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Research Article | Volume 5 Issue -2 (July - Dec, 2024) | Pages 1 - 4
Observation of erectile indicators in patients with Spinal Cord Injury
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1
Guangdong Work Injury Rehabilitation Hospital, 510440 Guangzhou, China
Under a Creative Commons license
Open Access
Received
July 7, 2024
Revised
July 27, 2024
Accepted
Aug. 8, 2024
Published
Oct. 2, 2024
Abstract

Background and objective:Spinal cord injury (SCI) is one of the high-risk patients in various countries around the world. Traumatic, iatrogenic, or vascular causes can all lead to spinal cord injury, presenting characteristics of high incidence, high disability rate, high cost, and a majority of young and middle-aged patients. The male to female ratio of SCI patients is 7.4/1, with an average age of (36.3±10.12) years[ ]. Patients who have been hospitalized for a long time without sexual activity, and sexual function recovery is relatively lagging, seriously affecting comprehensive recovery and quality of life. To investigate the differences of nocturnal penile erections between patients with complete and incomplete SCI.Methods:74 male patients with different degrees of SCI were enrolled from January 2019 to December 2023. According to The 2019 version of the International Standards for Neurological Classification of Spinal Cord Injury, these patients were divided into two groups: complete SCI (ASIA A) and incomplete SCI (including ASIA B, C, D, and conical cauda equina injuries). Rigiscan was used to monitor the nocturnal penile erections via measuring the penile tip average event rigdity%, base average event rigdity%, tip event tumescence% ,bsae event tumescence%,tip average event tumescence and baseaverage event tumescence.Results:Different plane SCI patients had neurogenic erectile dysfunction, and there was no significant difference between the peniletip average event rigdity%, base average event rigdity%, tipevent tumescence% ,bsae event tumescence%,tip average event tumescence and baseaverage event tumescenceof complete and incomplete SCI.Conclusion:Patients with spinal cord injuries at different levels all have neurogenic erectile dysfunction, and the severity of erectile dysfunction is not significantly correlated with complete SCI.

Keywords
INTRODUCTION

Primer erectile dysfunction (erectile dysfunction, ED) is the most common clinical male sexual dysfunction.Usually refers to the adult man in sexual stimulation and sexual desire, (for at least 6 months) the penis can not erection or erection weakness, erection time is short, so that can not be inserted into the vagina to complete the process of intercourse[1].According to the etiology, ED can be divided into psychogenic ED and organic ED, and organic ED can be divided into neurologic, vascular and endocrine, while spinal cord injury is one of the causes of neuroerectile dysfunction.ED is one of the most common complications in male SCI patients, seriously compromising the quality of life and mental health[2,3] More than 98% of men with SCI have varying degrees of sexual dysfunction [4].About 60% to 80% of men with thoracolumbar spinal cord injury cannot have an erection [5],and nearly 10% of patients have psychogenic priapile dysfunction [6].Rampin et al suggested that penile erection is the result of parasympathetic pathway activation and sympathetic pathway inhibition [7].

METHODS

Study subject

From January 2019 to December 2023,74 male spinal cord injury patients admitted in Guangdong Injury Rehabilitation Hospital were selected, and RigiScan was used to monitor the hardness, swelling proportion, base circumference and swelling circumference of night sleep primer erection; all patients had sexual needs, normal erection before injury, consciousness, no cognitive impairment, no organic disease.

The mean age was 40.80 ± 11.40years, and the disease duration was 12.24 ±10.75 months. There were 11 cases of cervical segment(1 ASIA A, 2 ASIA C, 8ASIA D), 24 cases of thoracic segment(12 ASIA A, 7 ASIA C, 5 ASIA D), 6 cases of lumbar segment (1 ASIA A, 1 ASIA C, 4 ASIA D) and 33 cauda equina injuries.

This study was approved by the ethical review of Guangdong Industrial Injury Rehabilitation Hospital (AF / FC-07 / 2020.35)

 

Spinal cord injury level and rating [8]

The 2019 version of the International Standards for Neurological Classification of Spinal Cord Injury were used to evaluate the spinal cord injury plane. In this study, the enrolled patients were divided into two groups: complete SCI ( AIS A) and incomplete SCI (AIS B, C, D, and conical cauda equina injuries).

 

Erectile function detection

NPT examination, which is often the preferred method for ED diagnosis and screening in healthy people at home and abroad, is recognized as the most reliable method to distinguish psychological ED and organic ED in the medical community [9]Using RigiScan monitor, guided by the doctor patients and escort families choose quiet residence without interference, before bed will be the monitor fixed in the thigh root, sensor cuff around the penis and penis coronal groove, turn on the power, the monitoring state, after the power, take off the detector, input computer printing, continuous monitoring for three nights. The equipment automatically records the penile tip average event rigdity%, base average event rigdity%, tipevent tumescence% ,bsae event tumescence%,tip average event tumescence and baseaverage event tumescence.The higher the value is, the better the erection function is.

 

Assessment of pelvic floor function

When the examiner pinched the penis head with a little pressure (the catheter), the sponge muscle and external anal sphincter contraction-spavernosal reflex; the anal finger examination determines whether the patient has anal voluntary contraction, and the rectum pressure determines whether the patient has deep rectal pressure sensation. The patient was asked for autonomic disturbances like headache, palpitations, and sweating during bladder filling.

 

Statistical analysis

Data were T-tested for independent samples using SPSS27 version statistical software with a significance level of P=0.05. The test variables were: tip average event rigdity%, base average event rigdity%, tipevent tumescence% ,bsae event tumescence%,tip average event tumescence and baseaverage event tumescence, expressed as (x-±s); the grouping variables were complete spinal cord injury grade A and incomplete spinal cord injury (B, C, D, conical cauda equina injuries).

RESULTS

Cervical segmentspinal cord injuries, 4 patients showed erections lasting more than 10 minutes (1 ASIA Cand 3 ASIA D); Two patients underwent AVSS measurement, but no erection lasting more than 10 minutes was observed.

Thoracic segmentspinal cord injuries,5 patients showed erections lasting more than 10 minutes (2 ASIA A, 1 ASIA C, and 2 ASIA D). 10 patients underwent AVSS testing, and it was observed that 1 patient had an erection lasting more than 10 minutes, and 1 patient experienced ejaculation.

Lumbar segmentspinal cord injury, no erection lasting more than 10 minutes was observed in all,three patients who underwent AVSS measurement, and no erection lasting more than 10 minutes was observed in any of them.

Conical cauda equina injury ,there are 12 cases of erections with a visible duration greater than 10 minutes. Nine patients underwent AVSS measurement, and one patient with an erection time greater than 10 minutes was observed.

There was no significant difference between thetip average event rigdity%, base average event rigdity%, tipevent tumescence% ,bsae event tumescence%,tip average event tumescence and baseaverage event tumescence in patients with complete and incomplete SCI. See Table 1

Table 1. Penile erection data of complete and incomplete SCI.


 

 Complete SCI Incomplete SCIvaluevalue
No. of patients1460  
Tip Data    
Avgevent rigdity%29.21±22.7230.38±22.86-0.1720.460
Event Tum%16.42±11.2717.75±13.35-0.3420.722
Avg event Tum7.0±1.06.57±1.70.9050.606
Base Date    
Avgevent rigdity%39.64±26.4741.36±23.49-0.2410.852
Event Tum%22.50±11.7524.00±14.13-0.3680.563
Avg event Tum7.9±1.47.0±2.31.3580.698
     
DISCUSSION

The erection of the penis depends on the dual innervation of autonomic (sympathetic and parasympathetic) and somatic (motor and sensory), and may also be affected by the cerebral cortex and thalamus [10].The sympathetic nerve starts from the T11 to L2 level of the thoracolumbar pulp, the parasympathetic nerve starts from the S 2 to S 4 level of the sacral pulp, the pudendal nerve starts from the S2 to S4 level of the sacral pulp, and is divided into penile dorsal nerve and perineal nerve at the posterior edge of the genital diaphragm.The sympathetic nerve starts from the T 11 to L2 level of the thoracolumbar pulp, the parasympathetic nerve starts from the S2 to S4 level of the sacral pulp, the pudendal nerve starts from the S2 to S4 level of the sacral pulp, and is divided into penile dorsal nerve and perineal nerve at the posterior edge of the genital diaphragm.The penile dorsal nerve transmits the sensation of the penile skin, urethra and corpus cavernosum through the S2 to S4 nerve roots into the spinal cord-thalamus-brain center; and the perineal nerve innervates the somatic movements of the penis.The higher CNS for regulates sexual function is located in the cerebral cortical and subcortical centers. The cerebral cortex center is mainly located in the brain limbic system, feeling vision, hearing, touch, smell and hallucinations and induce sexual impulse. The medial region of the anterior optic lobe is an important integrated center for sexual impulse and erection. The paraventricular nucleus of the hypothalamus is an important subcortical center for regulating penile erection, which can release a variety of central neurotransmitters, such as NO and dopamine, and induce cardiogenic erection [11].

The residual erection in patients after spinal cord injury has reflex erection, cardiogenic erection and mixed erection [12].Cardiogenic erection: when stimulated by vision, touch, hearing, smell and sexual fantasy, the brain emits an impulse, which can release nitric oxide, dopamine and other central neurotransmitters to induce penile erection.Cardiogenic erection remains intact in the T 11 to L2 segments and the damage plane is below the L 2 level. Reflective erection, more common in patients with T11 or above, can be induced when the penis and scrotum are sexually stimulated; it can be inserted into the vagina after the penis erection, but the maintenance time is short. Mixed erection, namely both psychogenic erection and reflex erection, the time and quality of penapism varies, more common in patients with SCI between the L 2 and S 2 plane [13]In patients with T 10 and above plane spinal cord injury, there were reflex erection and unintentional erection, but among patients receiving AVSS in this study, 2 cervical spinal cord injury and 7 T10 and above patients, the sacral cord was intact,and all patients should have reflex and / or psychogenic erection after sensory stimulation. However, only 1 patient with T10 spinal cord injury grade D had an erection of greater than 10 minutes.Patients with T11 to L2 plane spinal cord injury have reflexive erections and no cardiogenic erections; Patients with L2 to S2 level spinal cord injury had mixed erections, but no erections lasting more than 10 minutes were detected in the two patients monitored by AVSS.These patients may have an erection outside the monitoring time, or may have false negative results during AVSS monitoring. Nine patients with conical cauda equina injury underwent AVSS testing,and 1 patient with visible erection time longer than 10 minutes,that is, patients with S 2 to S 4 sacral pulp or cauda equina damage, had preserved psychogenic erection and no reflex erection[14,15]We believe that the impact on erectile function depends on the degree and severity of the injury, as well as personal factors such as partner relationship status, pre onset sexual experiences and attitudes, and the level of openness towards sex[14].

 

In our study, a total of 19 patients had erections lasting more than 10 minutes in overnight erectile monitoring, including 1 case of C3 ASIA D, 1 case of C4 ASIA D, 2 cases of C5 ASIA D, 1 case of T10 ASIA C, 2 cases of T11 ASIA D, 12 conical cauda equina injuries,however, these patients with self-evaluation of erectile dysfunction but normal NPT monitoring were considered to have cardiogenic erectile dysfunction [16]

Studies have shown that patients with incomplete spinal cord injury have higher erection rigdity and perirange activity index than those with complete spinal cord injury [17].However, in this study, there was no significant difference in penile tip average event rigdity%, base average event rigdity%, tipevent tumescence% ,bsae event tumescence%,tip average event tumescence and baseaverage event tumescence among patients with Complete and incomplete SCI.Considering various factors that affect nighttime sleep quality, such as neuropathic pain, according to research, about 53% of patients will experience neuropathic pain after SCI [18].The quality of nighttime sleep has a significant impact on the monitoring results of nighttime erectile function [19]But this may also be due to the small number of patients in this group, and further research is needed to verify these results.

Conflict of Interest:

The authors declare that they have no conflict of interest

Funding:

Medical Scientific Research Foundation of Guangdong Province of China (B2021459)

Ethical approval:

The study was approved by the Injury Rehabilitation Hospital.

REFERENCE
  1. Chen Yinhai, Liu Min, He Jinghua. Epidemiological survey of spinal cord injury patients [J]. Journal of Practical Medicine, 2011, 27 (6): 1032-1034.).

  2. Deng Mingyu. Utility in medicine [M]. (USA) New York: International Federation of Chinese Medical Psychologists, 1998:304-306

  3. LEE B S, KIM O.Sexual dysfunction and rehabilitation of pa‐tients with spinal cord injury [J].J Korean Med Assoc, 2020, 63 (10): 612-622.

  4. FENSTERMAKER M, DUPREE J M, HADJ-MOUSSA M, et al.Management of erectile dysfunction and infertility in the male spinal cord injury patient [J].Curr Urol Rep, 2018, 19 (7): 47.

  5. Ouyang Yaao, Liao Zhe'an, sexual dysfunction and quality of life of 62 male patients with spinal cord injury, Chinese Journal of Physical Medicine and Rehabilitation, 2008,30 (8): 534-536

  6. Li Jianjun, Zhou Tianjian. Prevention and prognosis of spinal cord injury and its induced disability [M]. Modern rehabilitation and treatment of spinal cord injury. Beijing: People's Health Publishing House, 2006:868.

  7. Liu Gang. Progress in clinical research on erectile dysfunction in spinal cord injury patients [J]. Rehabilitation Theory and Practice in China, 2004.10(5):283—284.

  8. RampinO,GiulianoF,BenoitG,et al.Central nervous system control of Erection[J].Prog Urol,1997,7(1):17-23

  9. Kirshblum, S, Schmidt Read, M, Rupp, R.Classification challenges of the 2019 revised International Standards for Neurological Classification of Spinal Cord Injury (ISNCSCI).SPINAL CORD.2021; 60 (1): 11-17. doi: 10.1038/s41393-021-00648-y

  10. Zhang Yan, Zhang Haitao, Wang Zhong, et al. RigiScan The Chinese expert consensus on the clinical application of the diagnosis and treatment of erectile dysfunction [J]. Sex Science in China, 2019,28 (12): 5-10.

  11. LUE T F.Neurogenic erectile dysfunction [J].Clin Auton Res, 2001, 11(5): 285-294.

  12. Zhou Huiliang. Treatment of erectile dysfunction in SCI patients [J]. Chinese Journal of Male Science, 2017,23(02):99-102.DOI:10.13263/j.cnki.nja.2017.02.001.

  13. Wyndaele, JJ.Treatments for erectile dysfunction in spinal cord lesioned patients.Are there alternatives to phosphodiesterase type 5 inhibitors?SPINAL CORD.2015; 53 (12): 841. doi: 10.1038/sc.2015.209

  14. Hess, MJ, Hough, S.Impact of spinal cord injury on sexuality: broad-based clinical practice intervention and practical application.J SPINAL CORD MED.2012; 35 (4): 211-8. doi: 10.1179/2045772312Y.0000000025

  15. Courtois, F, Charvier, K. Sexual dysfunction in patients with spinal cord lesions. Handb Clin Neurol. 2015; 130 225-45. doi: 10.1016/B978-0-444-63247-0.00013-4

  16. Tubaro, A. Sildenafil in the treatment of sexual dysfunction in spinal cord-injured male patients CURR OPIN UROL. 2001; 11 (2): 221. doi: 10.1097/00042307-200103000-00035

  17. Tay, HP, Juma, S, Joseph, AC. Psychogenic impotence in spinal cord injury patients. ARCH PHYS MED REHAB. 1996; 77 (4): 391-3. doi: 10.1016/s0003-9993(96)90090-8

  18. Liu Gang, et al. Analysis of influencing factors on penile erection function after spinal cord injury. Chinese Rehabilitation Theory and Practice 27.07 (2021): 840-843

  19. Wu Jingyi, Chen Fugang, Wang Litong. Research progress on repetitive transcranial magnetic stimulation for the treatment of neuropathic pain after spinal cord injury [J]. China Rehabilitation, 2024,39 (04): 241-245

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