How does multiple trauma, traumatic brain injury (TBI) or spinal cord injury (SCI) affect male sexual functioning?

Sex is an important part of life for many people, therefore dealing with erectile problems, living with the effects of physical injury, changes in your appearance or side-effects of treatment can have an enormous impact on your sex life and relationships.

Normal sexual behaviour and erectile function depends on a complex interaction between various body-systems, including the brain, nerves, blood-supply and hormones. All of these systems (alone or in combination) may be affected following multiple trauma, traumatic brain injury (TBI) or spinal cord injury (SCI). For men, trauma may result in problems with achieving or maintaining erections (commonly referred to as erectile dysfunction; ED), problems with ejaculation, or how they think/feel about sex - all of these problems may have an indirect, if not profound impact on long-term functional recovery and overall quality of life.

Following multiple trauma, spinal injury, or TBI, it is not unusual for some men to go through a period of reduced sexual drive (reduced libido). Apart from physical effects of injury, the way the body responds sexually also depends on thoughts and feelings – thoughts and feelings about yourself and others may be influenced by changes in mood, motivation, personality and thought-processes. This may be complicated by depression, emotional trauma following the injury, medication, or changes in hormone levels.

As some men grapple with the changes and implications associated with their injury, many may initially ignore the importance of sexual difficulties, as they remain focused on physical rehabilitation and recovery of mobility. Other men may be reluctant to acknowledge sexual difficulties, due to cultural or personal reasons.

There are a wide range of treatments and interventions that may be helpful for the man and his partner, which is why assessment of sexual function should be routinely incorporated into rehabilitation and follow-up services for trauma-survivors.  The information below describes common sexual problems after TBI, SCI or multiple trauma and ways to improve sexual functioning.

Normal erection physiology

Erectile dysfunction (ED) is the inability to achieve or maintain an erection that is sufficiently rigid for achieving satisfying sexual intercourse - it is either partial or complete, depending on the extent of damage to the brain, spine or peripheral nerves and blood vessels - all of which may be affected following multiple trauma, SCI or TBI.

The physiological mechanism of achieving and maintaining an erection is complex, but on a basic level, it essentially involves two different types of erections (reflex and psychogenic) functioning co-operatively. Both mechanisms augment each other during sex. An intact nervous system is required for a successful and complete erection, but even after injury, some men may be able to achieve either reflex or psychogenic erections.

Reflex erections occur with direct manual (tactile) stimulation of the penis. The ability to generate reflex erections relies on the preservation of nerve circuits in the lower, sacral segments (S2, S3 and S4) of the spinal-cord, without involvement of the brain.

The other types of erections, psychogenic erections, originate in the brain – these are the result of imaginary/erotic stimuli that exert their effect by chemical messages travelling down the spinal cord (through the thoracic T-10 to lumbar L-2 spinal regions), which trigger dilation of blood vessels that occurs during erection. In general, complete injuries to the spinal cord (above the sacral segments: thoracic T-10 to lumbar L-2) are more likely to result in difficulty in obtaining erections in response to imaginary stimuli, but reflex erections tend to remain intact. Men with SCIs between S2-4 and T10-L2 levels may retain both reflex and psychogenic erections.

Although the nerve signals are crucial, the strength or quality of a man’s erection is ultimately determined by the state of the blood vessels governing the flow of blood into sponge-like tissue of the penis (the corpora cavernosa). A chemical called nitric oxide (NO), secreted by the peripheral nerves causes the relaxation of smooth muscles responsible for regulating the diameter of blood vessels supplying the penis - this leads to increased blood-flow, which subsequently leads to penile erection.

What causes changes in sexual functioning after Multiple Trauma?

Apart from trauma to the head or the spine, problems may also occur as a result of incidental trauma and musculoskeletal injury to other parts of the body (especially in the case of multiple trauma, involving the abdomen or pelvic region). Similarly, trauma to the limbs, which may result in temporary immobilization, or painful movement, can also indirectly affect the ability to engage in sexual activity. Multiple trauma may also affect the nerves and blood vessels supplying the abdomen and pelvic region, which may directly affect the ability to achieve/maintain erections – the ability to experience normal sensation (sense of touch) may also be affected.


What can be done to improve sexual functioning after Multiple Trauma, SCI or TBI?

Understandably, some men feel embarrassed talking openly about sexual problems, but talking to your GP, hospital doctor or nurse means that you may be able to get appropriate support and treatment. It can also help to make you feel better and more in control - remember that sexuality is a normal part of human functioning, and problems with sexuality can be addressed, just like any other medical problem. If you are not comfortable discussing sexual problems with your doctor, it is important to identify an alternative health professional who you feel comfortable you can talk to.

Erectile dysfunction in men with TBI, SCI and multiple trauma is amenable to various treatments (available as either single or combination therapy), including oral treatment with phosphodiesterase-5 inhibitors (PDE5-Is), intracavernosal injections (ICI), intraurethral alprostadil, vacuum devices, and penile implants. Your GP, hospital doctor, nurse practitioner or Clinical Nurse Specialist (CNS) may be able to recommend some of these treatments to help getting erections for masturbation or sex. Under Department of Health guidelines, men with multiple trauma, SCI or TBI may be entitled to prescription of treatments for problems with erections (or other sexual problems) on the NHS. There is no age limit for receiving treatment, however there may be conditions around how much medication can be prescribed. Follow your doctor’s advice about how to take your treatment, and for how long. Treatments may not initially work and it may take some time and commitment, before you notice any benefits. If you have tried your treatment several times and it doesn’t seem to be working, go back and let your doctor or nurse know. It may be possible to review your treatment, offer alternatives, try a combination of treatments, or refer you to a specialist service such as an erectile dysfunction (ED) clinic.

Adjusting to life after a TBI, SCI or multiple trauma can often put additional stress on your intimate relationship. If you or your partner are experiencing difficulties with your relationship, consider talking to your partner about how you feel. Individual counselling or psychotherapy may help with any emotional issues that can affect sexual functioning, as can marital or couples therapy. Some men and their partners also find it useful to see a sex therapist, to overcome sexual problems and improve sexual functioning.

When engaging in sexual activity, adopt a position that you find most comfortable, so that you can move without experiencing pain, or losing balance. This may involve discussion with your partner and adopting a position that may be different to the one you have been used to, or attempting sex at a time of day when you are less likely to be tired/fatigued.

This content was kindly provided by Colm Treacy  MSc PGCE RMN RGN RNT FHEA, Senior Lecturer Kingston and St George’s, Joint Faculty Health, Social Care and Education.  Colm is clinical nurse specialist with expertise on male sexual problems after trauma.