menu-iconMore mobile-close-icon
Skip Navigation
Skip Navigation
PrintDownload PDFGet Adobe ReaderDownload to WordDownload as HTMLDownload as XMLCitation Manager
Save to Favorites
Guideline Summary
Guideline Title
Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals.
Bibliographic Source(s)
Consortium for Spinal Cord Medicine. Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals. Washington (DC): Paralyzed Veterans of America; 2010 Jan. 47 p. [97 references]
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Sexuality and fertility in adults with spinal cord injury (SCI)

Guideline Category
Counseling
Evaluation
Prevention
Treatment
Clinical Specialty
Family Practice
Internal Medicine
Neurology
Obstetrics and Gynecology
Physical Medicine and Rehabilitation
Psychology
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Health Care Providers
Nurses
Physical Therapists
Physician Assistants
Physicians
Psychologists/Non-physician Behavioral Health Clinicians
Social Workers
Guideline Objective(s)
  • To review the literature and gather the latest information regarding sexuality and reproductive health following spinal cord injury (SCI)
  • To provide multidisciplinary recommendations that address basic needs and uncertainties related to sexuality after SCI
  • To provide the information that needs to be communicated to individuals with SCI and their partners
  • To emphasize the importance of maintaining a positive attitude and providing encouragement to learn about this fundamental aspect of human existence
  • To address physical, interpersonal, emotional, and medical concerns of those with SCI
  • To address the importance of privacy and individuality as well as the practical needs of individuals with spinal cord injuries
Target Population

Adult men and women with spinal cord injury (SCI)

Interventions and Practices Considered
  1. Consideration of importance of sexuality and reproduction to individual
    • Providing access to education about sex
    • Consideration of treatment framework, such as permission, limited information, specific suggestions, and intensive therapy (PLISSIT)
    • Maintaining nonjudgmental attitude with maximum privacy and confidentiality
  2. Sexual history and assessment
    • Medical assessment of sexual reproductive system
    • Physical examination using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI) standards
    • Assessing impact of the individual's injury on sexual function
    • Detailed neuromusculoskeletal examination and functional assessment
    • Developing a sexual education and treatment plan
    • Full physical examination and neurological assessments regularly
    • Educating persons with spinal cord injury (SCI) about effects of medications, alcohol, tobacco, and obesity on sexual response and fertility
    • Evaluating for depression
    • Evaluating for testosterone deficiency
  3. Provision of sexual education and counseling
  4. Maintaining sexual well-being
  5. Physical and practical considerations
    • Bladder and bowl
    • Skin care
    • Secondary medical complications
    • Optimal positioning for sexual activity
  6. Effect of injury on sexual function, responsiveness, and expression
  7. Treatment of dysfunction
  8. Effects on fertility
    • Proper information on effect of injury on menstruation
    • Safest birth control
    • Ensuring best medical outcomes for the pregnant woman with SCI
    • Educating women about effects of perimenopause and menopause
    • Biological fatherhood and options for assisted fertility
    • Performing semen analysis for men
    • Providing education about adoption
  9. Relationship issues: assisting with education and problem-solving
Major Outcomes Considered
  • Fertility rates related to spinal cord injury (SCI)
  • Sexual dysfunction rates related to SCI
  • Effectiveness of interventions (physical, prescription, hormonal, psychological, surgical, laboratory) for sexual dysfunction and fertility related to SCI
  • Outcomes of pregnancy
  • Psychological and physiological outcomes

Methodology

Methods Used to Collect/Select the Evidence
Hand-searches of Published Literature (Primary Sources)
Hand-searches of Published Literature (Secondary Sources)
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Methodology

United Biosource Corporation (UBC) performed a systematic review of the literature published between January 1, 1995, and September, 1, 2007 (time of review) that describes issues related to sexuality and reproductive health in individuals with spinal cord injuries. Procedures for this review followed the best methods used in the evolving science of systematic review research. Systematic review is a scientific technique designed to minimize bias and random error by employing a comprehensive search process and a preplanned process for study selection.

Literature Search

The literature search involved identifying and retrieving all potentially relevant literature describing sexual and reproductive health in people with spinal cord injury (SCI). The literature search included both electronic and manual components. The electronic search was performed in MEDLINE (via PubMed), PreMEDLINE, CINAHL, SocioFile, PsycINFO, and the Cochrane Library, using the dates and terms listed in the original guideline document.

Also, the Cochrane Library was searched for any recent systematic review of the subject, which could be a source of further references. A manual check of the reference lists of all accepted studies and of recent reviews and meta-analyses was performed to supplement the aforementioned searches and ensure optimal and complete literature retrieval. A MEDLINE search cutoff date of September 1, 2007, was used with a cut-off date for retrieval of articles from libraries no later than one week prior to completion of the study listing. A listing of any studies that remain outstanding at the time of retrieval cutoff is provided to the sponsor as a part of the study listing deliverable.

Study Selection

To be eligible for inclusion in this study listing for possible systematic review, studies yielded from the search above must satisfy none of the following exclusion and contain at least one eligible inclusion criteria:

Exclusion Criteria (used to eliminate abstracts in level I screening):

  • Reviews or meta-analyses
  • Animal or in vitro studies
  • Pediatric studies (subjects younger than 18 years of age) or mixed populations where more than 15 percent are pediatric patients
  • Studies offering no intervention for sexual and reproductive health of those with SCI
  • No study not related to the sexual and reproductive health of people with SCI
  • Studies published only in abstract form
  • Studies published before 1995
  • Languages other than English

Inclusion Criteria (used to accept publications in level II screening):

  • Any published and unpublished study, reported in English, involving any research design, enrolling male and/or female adult populations with SCI
  • Design: article reports a fertility intervention, including pre- and postintervention fertility rates. Article contains original report of a measure of fertility rates in males, females, or both, and reports original intervention trial after spinal cord injury. Regarding male sexuality, the article reports pre- and postmeasures for sexual dysfunction after SCI, contains original report of a measure of sexual dysfunction, and discusses an intervention for sexual dysfunction.
  • Studies reporting interventions of physical, prescription medication, surgical, and laboratory interventions. Regarding male sexuality, studies reporting cognitive/behavioral, prescription medications, surgical, or hormonal interventions.
  • Studies reporting outcomes of pregnancy, live birth rates, sperm motility, successful sperm harvesting, ejaculations, sperm count, percent viable sperm, hormonal, ovulation rates, cycle function, other measures of sperm morphology, volume of ejaculation. For male sexuality, outcomes also regarding psychological and physiological outcomes.

After level I and level II screening was completed, a study listing with bibliographies of all papers retrieved and screened (accepted and rejected studies at level II) was submitted to Paralyzed Veterans of America (PVA) for review and comment.

Search Yield

After an initial search was performed, all of the abstracts were downloaded and a level I screening was performed in which abstracts were reviewed for exclusion criteria. The full article was then obtained for all accepted abstracts and for those abstracts for which a clear determination could not be made at level I screening. The full articles of accepted studies underwent a level II screening in which inclusion and exclusion criteria were applied. On completion of level II screening, all accepted articles were then eligible for data extraction. Any studies rejected at this level were reviewed by two researchers and listed in a reject log.

Number of Source Documents

145 papers were accepted for data extraction.

Methods Used to Assess the Quality and Strength of the Evidence
Weighting According to a Rating Scheme (Scheme Given)
Rating Scheme for the Strength of the Evidence

Levels of Evidence

  1. Evidence based on randomized controlled clinical trials (or meta-analysis of such trials) of adequate size to ensure a low risk of incorporating false-positive or false-negative results.
  2. Evidence based on randomized controlled trials that were too small to provide level I evidence. These may have shown either positive trends that were not statistically significant or no trends and were associated with a high risk of false-negative results.
  3. Evidence based on nonrandomized, controlled or cohort studies, case series, case-controlled studies, or cross-sectional studies.
  4. Evidence based on the opinion of respected authorities or that of expert committees as indicated in published consensus conferences or guidelines.
  5. Evidence that expresses the opinion of those individuals who have written and reviewed this guideline, based on experience, knowledge of the relevant literature, and discussions with peers.
Methods Used to Analyze the Evidence
Systematic Review
Description of the Methods Used to Analyze the Evidence

Evidence Review

During the panel deliberations and preparation of the recommendations, it became clear that the expert panel also drew extensively on a substantial literature base, providing support for their recommendations. Often a recommendation is based on older studies of spinal cord injury (SCI) patients or on studies of more heterogeneous groups of acutely injured patients with or without SCI, studies that were felt to be generalizable to the early SCI population. United Biosource Corporation (UBC) independently graded these studies.

Evidence Analysis

All studies accepted for data extraction were graded for level of evidence using the criteria from the Centre for Evidence-Based Medicine in Oxford, UK (www.cebm.net External Web Site Policy; accessed January 16, 2008). In addition, randomized clinical trials were assessed using the Jadad Quality Score Assessment. Industry sponsorship was also noted.

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

After studying the processes used to develop other guidelines, the consortium steering committee unanimously agreed on a new, modified, clinical/epidemiologic, evidence-based model derived from the Agency for Healthcare Research and Quality (AHRQ).

A steering committee was established to:

  • Advance the guideline development process
  • Identify and prioritize clinical practice guideline (CPG) topics
  • Assist in the expert panel selection process
  • Provide an initial explication of the topic to serve as the basis of the CPG outline
  • Monitor the guideline development process
  • Collaborate with the panel and coordinating office to develop a comprehensive dissemination and utilization plan

The steering committee is comprised of one representative from each consortium member organization. Paralyzed Veterans of America (PVA) staff members (the "coordinating office") provide administrative support to the consortium. The process used to develop the guidelines is based on the model derived from AHRQ. The model is:

  • Interdisciplinary, to reflect the multidisciplinary needs of the spinal cord medicine practice community
  • Responsive, with a well-managed timeline for completion of each guideline
  • Reality-based, making use of the scientific literature where it exists and using practical and clinical expertise where there are gaps in the scientific literature

Upon completion of the literature search, each panel member is provided with a list of accepted articles, their evidence level (I–V), and the full text of the article. It is expected The Consortium for Spinal Cord Medicine that each panel member will read the literature provided as a result of the systematic review. Panel meetings are scheduled with the following goals:

  1. Develop an outline for the CPG based on the explication provided by the steering committee
  2. Assign each panel member writing assignments
  3. Determine deadlines for assignments

As the coordinating office receives completed assignments from panel members, a document is created. This document becomes the CPG working draft. Based on the references cited in the rationales for each recommendation, "scientific evidence" and "grade of recommendation" are assigned to each recommendation. A final meeting of the panel is convened to vote on the "strength of panel opinion" for each recommendation.

Grading the Guideline Recommendations

After the guideline was drafted, each recommendation was graded according to the level of scientific evidence supporting it. The framework used is outlined in table 1 of the original guideline document. These ratings, like the level of evidence table ratings, represent the strength of the supporting evidence, not the strength of the recommendation itself. The strength of the recommendation is indicated by the language describing the rationale.

Grading of Panel Consensus

The level of agreement with the recommendation among panel members was assessed as either low, moderate, or strong. Each panel member was asked to indicate his or her level of agreement on a 5-point scale, with 1 corresponding to neutrality and 5 representing maximum agreement. Scores were aggregated across the panel members and an arithmetic mean was calculated. This mean score was then translated into low, moderate, or strong, as shown in the "Rating Scheme for the Strength of the Recommendations" field. Panel members could abstain from the voting process for a variety of reasons, such as lack of expertise associated with a particular recommendation.

Rating Scheme for the Strength of the Recommendations

Categories of Strength of Evidence Associated with the Recommendations

  1. The guideline recommendation is supported by one or more level I studies.
  2. The guideline recommendation is supported by one or more level II studies.
  3. The guideline recommendation is supported only by one or more level III, IV, or V studies.

Levels of Panel Agreement with Recommendation

Low Mean agreement score 1.0 to less than 2.33
Moderate Mean agreement score 2.33 to less than 3.67
Strong Mean agreement score 3.67 to 5.0
Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
External Peer Review
Internal Peer Review
Description of Method of Guideline Validation

When all elements of the clinical practice guideline (CPG) outline are completed and a draft manuscript of the guideline is prepared, field review is conducted. Field reviewers are then chosen by the steering committee to provide feedback on the draft CPG. Field reviewers must:

  1. Be well versed in the topic area
  2. Be peers of the panelists
  3. Represent the consortium member organizations in some way

Panel members may also suggest reviewers. When field reviewer comments are received by the coordinating office they are transmitted to the panel chair.

The guideline goes through a three-tiered editing process:

  1. Medical review by a recognized technical review firm, to ensure that all medical references are properly cited and that there are no medical errors
  2. Legal review, to ensure that there are no copyright infringement or liability issues
  3. Stylistic editing, for grammar, spelling, and continuity

Once editing and design have been completed, the clinical practice guideline is posted on the Paralyzed Veterans of America website and published in the Journal of Spinal Cord Medicine.

Recommendations

Major Recommendations

Rating schemes for the levels of scientific evidence (I, II, III, IV, V), grade of recommendation (A, B, C) and the strength of panel opinion (Low, Moderate, Strong) are defined at the end of the "Major Recommendations" field.

Importance of Sexuality and Reproduction to the Individual

  1. Maintain an open discussion and provide access to education about sex in both formal and informal settings throughout the treatment continuum.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  2. Consider using a treatment framework, such as the Permission, Limited Information, Specific Suggestions, and Intensive Therapy (PLISSIT) model, for education.

    (Scientific evidence–IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  3. Encourage individuals to take an active role in obtaining information related to sexual issues.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  4. Provide assurance to the individual as soon as feasible (preferably during early acute care) that basic information about sexuality will be provided and that more extensive information will be available throughout care.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  5. Introduce the topic of sexuality by discussing the subject in a straightforward and nonjudgmental manner. Ask open-ended questions that encourage an ongoing dialogue whenever possible.

    (Scientific evidence–IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  6. Maintain a nonjudgmental attitude regarding sexual orientation and gender identity in order to elicit honest and productive discussion, while providing maximum privacy and maintaining confidentiality.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  7. Determine the individual's interest and readiness to learn about sexual function and expression following his or her spinal cord injury (SCI). Be aware that some people with SCI may not feel comfortable in raising the topic directly.

    (Scientific evidence–IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  8. Encourage people with SCI to explore the role of sexuality in their lives and the various ways in which they may express their sexuality.

    (Scientific evidence–III/IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  9. Ensure that, for all individuals in rehabilitation or institutional settings, sexual expression is treated with privacy, respect, and dignity.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

Sexual History and Assessment

  1. Include general questions about sexuality and sexual function as early as possible in the rehabilitation process. Ask direct, open-ended questions to facilitate a discussion of sexual matters.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  2. Ask individuals with SCI if they have experienced any previous sexual trauma, sexual dysfunction, or sexually transmitted disease that could affect their sexual function following injury.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  3. Consider the individual's life context (cultural, environmental, spiritual, and social) during sexual education and counseling.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  4. Ensure that a medical assessment of the sexual reproductive system is conducted after SCI. The assessment should include a thorough examination of breasts and genitalia, as well as screenings for cervical, ovarian, uterine, breast, prostatic, and testicular cancers. Screening for sexually transmitted diseases, including human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS), should be provided as deemed appropriate through consultation with the individual. Provide counseling about human papillomavirus (HPV) immunization as appropriate.

    (Scientific evidence–I/III/IV/V; Grade of recommendation–A; Strength of panel opinion–Strong)

  5. Perform a physical examination using the International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI), with special attention to the preservation of sensation from T11–L2 and S2–5 along with determination of the presence of voluntary anal contraction and reflexes to assess sexual function.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  6. Assess the impact of the individual's injury on sexual responses (i.e., genital responses, based on a neurologic examination, such as the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury).

    (Scientific evidence–II/III; Grade of recommendation–B; Strength of panel opinion–Strong)

  7. Perform a detailed neuromusculoskeletal examination and functional assessment. Use the results of the examination to assist in counseling regarding sexual activity.

    (Scientific evidence–II/IV/V; Grade of recommendation–B; Strength of panel opinion–Strong)

  8. Develop a sexual education and treatment plan with the individual consistent with the results of the sexual history, interview, relationship status, and physical exam findings.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  9. Perform full physical examinations and neurological assessments regularly, in order to detect changes over time that may affect sexual function. The assessments should include the International Standards to Document Remaining Autonomic Function after Spinal Cord Injury to determine the neurological level and extent of injury.

    (Scientific evidence–III/IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  10. Educate persons with SCI about the effects of medication on sexual response and fertility. Medications include prescription, over-the-counter, or herbal remedies and/or supplements.

    (Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

  11. Educate the individual about the effects of alcohol, tobacco, and other drugs, as well as unhealthy eating habits and obesity, on sexual response and fertility.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  12. Evaluate the individual with SCI for a diagnosis of depression or other psychological disorders if he or she exhibits such symptoms as loss of libido, poor concentration, fatigue, and/or changes in sleep or appetite.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  13. Evaluate for a diagnosis of testosterone deficiency in men with SCI presenting with suppressed libido, reduced strength, fatigue, or poor response to phosphodiesterase type 5 inhibitors (PDE5is) for erection enhancement.

    (Scientific evidence–III/IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

Education

  1. Maintain professional boundaries under all circumstances when addressing sexual issues with individuals with SCI and their partners.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  2. Consider age at onset of injury and previous sexual experience when assessing the sexual knowledge of the adult individual with SCI. Provide sexual education and counseling accordingly.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  3. If explicit educational media (videos, pictures, books, magazines, etc.) are going to be used for education, evaluate the individual's readiness to view such material and use material only when health-care providers with counseling skills are available to help the individual process the information and gauge his or her reaction to the media. Use these materials only in accordance with state and/or institutional laws.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

Maintaining Sexual Well-Being

  1. Provide information on methods to enhance sensuality by using all available senses.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  2. Provide information on sexual assistive devices (sex toys) that are sometimes used to enhance sexual experiences. Provide appropriate cautions about contraindications as well as information regarding skin protection, prolonged penile constriction, and dysreflexia. Inform individuals that sexual enhancement devices may be modified to accommodate limited mobility.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  3. Encourage individuals to consider expanding their sexual repertoire to enhance their sexual pleasure following injury. Discuss the broad range of options for sexual expression and pleasure for individuals with SCI.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

Physical and Practical Considerations

Bladder and Bowel

  1. Encourage individuals to consider bladder care prior to sexual activity and to explore contingency plans, as necessary, if incontinence should occur.

    (Scientific evidence–II/IV; Grade of recommendation–B; Strength of panel opinion–Strong)

  2. Encourage individuals to consider bowel care prior to sexual activity and to explore contingency plans, as necessary, if incontinence should occur.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

Skin Care

  1. Inform individuals that existing pressure ulcers do not necessarily preclude engagement in sexual activity and discuss ways to avoid injuring skin or exacerbating existing pressure ulcers.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  2. Instruct individuals to inspect insensate skin surfaces, particularly around the genitalia and buttocks, immediately after sexual activity as these areas may have received excessive friction, pressure, or tears.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong) 

Secondary Medical Complications

  1. Educate individuals with SCI about optimal positioning during sexual activity in order to protect limbs from damage.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  2. Inform individuals with SCI that it is common for their level of spasticity to change as a result of sexual activity.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  3. Educate individuals about the relationship between sexual activity and the possible onset of autonomic dysreflexia (AD), with or without symptoms, especially in people with injuries at or above T6. Instruct individuals with SCI to modify sexual activity if they experience AD.

    (Scientific evidence–I/II; Grade of recommendation–A; Strength of panel opinion–Strong)

  4. Ensure that individuals with SCI understand that they remain at risk for acquiring or transmitting sexually transmitted infections (STIs), also commonly known as STDs (or sexually transmitted diseases).

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

Optimal Positioning for Sexual Activity

  1. Educate individuals about obtaining assistance from caregivers in their preparation for sexual activity.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  2. Ascertain the necessary spine precautions specific to the individual and translate that information into safe levels of sexual activity. After spinal cord injury, intimacy and affection are encouraged; however, individuals need to be cognizant of the potential risk of further injury.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  3. Suggest environmental modifications that enhance the quality of the sexual experience.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  4. Teach the person with SCI optimal positioning and bed mobility in accordance with his or her injury.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  5. Educate individuals with SCI and their partners about safety measures to consider when engaging in sexual activity while in a wheelchair. Encourage individuals to learn about the safety limits of their particular chair.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  6. Discuss safety issues related to the use of shower and shower equipment for sexual activity (e.g., burns induced by hot water, risks of slipping or falling, and weight limits that may apply to shower chairs). Inform the individual that high-weight capacity shower chairs are available.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  7. Discuss the use of adaptive equipment required by aging individuals with SCI and people with aging partners.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

Effect of Injury on Sexual Function, Responsiveness, and Expression

  1. Discuss the fluctuations that may occur with sexual desire and interest following SCI.

    (Scientific evidence–II/III/IV/V; Grade of recommendation–B; Strength of panel opinion–Strong)

  2. Discuss the potential for discovering and developing new areas of the body that may stimulate sexual arousal (erogenous zones) and lead to sexual pleasure and possible orgasm.

    (Scientific evidence–III/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  3. Explain that reflex erections may occur with either sexual stimulation or nonsexual stimuli.

    (Scientific evidence–II/III; Grade of recommendation–B; Strength of panel opinion–Strong)

  4. Explain to the individual the potential impact of injury on arousal and orgasm.

    (Scientific evidence–II/III/IV; Grade of recommendation–B; Strength of panel opinion–Strong)

  5. Discuss the potential ability for men to achieve ejaculation and genitally induced orgasm following SCI.

    (Scientific evidence–I/II/IV; Grade of recommendation–A; Strength of panel opinion–Strong)

  6. Support individuals with SCI if they wish to experiment with giving and receiving erotic pleasure through touch.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  7. When appropriate, educate individuals with SCI that masturbation can be an enjoyable form of sexual expression.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Treatment of Dysfunction

  1. Provide resources for sex education, counseling, and sex therapy when indicated.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  2. Caution men and women with SCI about the potential risks related to services or products available without a prescription.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

  3. Treat erectile dysfunction (ED) in men with SCI with the least invasive methods before prescribing interventions that may produce an adverse reaction. Encourage men with SCI to enhance their existing sexual function before using medical interventions.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

  4. Consider testosterone replacement therapy for men with SCI if a testosterone deficiency is determined to be a contributing factor in the man's sexual dysfunction or lack of libido.

    (Scientific evidence–III/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  5. Inform men with SCI about the full range of options for treating erectile dysfunction and develop an individualized treatment plan as needed.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

  6. Educate men with SCI about oral medications to treat erectile dysfunction.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

  7. Educate men with SCI about intracavernosal injections for the treatment of erectile dysfunction.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  8. Educate men with SCI about vacuum devices for the treatment of erectile dysfunction.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

  9. Educate men with SCI about using intraurethral medications to treat erectile dysfunction.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  10. Provide information about penile implants for the treatment of erectile dysfunction (also known as implantable penile prostheses) when nonsurgical treatments are ineffective or unsatisfactory.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  11. Discuss the potential risk of penile trauma for men with SCI.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

  12. Inform women with SCI about external devices that are available to enhance genital arousal and orgasmic potential.

    (Scientific evidence–III; Grade of recommendation–C; Strength of panel opinion–Strong)

Effects on Fertility

Female Fertility

  1. Ensure that women with SCI have proper information regarding the effect of injury on menstruation.

    (Scientific evidence–IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  2. Ensure that women with SCI are informed about reproductive health, obstetric and gynecological services specific to their needs.

    (Scientific evidence–IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  3. Determine the safest birth control method for the woman with SCI. Risks associated with the various birth control methods should be assessed and discussed with the woman.

    (Scientific evidence–IV/V; Grade of recommendation–C; Strength of panel opinion–Strong)

  4. Provide women with SCI information about fertility and pregnancy.

    (Scientific evidence–II/IV; Grade of recommendation–B; Strength of panel opinion–Strong)

  5. Outline the steps that can be taken to ensure the best medical outcomes for the pregnant woman with SCI. Recommend that a medical provider with SCI expertise be involved throughout the pregnancy.

    (Scientific evidence–II/IV; Grade of recommendation–B; Strength of panel opinion–Strong)

  6. Ensure that wheelchair seating will allow for an upright seated posture with proper alignment throughout pregnancy; this will require repeated adjustments to the wheelchair.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  7. Ensure the implementation of safe transfer techniques during pregnancy.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  8. Regularly assess the status of activities of daily living to ensure that safe and efficient movements and positioning are being used during pregnancy. Determine if assistive devices need to be modified or changed.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  9. Plan for labor and delivery to accommodate the particular needs of the woman with SCI, and carefully monitor the potential onset of autonomic dysreflexia during labor and delivery.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  10. Educate women with SCI about the effects of perimenopause and menopause after SCI.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

Male Fertility

  1. Discuss the prognosis for biological fatherhood and options for assisted fertility.

    (Scientific evidence–I/II/III/IV; Grade of recommendation–A; Strength of panel opinion–Strong)

  2. Perform semen analysis for men interested in biological fatherhood in order to provide information and make recommendations for achieving pregnancy.

    (Scientific evidence–I/III/IV; Grade of recommendation–A; Strength of panel opinion–Strong)

For Men and Women

  1. Provide education about adoption as an option for some individuals with SCI.

    (Scientific evidence–II; Grade of recommendation–B; Strength of panel opinion–Strong)

Relationship Issues

  1. Encourage individuals with SCI to discuss any concerns that they may have regarding relationships post injury.

    (Scientific evidence–III/IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  2. Provide opportunities for people with SCI to include their partners in discussions regarding intimacy, sexuality, and fertility.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  3. Provide opportunities for partners to ask questions and get information about sexuality and fertility whenever possible. In so doing, providers must protect the confidentiality of both parties.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  4. Assist with education and problem solving for people with SCI who may be interested in a sexual relationship with another person who also has a disability.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  5. Discuss the maintenance of healthy interpersonal relationships that existed prior to injury. Assist individuals with developing social skills that will promote healthy interpersonal and sexual relationships.

    (Scientific evidence–IV; Grade of recommendation–C; Strength of panel opinion–Strong)

  6. Offer guidance on using the Internet to meet potential partners for intimate relationships and marriage.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

  7. Encourage individuals with SCI to develop and/or maintain positive relationships with their children.

    (Scientific evidence–II/III/V; Grade of recommendation–B; Strength of panel opinion–Strong)

  8. Support the individual with his or her reintegration into the family.

    (Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

  9. Ensure that individuals with SCI receive counseling that promotes a positive body image and encourages a respect for one's body after SCI.

    (Scientific evidence–V; Grade of recommendation–C; Strength of panel opinion–Strong)

  10. Discuss options for providing assistance for activities of daily living from someone other than the romantic partner.

    (Scientific evidence–N/A; Grade of recommendation–N/A; Strength of panel opinion–Strong)

Definitions:

Levels of Evidence

  1. Evidence based on randomized controlled clinical trials (or meta-analysis of such trials) of adequate size to ensure a low risk of incorporating false-positive or false-negative results.
  2. Evidence based on randomized controlled trials that were too small to provide level I evidence. These may have shown either positive trends that were not statistically significant or no trends and were associated with a high risk of false-negative results.
  3. Evidence based on nonrandomized, controlled or cohort studies, case series, case-controlled studies, or cross-sectional studies.
  4. Evidence based on the opinion of respected authorities or that of expert committees as indicated in published consensus conferences or guidelines.
  5. Evidence that expresses the opinion of those individuals who have written and reviewed this guideline, based on experience, knowledge of the relevant literature, and discussions with peers.

Categories of Strength of Evidence Associated with the Recommendations

  1. The guideline recommendation is supported by one or more level I studies.
  2. The guideline recommendation is supported by one or more level II studies.
  3. The guideline recommendation is supported only by one or more level III, IV, or V studies.

Levels of Panel Agreement with Recommendation

Low Mean agreement score 1.0 to less than 2.33
Moderate Mean agreement score 2.33 to less than 3.67
Strong Mean agreement score 3.67 to 5.0
Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of evidence supporting the recommendations is specifically stated for each recommendation (see the "Major Recommendations" field).

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate sexuality and reproductive health in adults with spinal cord injury

Potential Harms
  • Exacerbation of skin ulcers, friction, pressure or tears following sexual activity or the use of sexual assistive devices
  • Possible onset of autonomic dysreflexia (AD), with or without symptoms, especially in people with injuries at or above T6 following sexual activity or the use of sexual assistive devices
  • Some men with sensation in the penis may experience a short period of minor pain at the injection site following intracavernosal injections.
  • Priapism is another potential complication of intracavernosal injection therapy. Priapism is the potentially harmful medical condition in which the erect penis does not return to its flaccid state despite the absence of physical and psychological stimulation within 4 hours. Men with spinal cord injury (SCI) should be informed that priapism is considered a medical condition that should receive proper treatment by a qualified medical professional.
  • Persons with SCI using indwelling urethral catheters need to take precautions to prevent dislodging or contamination during sexual activity.
  • Due to diminished or absent sensation, men with SCI are at a higher risk for penile bending (Peyronie's disease) secondary to trauma of the tunica albuginea that surrounds the corpora cavernosa. During vigorous thrusting of the penis, unintentional blunt force on the erect penis, which would normally be very painful, may go unnoticed in men with diminished or no sensation. This force can tear or stretch the tunica, causing scarring and plaque formation (curvature), which is palpable by physician examination.
  • Trauma from injections into the cavernosal tissue through the tunica (for erection enhancement) may cause inflammation. This may result in tunica scarring, microhemorrhage along the needle track, and calcium deposits, which may lead to penile curvature.

Contraindications

Contraindications
  • Individuals should be advised to ensure that anything edible (e.g., strawberries, chocolate, certain alcoholic beverages) is not contraindicated by medications or health conditions.
  • Vacuum devices (VCDs) are contraindicated for men with SCI who are taking blood thinners or who have been diagnosed with sickle cell disease.
  • Absolute contraindications to the use of phosphodiesterase-5 inhibitors (PDE5is) include the concomitant use of nitrates, certain alpha blockers, or the presence of retinitis pigmentosa. Relative contraindications include symptomatic hypotension and use of other erection enhancement therapies.

Qualifying Statements

Qualifying Statements

This guideline has been prepared based on scientific and professional information available in 2007. Users of this guideline should periodically review this material to ensure that the advice herein is consistent with current reasonable clinical practice. The websites noted in this document were current at the time of publication; however, because web addresses and the information contained therein change frequently, the reader is encouraged to stay apprised of the most current information.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Patient Resources
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Living with Illness
IOM Domain
Effectiveness
Patient-centeredness
Safety

Identifying Information and Availability

Bibliographic Source(s)
Consortium for Spinal Cord Medicine. Sexuality and reproductive health in adults with spinal cord injury: a clinical practice guideline for health-care professionals. Washington (DC): Paralyzed Veterans of America; 2010 Jan. 47 p. [97 references]
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Jan
Guideline Developer(s)
Consortium for Spinal Cord Medicine - Nonprofit Organization
Paralyzed Veterans of America - Nonprofit Organization
Source(s) of Funding

Administrative and financial support provided by Paralyzed Veterans of America

Guideline Committee

Guideline Development Panel

Composition of Group That Authored the Guideline

Panel Members: Stanley H. Ducharme, PhD (Panel Chair), Boston Medical Center, Boston University School of Medicine, Boston, MA; Donald G. Kewman, PhD, ABPP, Topic Champion, Nevada City, CA; Theresa Chase, ND, RN, Craig Hospital, Englewood, CO; Graham Creasey, MD, FRCSEd, VA Palo Alto Health Care System, Palo Alto, CA; Stacy Lorraine Elliott, MD, Vancouver Hospital, Vancouver, BC, CANADA; Lance L. Goetz, MD, VA North Texas Health Care System, University of Texas–Southwestern, Dallas, TX; Jennifer D. Hastings, PT, PhD, NCS, University of Puget Sound, Tacoma, WA; Paula K. Martin, OTR/L, Woodrow Wilson Rehabilitation Center, Fishersville, VA; Romel W. Mackelprang, DSW, Eastern Washington University, Cheney, WA; Marcalee Sipski, MD, Renown Rehabilitation Hospital, Reno, NV; Mitchell Tepper, PhD, MPH, Morehouse School of Medicine, Atlanta, GA; Florian P. Thomas, MD, MA, PhD, St. Louis VA Medical Center Spinal Cord Injury/Dysfunction Service, St. Louis University, St. Louis, MO

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available in Portable Document Format (PDF) from the Paralyzed Veterans of America (PVA) Web site External Web Site Policy.

Print copies: Available from the Consortium for Spinal Cord Medicine, Clinical Practice Guidelines, 801 18th Street, NW, Washington, DC 20006.

Availability of Companion Documents

None available

Patient Resources

The following is available:

  • Sexuality and reproductive health for adults with spinal cord injury: what you should know. Consumer guide. Washington (DC): Paralyzed Veterans of America; 2010 Jan. Electronic copies: Available in Portable Document Format (PDF) from the Paralyzed Veterans of America (PVA) Web site External Web Site Policy.

Print copies: Available from the Consortium for Spinal Cord Medicine, Clinical Practice Guidelines, 801 18th Street, NW, Washington, DC 20006.

Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

NGC Status

This NGC summary was completed by ECRI Institute on November 29, 2012.

Copyright Statement

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions. This summary was copied and abstracted with permission from the Paralyzed Veterans of America (PVA).

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

Read full disclaimer...