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8.3. Medical Considerations

Disclaimer:

Content in this section is intended for adult (age 18+) educational purposes. United Spinal Association bears no responsibility for the accuracy, legality, or content of the external site or for that of subsequent links. Contact the external site for answers to questions regarding its content. Information about a therapy, service, product, or treatment does not imply endorsement and is not intended to replace advice or directives from your healthcare provider. The information is provided for your general information and is not intended as medical advice. There is always a risk with any type of sexual activity, speak with your healthcare provider about options that are best for you, taking your individual circumstances into account.

Medical Considerations and Related Resources

Intimacy and sexual expression are fundamental aspects of life for people and are associated with improved quality of life for both men and women with spinal cord injury. Some considerations for your health are discussed below.  

Sexually Transmitted Infections and Safe Sex

When participating in sexual activity with a partner, an important thing to keep in mind is the factor of sexually transmitted infections (STIs - also known as Sexually Transmitted Diseases). After an injury, the ability to contract STIs does not change, and protection is needed when engaging in sexual activity. Using condoms can reduce the risk of contracting or transmitting STIs.

Additionally, it’s important for women with SCI/D to discuss contraception options with their physician.  Each method has its own specific risks, and your physician can help you choose the option that is most appropriate for you, taking your individual health circumstances into account.

SciSexualHealth.ca: Contraception

• Developed by Spinal Cord Injury BC (SCI BC), a non-profit organization dedicated to helping people with spinal cord injuries and related disabilities, adjust, adapt, and thrive. Content on how you can practice safe sex, protect against sexually transmitted infection/diseases, and avoid unplanned pregnancy. (2019)

Mental Health and Sexuality

After an SCI, taking care of your mental health is part of the recovery process. Learning to adjust to your “new normal” comes with emotional ups and downs. There may be symptoms of depression and anxiety that impact your relationships and your ability to be intimate and many people find that when they become less depressed, interest in sexual activity increases. Consult your health care provider for treatment and resources to improve your mental health. 

Model Systems Knowledge Translation Center: Factsheet: Depression

The MSKTC provides health information based on research evidence and/or professional consensus and has been reviewed and approved by an editorial team of experts from the different Model Systems. This factsheet covers information regarding the mental health of individuals impacted by SCI/D including causes, symptoms, and treatment of depression. (2010)

Autonomic Dysreflexia (AD)

Autonomic Dysreflexia (AD) is characterized by the sudden onset of elevated blood pressure (BP) with systolic blood pressure increasing >20 mmHg above your normal baseline measurement. AD may occur in individuals with a spinal cord injury/disorder at spinal cord neurological level T6 and higher. AD can result in dangerously high blood pressure so it’s important to understand the causes, signs, and symptoms to be able to recognize and treat it.  AD may be caused by any stimulation below the level of the injury, including sexual activity. The risk of AD increases for susceptible people with SCI who engage in more intense sexual stimulation, including the use of vibrators. Susceptible individuals may be encouraged to periodically monitor their BP during sexual activities. Taking your blood pressure before and during sexual activity can improve awareness of your overall health and well-being. Some individuals experience silent AD, meaning their blood pressure is elevated but they do not experience other obvious symptoms that alert them to the condition.  

Signs and symptoms include:

• Elevated systolic and diastolic blood pressure (systolic blood pressure > 20 mmHg above baseline)
• Sudden-onset headache
• Sweating (often profuse)
• Flushing
• Goosebumps
• Blurred vision
• Nasal congestion
• Anxiety or feelings of doom
• Nausea and vomiting
• Low or high heart rate
• For some individuals, the only symptom may be elevated blood pressure

Numerous studies have found that with sexual activity, orgasm, or ejaculation, blood pressure naturally increases. Blood pressure is known to increase more during sexual activity for individuals with SCI at T6 and above than it does in able-bodied individuals. When experiencing symptoms of AD during sexual activity, stop sexual activity immediately, sit up straight and lower your legs. Remove any restrictive clothing and unkink catheter tubing if applicable. Monitor BP every 2-5 minutes. BP should decrease, returning close to baseline within 5 minutes of stopping sexual activity. If AD can not be resolved contact emergency services. See the Autonomic Dysreflexia resources below for further information on AD management and discuss management of this potential complication with your physician.    

If you have been experiencing AD during sexual activity, it is important to discuss this with your physician. In some cases, your physician may prescribe medication for use prior to sexual activity to alleviate the problem. It’s important to note that some medications that are used to treat AD, such as Nitropaste, are contraindicated with medications commonly used for erectile dysfunction.  It’s very important to discuss these issues with your physician to determine the safest choices for you.  

Related Autonomic Dysreflexia resources; United Spinal Association Knowledge Book (a compilation of related resources) 

Clinical Practice Guideline – Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows.  Published by the Paralyzed Veterans of America (PVA) on behalf of the Consortium for Spinal Cord Medicine (2020)

Skin

Hygiene

Before and after sexual activity, it is important to thoroughly check the skin for any rubbing, redness, tears, etc. Making sure the skin is clean and dry decreases the risk of irritation and injury. If you are unable to self-inspect, direct a partner or care attendant in the overall skin integrity inspection. Using bamboo or silk bed sheets can minimize friction caused by movement.

Sensation

After SCI/D, sensation may have changed. By exploring your body, you can find what feels pleasurable. Despite decreased or absent sensation, many find that they still have erogenous areas that respond to intimate stimulation. Some individuals report heightened arousal with stimulation at their “transition zone”, the area of skin just below the last region of skin with preinjury levels of sensation which may have some altered sensation. Sexual activity in the shower/tub can facilitate an improved sensual experience as water tends to feel good on the skin. Things to be mindful of while in the shower/tub are the weight restrictions if using shower chairs, wet surfaces being slick, and can be hazardous, causing further injury. A shower/tub space can be limited, and positioning may be difficult. Remember to have patience with yourself and your partner while exploring, but most importantly, stay safe and have fun!

Erogenous stimulation and exploration

• Erogenous areas are parts of the body that elicit sexual response and arousal. These areas often include the neck, ears, the insides of the thigh, scalp, etc.
• Masturbation is a great way to find out what feels best for you while providing a safe, low-stakes environment for exploration.
• Sensation play and tantric touch are ways to explore without penetration and can be enjoyable for both yourself and partners. Tantric touch involves light, sensual, and loving touch meant to elicit arousal

Continence

Incontinence (involuntary leakage) is common for individuals with SCI/D during sexual activity. Certain positioning and sexual activities can increase pressure on the bladder and bowel, leading to potential incontinence. 

Bladder Management

Before sexual activity, preparation can include performing bladder routine, such as emptying bladder prior to sexual activity to minimize incontinence.

Other considerations:

• Cleaning around catheters and genital regions.
• Emptying collection bag(s) before and after sexual activity.
• Using waterproof/resistant sheets or throws can be helpful for any leakage. Doubling the layers of waterproof pieces can help provide a clean and dry backup, spending less time changing sheets, and you can get back to business without spoiling the mood.
  • Brollysheetsusa.com: Waterproof Sheets
  • Nomorewetspot.com: Waterproof Blankets
  • Liberator.com: Decor

Catheter considerations

• For some, the timing for removal of indwelling catheters can be concurrent with sexual activity. In this case, the catheter is removed before sexual activity and replaced with a new catheter after. 
• If you are having indwelling catheter difficulties during sexual activity that are significantly impacting you, consider discussing other bladder management options, such as a suprapubic catheter, with your healthcare provider.
• Some men choose to fold their indwelling catheters back alongside the shaft of the penis and wear a condom over the penis and tubing during sexual activity.
• Some women report pain due to tugging during movement and taping catheters to the abdomen or thigh can help keep tubing out of the way and in place.

Bowel Management

Before sexual activity, bowel maintenance and preparation can include:

• Performing routine bowel management programs to promote regularity.
• Some people prefer to empty their bowels before sexual activity; however, digital stimulation or medication use may lead to residual bowel emptying.

• Refraining from eating up to 30 minutes before sexual activity. Eating partnered with physical activity within this time frame initiates the digestive process, which may lead to accidents.

Anal Sensation

The sensation of the perineum and anus is sometimes preserved after SCI/D. Exploring sensations as part of sexual activity can help you understand and enjoy different areas of your body. Some considerations to take before sexual exploration or activity are:

• Incontinence
  • Touching or penetrating the anal sphincter during sexual activity without emptying bowels may stimulate a bowel movement.
• Hemorrhoids and Inflammation
  • Touching or penetration of the rectum can exacerbate any hemorrhoids or inflammation.
• Rectal surgery
  • If you have undergone rectal surgery, anal exploration and play may be a health risk. Discussing this with your healthcare provider is the first step to understanding the possibilities of your body.

Ostomies

New Mobility.com: Relationship Baggage: Dating with a Colostomy (2018/02)

Ostomy Hygiene

• Managing the surrounding skin surface and ostomy bag can improve self-esteem, confidence, and quality of sexual encounters. See above section, Skin: Hygiene

• • • Hollister.com: Sex After Ostomy Surgery: Do’s and Don’ts: Hollister Incorporated develops, manufactures, and markets healthcare products and services worldwide. They offer advanced medical products for Ostomy Care as well as providing innovative healthcare programs, services, and educational materials for patients and healthcare professionals. (2018)
    • Convatec.ca: Intimacy with an Ostomy: ConvaTec is a global medical products and technologies company, with leading market positions in wound therapeutics, ostomy care, continence and critical care, and infusion devices. (2020)

• Odor management: There are several options for dealing with ostomy bag odor management. Deodorizing sprays and drops can be used to address any unpleasant smells coming from your ostomy bag.

• Coverings: Mini-pouch or pouch coverings can improve confidence during sexual activity.

Spasticity and Pain

Spasticity or spasms during sexual activity are common among people with SCI/D. For some, spasticity can facilitate movement during sexual activity, while for others spasticity can interfere with positioning. Some medications used for managing spasticity may impact libido (sexual drive). If you are experiencing negative side-effects, speak to your healthcare provider. Stretching before sexual activity can be incorporated into foreplay and can minimize spasms and contractures. Pillows or wedges can improve positioning and increase comfort (see See 8.4 Functional Mobility and Positioning section). Planning for taking pain medication can ease some of the complications which may arise during sexual activity. Keep in mind what might be sex-related pain versus typical pain.

Limb Protection

Individuals with SCI/D have an increased risk of bone fractures as their bone density decreases over time. Positioning for sexual activity should include positioning aids (pillows and cushioning) to protect limbs from pressure and extreme joint angles. When contractures or other conditions that limit range of motion are present, limbs should be supported with pillows or bolsters and forceful pressure should not be used.

Respiratory Health

Taking care to remain comfortable and aware during sexual activity requires appropriate communication with a skilled partner, proper positioning that does not block or impede respiration. Consult your health care provider if you require any assistance with your respiratory needs.

*Consortium for Spinal Cord Medicine (2020). Evaluation and Management of Autonomic Dysreflexia and Other Autonomic Dysfunctions: Preventing the Highs and Lows. Paralyzed Veterans of America. https://pva.org/research-resources/publications/clinical-practice-guidelines/