the risk of transmission of sexually transmitted diseases. Hand coordination is important in instances of using contraceptive methods, e.g. diaphragm. Oral contraception is associated with increased incidence of thrombo-embolism and must be prescribed with caution in women with SCI. Oral contraceptives that contain only progesterone may be safer than medications that contain both estrogen and progesterone. IUD (intra-uterine devices) may be associated with increased incidence of pelvic inflammatory disease (PID). Untreated PID may lead to autonomic dysreflexia. In addition, women with SCI may not be able to perceive if the devise has migrated out of the cervix. (McDonald & Fish, 2002)

Immediately after SCI, 44 to 58% of women suffer from temporary amenorrhea. (Berezin et al., 1989) As mentioned earlier, while menstruation usually returns not soon after injury, the level and completeness is not correlated with the interruption of menstrual cycles. In a few of women with SCI, there are also changes in cycle length, duration of flow, amount of flow and amount of menstrual pain. Most women with SCI are fertile.

Pregnant women with SCI have an increased risk of urinary tract infections, leg edema, autonomic dysreflexia, constipation, thrombo-embolism and pre-mature birth. Since uterine innervation arises from the T10 to T12 levels, patients with lesions above T10 may not be able to perceive uterine contractions or fetal movements. During the second and third trimester, pregnant women may have difficulty in performing functional tasks that were previously completed independently. Transfers may require the assistance of a caregiver and a power wheelchair may be necessary for mobility. Locating an obstetrician and anesthesiologist with a supportive attitude, an accessible office and experience in SCI are additional inconveniences.

Spinal Cord Injury does not interfere with a woman's ability to become pregnant. The menstrual cycle is controlled by the hormonal systems inside a woman's body and these are unchanged after SCI. The decision to have a child is a serious one no matter whether you are able-bodied or disabled. Women should be counseled to accept difficulties, inconveniences and lifestyle changes during pregnancies. Achieving closure and rationalizing the disability is the best way to approach pregnancy. One cannot expect to recapture pregnancy features of an able-bodied person. (Melnyk, Montgomery, & Over, 1979) Therefore, women who do not wish to become pregnant must also ensure that they use proper birth-control techniques.

Would be mothers with SCI have to keep important consideration in mind: Women need to have the right information and a good understanding before, during and after the pregnancy. A pregnancy support team (doctor, obstetrician, nurse, or midwife) that are also trained in spinal cord injuries and the special considerations for pregnancy, labor and delivery with an SCI. In every aspect of the pregnancy, the partner or labor support person has to be well informed about SCI and labor and delivery, and should be able to provide comfort and act as an advocate when necessary.

Mobility is significantly impaired. As the pregnancy progresses it has implications for many aspects of your personal care and mobility. Washing, dressing, transferring and driving are affected. Planning for any additional care and carrying out day-to-day activities is essential. Increased size and weight can make weight shifts more difficult and increase the pressure on your skin at the same time. (Schurch, Curt, & Rossier, 1997) Difficulty with transfers also adversely affects the skin. Good skin care and good nutrition are very important. Constant weight shifts and transfers are important to prevent sores.