A spinal cord injury (SCI) is a life-altering event that impacts numerous bodily functions, including sexual health. For many with an SCI, the ability to achieve an erection is affected, a condition known as erectile dysfunction (ED), which arises from damage to nerve pathways. While this presents a challenge, a range of effective treatments is available, offering pathways to restoring sexual function.
Understanding Erections After a Spinal Cord Injury
An erection is a complex process involving the brain, nerves, and blood vessels, and an SCI can disrupt this communication. The ability to have an erection after an injury depends heavily on the location and severity of the damage to the spinal cord. Two primary types of erections are relevant in this context: psychogenic and reflexogenic.
Psychogenic erections originate from mental stimuli, such as erotic thoughts or visual cues. Nerve signals travel from the brain down the spinal cord to the thoracolumbar region (T11-L2) to initiate the erection. If an injury occurs above this level, it can block these brain-driven signals, making psychogenic erections difficult or impossible to achieve.
Reflexogenic erections are triggered by direct physical touch to the penis or other genital areas. These erections are controlled by a reflex arc in the lower part of the spinal cord, specifically the sacral region (S2-S4). As long as this area of the spinal cord is undamaged, men with injuries above the sacral region can often still have reflex erections. For instance, more than 90% of men with complete upper motor neuron injuries retain the ability to have reflexogenic erections.
First-Line Pharmacological Treatments
For many men with SCI, oral medications are the most common starting point for managing ED. These drugs, known as phosphodiesterase type 5 (PDE5) inhibitors, include well-known options such as sildenafil and tadalafil. They work by enhancing the effects of nitric oxide, a chemical the body releases to relax muscles in the penis, allowing for increased blood flow.
The effectiveness of PDE5 inhibitors in men with SCI is closely linked to the type of erection they can achieve. These medications do not automatically cause an erection; they require sexual stimulation to work. For individuals with intact reflex pathways, physical stimulation can trigger the local nerve response needed for the medication to be effective. Success rates for these oral medications are reported to be between 70-80% in the SCI population.
Another pharmacological option is a medicated urethral suppository, which involves inserting a small pellet containing the drug alprostadil into the urethra. The medication is absorbed through the urethral walls directly into the erectile tissues of the penis. This method bypasses the need for nerve signals from the spinal cord. While it is an alternative for those who cannot take or do not respond to oral medications, its use is sometimes limited in men with complete injuries.
Device-Assisted and Injection Therapies
When oral medications are not suitable or effective, other non-surgical treatments can provide reliable alternatives. One widely used option is the vacuum erection device (VED). A VED consists of a plastic cylinder placed over the penis, a pump that creates a vacuum inside the cylinder, and a constriction ring. The vacuum draws blood into the penis, and the constriction ring is slipped onto the base to trap the blood and maintain rigidity.
This mechanical approach is effective because it does not depend on nerve signals, making it a viable solution regardless of the injury’s level or completeness. Another effective method is intracavernosal injection (ICI) therapy. This involves using a very fine needle to inject medication, most commonly alprostadil, directly into the corpus cavernosum—the spongy tissue along the sides of the penis.
The injected medication works by relaxing the smooth muscles and widening the blood vessels, causing a firm and predictable erection, often within minutes. Like vacuum devices, injections bypass the damaged nerve pathways and are successful for many individuals with SCI. Patients receive training from a healthcare provider to learn the proper injection technique to ensure safety and effectiveness.
Penile Implant Surgery
When other treatments have been explored without success or are not preferred, penile implant surgery offers a permanent solution for ED. A penile prosthesis is a medical device surgically placed entirely inside the body to provide a reliable erection. This option is considered a final step because the procedure is irreversible and involves replacing the natural erectile tissue.
There are two main types of penile implants. The first is the semi-rigid or malleable implant, which consists of a pair of bendable rods placed inside the erection chambers of the penis. This implant provides a penis that is always firm but can be positioned for sexual activity or concealment. The second, more common type is the inflatable implant, which includes fluid-filled cylinders in the penis, a pump in the scrotum, and a reservoir in the abdomen. Squeezing the pump moves fluid into the cylinders, creating a controlled erection.
The surgery is a decision that yields high satisfaction rates among patients and their partners. It provides a discreet and long-term resolution to ED, allowing for spontaneity without needing medications or external devices. The mechanical nature of the implant ensures that an erection can be achieved regardless of the nerve pathways affected by the spinal cord injury.
The Role of Counseling and Communication
A spinal cord injury and its effect on sexual function can have a psychological impact, affecting self-esteem, masculinity, and relationship dynamics. Addressing these emotional and interpersonal aspects is a part of adapting to life after injury. Professional counseling, particularly with a therapist specializing in sexual health and disability, can provide a safe space to navigate these complex feelings.
Therapy can help individuals process grief over lost function and build a new sense of sexual identity. It can also equip them with strategies to manage performance anxiety and rebuild confidence. For those with partners, couples counseling can be helpful. It facilitates open communication about fears, desires, and expectations, helping both partners adjust to new realities and explore different forms of intimacy.
Open dialogue with a partner is important for navigating the changes in sexual function together. Discussing which treatments to try, how to incorporate them into sexual activity, and discovering new sources of pleasure can strengthen a relationship. This collaborative approach helps demystify the challenges of ED and reframes sexuality as an adaptive and shared experience.