What is Sexual Health?
Sexual health is an important part of your overall health and quality of life. After a spinal cord injury (SCI), changes in sensation, movement, sexual function, body image, fertility, or confidence may affect how you experience sexuality and intimacy.
Sexuality and intimacy look different for everyone. Many couples find new ways to connect and enjoy intimacy after SCI including emotional and physical closeness, touching, hugging, kissing, holding hands, and romance. Talk openly with your partner about comfort, pleasure, concerns, goals, and trying new ways to be intimate. Adaptations can often be made to support sexual health and intimacy, and your rehabilitation or healthcare team can help you explore options that are safe and appropriate for you.
How Can SCI Affect Sexual Health?
You may notice changes in sensation, strength, movement, erections, vaginal lubrication, orgasm, energy, pain, muscle spasms, bladder or bowel control. Many treatments and strategies can help. Some frequently asked questions to discuss with your healthcare provider include:
- Can I still be sexually active after SCI?
- How will sexual activity change?
- Will I have orgasms?
- Can I achieve erection?
- Will I be able to satisfy my partner?
- Are there any risks with intercourse?
- Can I have children?
Safety Tips for Sexual Activity
- Before: empty your bladder if recommended, complete your bowel program, check your skin, and choose a time when you are more energetic.
- During: move slowly, use pillows, protect areas with less feeling, and stop if you have pain or feel sick.
- After: check your skin, watch for pressure injuries, stay hydrated, and tell your provider about concerns.
Achieving Erection
An erection occurs when there is an increase in blood flow to the penis in response to multiple forms of sensory input. After SCI, feeling, movement, and our body’s natural reflex patterns may change, especially at or below the level of injury. Nerve supply to reproductive organs reside in the pelvis; therefore, if you experience any changes in bladder/bowel function, you are likely experiencing changes in sexual function.
Types of Erection
Psychogenic
After a spinal cord injury (SCI), it may be harder or impossible to get an erection from sexual thoughts alone. This is because the nerves that carry signals from the brain for this type of erection travel through the spinal cord between levels T11 and L2. If the spinal cord is injured above this area, the signal from the brain may not be able to reach the penis.
Some erections happen because of sexual thoughts, feelings, sights, sounds, or touch that a person finds sexually exciting. These are called psychogenic erections. For people with an injury at T10 or lower, psychogenic erections may still be possible. However, the penis may become longer and fuller without becoming firm enough for sexual intercourse.
Reflexogenic
The nerves that control reflex erections are located in the lowest part of the spinal cord (S2–S4). After a spinal cord injury (SCI), many people with an injury at T10 or above (an upper motor neuron injury) can still have reflex erections when the penis or genital area is touched. A reflex erection happens when the penis or genital area is touched or stimulated. This may occur during sexual activity, such as touching, caressing, or oral sex. It can also happen from nonsexual touch such as washing the genital area, transferring, repositioning in bed, friction from clothing/bed linens, or other nonsexual daily activities.
Nocturnal/spontaneous
A spontaneous erection is an erection that happens during sleep or when waking up, without sexual thoughts or physical stimulation. These erections are a normal part of sleep and help keep the tissues of the penis healthy. Some people with a spinal cord injury (SCI) may continue to have nighttime or morning erections. The length and firmness of these erections vary from person to person and may affect whether they are useful for sexual activity.
Ways to Get and Keep an Erection
Several treatment options may help improve erections after a spinal cord injury (SCI). Talk with your healthcare provider about which option is best for you.
Constriction Bands
A constriction band is placed around the base of the penis after an erection develops. It helps keep blood in the penis, allowing the erection to last longer. These bands are usually low cost and reusable and may work well for people who can get a firm erection with stimulation. For safe use:
- Choose a band designed specifically for sexual use. Do not use metal rings.
- Remove the band after 20–30 minutes to reduce the risk of injury.
- Check the skin after removing the band.
- Mild bruising may occur. Use extra caution if you take blood-thinning medications and discuss concerns with your healthcare provider.
Vacuum Erection Device (Penis Pump)
A vacuum erection device uses gentle suction to pull blood into the penis. A constriction band is then placed at the base of the penis to help maintain the erection.
Key points:
- Available as hand-operated or battery-powered devices.
- Does not require medication, making it a potential option for people who cannot or do not want to use oral medications.
- May be effective for many people with SCI, including those who have difficulty achieving or maintaining an erection.
- Follow the device instructions and remove the constriction band within the recommended time to prevent injury.
Oral Medications for Erections (PDE5 Inhibitors)
PDE5 inhibitors increase blood flow to the penis, making it easier to achieve and maintain an erection during sexual activity. Common medications include sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®), and avanafil (Stendra®). These medications may be an effective option for many people after SCI, but there are several important things to know:
- Most medications begin working within 30–60 minutes and work best with sexual stimulation.
- Tadalafil (Cialis®) may remain effective for up to 36 hours, allowing more flexibility with timing.
- A high-fat meal may delay how quickly some medications begin working.
- Generic sildenafil is often less expensive than other PDE5 inhibitors.
- Do not take PDE5 inhibitors with nitroglycerin or other nitrate medications, including nitroglycerin used to treat autonomic dysreflexia. Taking these medications together can cause a dangerous drop in blood pressure.
- Possible side effects include headache, facial flushing, stuffy nose, dizziness, and low blood pressure.
- An erection lasting more than 4 hours (priapism) is a medical emergency and requires immediate medical attention.
- Talk with your physician before starting or taking these medications to make sure they are safe and appropriate for you.
Other Interventions to Discuss with your Healthcare Provider:
- Penile Injections
- Urethral Suppositories
- Surgically Implanted Prothesis
Autonomic Dysreflexia (AD) and Sexual Activity
Autonomic dysreflexia (AD) is a sudden, dangerous rise in blood pressure. People with a spinal cord injury at T6 or above are at risk.
Sexual activity can sometimes trigger AD. Possible triggers include:
- Sexual stimulation or orgasm
- Vigorous stimulation of the genital area
- Use of vibrators or other sexual devices
- Infections involving the bladder or reproductive organs
If you develop symptoms of AD during sexual activity:
- Stop sexual activity immediately.
- Sit upright if possible.
- Loosen or remove tight clothing, such as abdominal binders or compression stockings.
- Check for and remove the cause of the AD, if it can be done safely.
- If your symptoms do not improve quickly or your blood pressure remains high, call 911 or seek emergency medical care.
If you have a history of AD, talk with your healthcare provider before becoming sexually active. They may recommend keeping emergency medication, such as nitroglycerin ointment, available and will teach you when and how to use it safely.
If you are planning a pregnancy, work with an obstetrician (OB/GYN) who is familiar with spinal cord injury and autonomic dysreflexia.
Fertility After Spinal Cord Injury
SCI can affect male fertility by changing ejaculation, sperm movement, and sperm quality. Although some men may have difficulty ejaculating during sexual activity, SCI does not necessarily mean you cannot have biological children.
If you are interested in having children, talk with your healthcare provider or a fertility specialist. They can evaluate your fertility and discuss options to help with sperm collection and pregnancy, including medications, ejaculation assistance, or other fertility treatments.
When to Contact Your Healthcare Provider
Sexual health and intimacy are important parts of your overall well-being. Talk with your healthcare team if you have concerns about sexual function, pain, skin changes, bladder or bowel function, autonomic dysreflexia, fertility, or treatment options.
Your healthcare team can help you find safe and effective ways to support sexual function, intimacy, fertility, and quality of life after SCI. You do not have to manage these changes alone. Sexual health is a normal and important part of rehabilitation.