Foreign [Music] good afternoon or good evening everybody uh wonderful to uh to have this uh this webinar tonight uh my name is Thomas Johnson I will be the the moderator of this webinar tonight okay okay webinar on sexual functioning in uh men with spinal cord injuries it's a joint webinar organized by the international functional electrical Stimulation society as you can see this is a collaboration and the mission of the international of this group is to promote the research and application and understanding of electrical stimulation Technologies in Rehabilitation and Medicine we have a very nice website
and you can have you know please have a look at it and the other partner in this webinar is the spinal injuries Association it's the largest or one of the largest Um charity groups in the United Kingdom for Sci please Damien you can maybe talk a little bit more about it you you know about it um yes this is uh one webinar in a series of webinars we uh ifas we try to organize on a regular basis these webinars and this time we'll do it a collaboration with SIA and tonight it is on the sexual
functioning for men following spinal cord injury current Treatments and Recent research um we have uh three presenters and I will introduce them later in a little more detail but we have Damien Smith Neil Marshall and Thompson Street okay so like I said it is the the topic of this webinar is sexual functioning for men following spinal cord injuries current treatments and and Recent research I would like to introduce a little bit the the topic of tonight when I talk to my students about Spinal cord injury their human movement scientist students so they don't know anything
about spinal cord injury I always show them this slide and I asked them what what is a spinal cord injury what is what are the problems and they say well paralyzed muscles they're in wheelchairs and then I tell them ask them okay that that is pretty clear pretty obvious but what else and then they they it becomes silent and they I wait Around and say well you got the idea right this is an iceberg so what are the what are the other problems and uh well they don't know and I start talking and I said
they have a few more problems or they can have like cardiac Innovation problems sensory deficits temperature regulation urinary tract infections and the list goes on and on and then I say well it's not it's probably not um everybody with a spinal cord injury has all these problems but definitely Every person with the spinal cord injury has some of these problems and all together they're very important and they determine the the quality of life of individuals with spinal cord injury Rehabilitation and life after Rehabilitation it's not only about the paralyzed muscles but it's about all the
other problems as well and a very important aspect of these problems is are sexual problems and not a lot of people outside the rehabilitation area Think about sexual problems or bowel problems or incontinence but they may they are very important for the quality of life of people with spinal cord injury so I'm very happy that we uh we will discuss some of this tonight uh unfortunately that is not my area of expertise I'm more like an exercise physiologist but luckily we have a great lineup of speakers uh who will Who know everything about this topic
uh we have attempts in street she will talk about Uh a survey that she uh that she worked on uh after that we will have Damien Smith on current treatments for sexual functioning Thompson will continue then with some research a research study on abdominal electrical stimulation and sexual functioning and Neil Marshall will talk about his research project on The Perennial electrical stimulation afterwards we will have there's plenty of time for for questions if you want ask a question you can use the Q a Button to post your question you can write them down it is
synonymous so please post your question in there and we will try to um to answer those questions after the talks also after each talk there if you want to have a specific question on this topic you can just ask them and ask immediately but we're going to start now with uh with tempsin so maybe you can put on your your slides again terms in terms And it's an NIH NHS research fellow at the Salisbury neh Foundation trust she has a background in neural Rehabilitation and among her research interests are using electrical stimulation for neural Rehabilitation
bowel and bladder function and sexual function and respiratory function and she is also a board member of ifas at next to that she's a good friend of mine so please Samsung the floor is yours thank you very much uh Thomas for that Lovely introduction um so the um the background to doing this information webinar came from uh doing a survey with the spinal injuries Association on sexual functioning originally we did the survey because we wanted to understand more about what the research needs were for um in this area um and the survey findings led to
the development of this information uh webinar Um and we were somewhat surprised by some of the findings um but some of the things we were expecting to see so I'll just get right into them so we had 176 people who responded um to the survey um in terms of the time of injury uh we had a really good spread in terms of when people had had their injury but we did have a good representation from people who had their injury more recently so in the last sort Of 10 to 15 um sort of years which
I would say would be sort of Representative of what we would see in current day practice so I would argue that we do have some good representation of what people might be experiencing currently at the moment in terms of the age range we had a widespread of Ages with most people being in the 55 to 64 year bracket in terms of injury level we had around 100 people with an incomplete injury Responding um and then uh I think it was it was 59 people with a complete injury and then 17 didn't know or weren't sure
of the injury level uh the most frequently frequent people responding um had an injury level of C5 C6 C4 but then again we also had a pretty good spread across different levels so the question which really led to this information event was this question about people feeling informed of the Choices and treatment or medication for sexual functioning that they had and we were surprised somewhat to see that a lot of people didn't feel informed at all about uh what what choices that they did have and what treatments were available and um this is why Damian
is going to talk about a little bit later on about the current treatments that are actually available a really important question um other questions we asked we asked About the level of sexual activity with a partner or masturbation prior and after injury and prior to injury people reported being regularly active and after injury there was a more of a tendency to be uh not active at all or or indeed less active this could be due to a little bit influenced by life stage and time um uh it came on but certainly um this is something
to to look at the satisfaction with level of sexual Activity um again uh stood out and a large number of people reported not being satisfied at all we didn't have um uh uh sort of I guess data from talking to people who didn't have a spinal cord injury to check this this level but there certainly seems to be room for um for improvement and for for providing available treatments and indeed further research in this area Um an interesting one was the most important factor for sexual functioning so this is really important in terms of further
research areas that you want to explore what is actually important to people in terms of their sexual functioning what do things do they value so we want to concentrate on things that are going to be supportive and and and and be useful to people um so the top one was being close and intimate with someone else and then the Second one was orgasm feeling arousal and pleasure but partner satisfaction also was was quite high up there so this is important to take into account a lot of research that is available has tended to focus more
on the sort of the physical attributes that can be readily something can sort of be sorted out with and you know something that you can do with maybe a pill or some sort of medication but taking into account things that are a little bit Harder to measure like orgasm feeling pleasure and arousal maybe a little bit more difficult to measure and something that's maybe been a little bit more neglected in the research literature again something else really important to us in terms of further research is identifying the issues which are going to affect people's sexual
functioning um who've had a spinal cord injury and um erectile dysfunction featured quite highly as as an issue and other issues Other areas where reduce sensation um and something that came out also was bowel and bladder issues um so some of these uh Damien will be talking a little bit about how it's possible to manage some of these issues that have been risen um some of them we do have an understanding of how we can we can um we can manage them but others again we probably need to think a lot more about in terms
of further research in This area to provide uh support for those areas okay in terms of the effectiveness of treatment attempted for sexual functioning medication unsurprisingly was something that featured quite highly and people found although that was the thing that they were maybe using the most frequently that there was only partly effective so definitely room for further Improvement there and sex Devices also were only found to be partly effective so so definitely room for more Improvement there um in terms of this the type of medication that people are using this is as we would expect
um Viagra Cialis to telephone um this was also again found to be um partly effective and a lot of people were not taking medication and not finding finding it effective and then I guess a sort of a similar Similar picture for for sexual functioning devices the most common thing that people are using so manual stimulation vibrator uh or massager again only partly effective and a lot of people were not using AIDS or devices not finding them effective um this one was a little bit uh more interesting in terms of probably the treatment and care that
people were receiving maybe during their Rehabilitation uh whichever pathway they They were taking um and the reason for not receiving treatment for sexual functioning um the the the the biggest thing that came out was I was not aware that these were treatment options which is a little bit concerning that people weren't um aware of the treatment options that are available so something that we're going to do today is just talk about some of those treatment options that are available for people and also provide a Contact UM details for people to find out more about this
in their own time as well and talk on an individual case for themselves um for their current situation we also found that um so similarly that treatment wasn't offered um to people during their Rehabilitation um and people also said that they weren't provided with the opportunity Just to discuss the issue um so it would be um interesting to kind of understand a little bit more unpack that a little bit more to understand exactly what that was so we just put out a General survey we we had some comments where people could embellish their answers a
little bit more and talk a little bit more in depth to explain things but I think we really need to understand a little bit more about why this is happening and and you Know how we can find ways around it or solving it um something interesting about the patient um sort of I guess clinician relationship is people not feeling comfortable with approaching their clinician but I guess you know it's it's an area that maybe not everybody feels comfortable with talking about straight away so finding ways around that to make people feel more comfortable is Something
that we need to look at one of the ways that we could maybe find to make people feel more comfortable and getting information about their own situation is an online resource and there was quite a lot of support for having some kind of reliable online resource that people can um can access and this is something that we've been talking to the spinal injuries Association about about potentially having some kind of online Resource available for people to use okay so the main reason behind some of this work with the the survey was to look at um
potentially doing further research into electrical stimulation treatments because we'd had some experience where we'd seen some success from some case studies so we really wanted to understand whether we could take this further if this is something that people would be interested Um in potentially trying out as a treatment um so uh the electrical stimulation directly to the Gen genitals was found to be um quite a popular option and so people said that yes definitely they would go for that not everybody said that but there was um there was some support for that people saying yes
definitely other people saying maybe so perhaps something That they would consider maybe with a bit more information abdominal electrical stimulation was also an error which people were interested in potentially trying out so maybe and also yes definitely people reported uh what was interesting was spinal stimulation um invasive spinal stimulation so implanted stimulation um there was a lot of people who there was a bit more I guess of a move to People not wanting to go down that path but then with spinal stimulation non-invasive people were a little bit unsure they weren't sure either way so
again probably more information needed more research in that area okay so just to summarize for me we need to look at further research for alternative treatments and there was support for that there's support for Research into electrical stimulation Technologies we Identified a need for further information about available treatments which we're going to talk to in a minute Damien's going to talk about that now and there was support for an online resource for sexual functioning so developing something in that area thank you very much Damien would you like to go ahead yeah thanks very much tamzin
so um I think your survey um enables me to sort of follow down Quite nicely because you know certainly some of those themes that have come out from that are really really pertinent yeah and particularly um with how you know people feel that they're not getting the information or advice that you would hope that they would do so I think you know that is something that I will touch upon as well so I'm you know for this session I'm not going to go into too much detail about the anatomy and physiology side of Things because
not this not important but I think talking about some of the treatments is probably more relevant but I will touch on some of the anatomy physiology um just because there is quite a distinct difference when it comes to spinal cord injury called require syndrome and the different presentations which will enable me to be able to give the right advice to the right person um next slide please So I'm just going to leave that up there for a moment and um hopefully you'll get an idea of you know why it is that I put this slide
together um from my point of view I think you know talking about sexual function for me it's no different about talking about you know every other aspect of um you know somebody's you know the impact of spinal cord injury but it is still an area that isn't always spoken about and You know that certainly um was proven you know with the results of the survey that was carried out so it is often that elephant in the room that you know people are quite happy to talk about all the other aspects but sexual function is just
as important um so next slide please so it goes without saying that you know if somebody has a spinal cord injury called recliner syndrome you know it is a major Life-changing trauma and for most people they can identify with their life before spinal cord injury so they know what their life was was like before um and then it's a massive um task to try and come to terms with their new life and I just some of these bullet points that I've got and that you can see on your screen there um just to give you
an idea of you know what the process might be if somebody Has a spinal cord injury and if they go into a specialist center you know what's actually happening to them you know often one of the first things that will happen is that they'll be stripped off completely naked you know body um sorry you know you know everything becomes um very abnormal dignity flies out the window you know the reason that that patient stripped off naked is because you know often they're on bed rest it's Easier to be able to monitor them you know look
at that check their skin and make sure that you know they're kept in spinal alignment to help preserve the spinal cord as much as possible but as I say dignity sort of flies out the window you know all of a sudden you know they had there's this massive loss of identity that that person doesn't feel like the person that they were before they had their spinal cord injury you know the body becomes public Property you know often they are reliant on other Healthcare professionals to do the things that they took for granted pre-injury or you
know those that can be more independent as they're learning how to come to terms with their injury um just everyday tasks can take that much longer getting themselves washed dressed um and that goes hand in hand with tiredness as well so you know if you imagine you know the Amount of effort that you know we take for granted you know hop out of bed jump through the shower get dressed and we're ready to go um the amount of effort it might take for somebody with a spinal cord injury um the tiredness that goes with that
possibly um sexual function might not be the Forefront of their minds at that point because they're probably just absolutely exhausted just from getting up in the Morning but you know that can change and I think with the right support um you know we can get them more into that mindset that you know we want to try and normalize them as much as possible but spinal cord injury it does affect all the body systems yeah it does affect the bladder it does affect the bowels it does affect you know people's um tolerance to pressure so you
know Their risk of pressure ulcers has increased it could affect their respiratory function um it affects everything but you know I put there it does include sexual function and you know this should be talked about on the same level as everything else that we're talking about you know when we're trying to empower those patients to become experts in their own condition you know I think if somebody comes Through you know a specialist center or even through a major Trauma Center they're not experts in spinal cord injury you know why should they be you know what
we want to try and do is give them the knowledge to be able to direct their own care to understand their own condition and that includes everything they should be just as aware of the impact of their spinal cord injury how that impacts on their sexual function as well And it's not just sexual function um you know often we talk about sexual function and we talk about sexuality as well you know we're living in a much more diverse um society and certainly you know when I first joined the spinal unit in Salisbury back in 1996
you know I was there for 25 years as a clinical nurse specialist um often sexual function was sort of Fairly black and white you know generally you know we would talk about heterosexual sex but you know nowadays you know we have to be more aware you know um we have to be very um aware of you know that individual's sexuality you know their sexual preference you know how they identify because it's not just one rule if it's each person Um you know we have to you know treat that person holistically like we would do with
everything else that we're talking to them about and um the same goes for sexual function you know understanding that individual what's important to them um so we can make sure that they have the right advice and the right information the next few slides you know we're just going to talk about you know sexual Function following spinal cord injury but also called recliner syndrome and on the next slide I'll just explain you know what the differences are and just you know anatomically just what some of the key um you know sort of areas are that make
it more important for myself to be able to you know know what somebody's presentation will be what their impact their personal impact of their spinal cord injury how That will affect them so and I will keep this as sort of as brief and sort of straightforward as possible but the spinal cord is basically an extension of the brain and it forms the central nervous system so it helps us to control pretty much everything that we do do you know things that we can control things that we don't control and when I say things that we
don't control you know things like our heart rate our blood pressure the way That we regulate our body temperature but it also helps you know us to control the things that we have got control over so you know our ability to walk our ability to be able to control our bladder and our bowel function but when you have a spinal cord injury you know that the spinal cord is that conduit for messages to travel backwards and forwards you know from the affected area to the brain but if you have a spinal cord injury often those
messages Get blocked um they might be completely blocked they might be partially blocked depending on the degree of damage um to the spinal cord or the cord recliner but just looking at that diagram you know the the spinal cord sort of ends um it's all the sort of thoracic lumbar area so around that it's all T12 L1 level and I'm very aware that I'm using terminology that people may not be Familiar with but you know very very simply you have you know the cervical spinal nerves and the thoracic spinal nerves where the thoracic spinal nerves
end you've got an area called the conus medallaris which is the reflex center of the spinal cord and this is quite a key area when it comes to how somebody may present you know when they've got this type of nerve damage because if people damage their cervical or their thoracic nerves They would generally present in a particular way where these reflexes will still be present and on the next slide in a moment I just give you an example of what these reflexes are but if the reflexes are present then that can be used to that
individual's advantage and for all sorts of things and particularly with the bladder the bowels and sexual function because those nerves that control bladder function bowel function and sexual function They're the same group of nerves and they're the sacral nerves S2 3 and 4. so as you can see where the arrow is that's right at the very bottom there but below that conus medallaris you've got the cord require and the chordaquina you know the quadraquinas Latin for horse's tail so it gives you an idea of you know visually what you're actually looking at because the spinal
cord itself above that is all quite neat and compact you Know those nerve fibers are nicely bundled together but below that conus medallari into the Corder equina um those nerve Roots start to to Fan out like a horse's tail but as you can see where those sacral nerves are um it doesn't matter whether somebody has a cervical spinal cord injury a thoracic or lumbar injury um chances are they're going to have Some bladder bowel and sexual dysfunction because those nerves are right at the base um any sort of damaged area you know above that you
know those messages are going to have trouble you know traveling backwards and forwards so I think we can safely say that pretty much most people with a spinal cord injury with called recliner syndrome they are going to have some bladder bowel and sexual Dysfunction because of you know the location of where those nerve roots are so just to give you an idea of what a reflex is you know that conus medallarus that reflex center um you know a reflex is basically you have a sensory nerve that picks up a stimulus so that can be you
know a physical stimulus um you know sensory stimulus and it basically fires off to the spinal cord crosses over an intermediary neuron and and fires off a Motor neurone to cause a muscle contraction so that's a reflex and just to give you some sort of context um you've probably seen you know if you go into a GP practice and the GP if he says right cross your legs they tap you under the knee with a patellar hammer and then the leg just flicks out that's a reflex those messages are just traveling to the spinal cord
and bouncing straight back from the spinal cord they're not Traveling up the spinal cord to the brain so there's no cognitive control over it it's a reflex um another example of reflexes if you were to touch something hot on the stove um that sensory input from that hot object fires off to the spinal cord and bounces straight back to cause the muscle to contract which removes your hand away from that hot object it's a reflex you have no control over that But you can use that to your advantage when you're talking about sexual function and
we tend to break it down into two different ways so how people achieve an erection you can break it down to a reflexogenic erection which is a reflex so the the diagram sort of on the left hand side there is just an indication of somebody with a catheter going in through the penis into the bladder just that physical stimulation of having a catheter in the Penis might be enough to trigger a reflex erection so that patient may not have any control over it but they can still get an erection but just to bear in mind
these These are the patients that generally have a spinal cord injury above that conus medallarus that reflex center where their reflexes are more likely to be intact and the little cartoon just on the right hand side you know where you know the Doctor doesn't want you getting too excited so I'll be giving you your bed bath today um you know just that physical stimulation of you know washing around the genital area might be enough to cause a reflex erection it's very very important that you know as a healthcare professional that's providing that care to the
patient that they're explaining what's actually happening because I've come across many Patients that are quite embarrassed because maybe you know back in the day it was me that was helping them have a wash in the morning and if they get an erection you can just see that thought process that they're thinking you know does he think that I'm attracted to him um you know it's I've got duty of care to be able to explain to him you know because you know if I'm giving you a wash You may get an erection or if you do
get an erection it's a reflex response and um you know I don't want them to get embarrassed um but equally I think it's very important for healthcare professionals to understand that as well so it takes away some of the embarrassment for them that they understand what's actually happening so you mentioned about a reflex erection so that is just the physical stimulation That's triggering that reflex but there's also another way that people will achieve an erection and this is or irrespective of spinal cord injury as well but we refer to it as a psychogenic erection so
this is where you have those um erotic thoughts and it's having those thoughts that can trigger that erection as well or to to help provide an erection for that patient so that there are those two different ways that somebody May achieve an Erection and you can use them to your advantage I think you know the reflexogenic erections where um it's triggered by physical stimulation is probably some more easier to assist in getting erection whereas the psychogenic erection it's a bit more reliant on sort of maintaining that thought process I think you know I'm looking at
the time thinking is ten past seven and I haven't Had my dinner yet you know if somebody starts having those you know they sort of get off track and um they can sort of very quickly lose that psychogenic erection so it takes a bit more concentration to be in that zone if you like but I think you know having that understanding that you know people can achieve erections in various different ways it's very important for the patient to understand that as well and I think If the patient understands that then you know that gives us
a bit more um sort of grounding as far as you know what um the options are for them but the psychogenic erection you know sort of being in there in that moment psychologically can be very very difficult because spinal cord injury throws all sorts of other challenges um to the patient as well which I'll explain in the next slide Um if you wouldn't mind please Tamsin so I think you know this is very well documented that um if you were to give somebody with a spinal cord injury um a choice and the choice would be
we'll either give you butter and bowel function or the ability to walk you can't have both you must choose one what would you choose and every single time pretty much without a doubt that patient will say I'm not worried about not being able to Walk but to be able to be able to control my bladder and bowels um will make my life so much more um tolerable because you can argue that somebody with a spinal cord injury is doubly incontinent I would argue that with the right interventions you can help to make that patient continent
but there is still that fear that anxiety at the back of their mind that maybe their Bladder or their bowels might open a point that they don't want it to so as I put up there you know accents they might be unavoidable but they're really not common and I think you know the the timing of sexual activity about around bladder and bowel routines um gives a lot more confidence that it's not going to be an issue and you know certainly in my 27 years of experience of working with people with Spinal cord injury it is
a very very rare occurrence that people will have incontinence issues um with their bladder or their bowels you know while they're having sex but it's only worth making that patient aware that you can take away some of that anxiety by creating or you know having a very good routine um and yeah that's where us as Healthcare professionals can try and identify you know what the best routine For that patient might be to sort of minimize um an event like that so I guess the most important thing you know when I've given talks to inpatients before
it Salisbury spinal center I can go through the anatomy the physiology but at the end of the day you know most of the patients all they want to know is can I get an erection yes you probably can um okay well you know what will help me To get an erection or to be able to maintain their action those tend to be the key points for those patients um next slide please so this is where you know I would talk to the patients about you know the the different treatments that are available to them and
I think you know treatments have evolved um medications have evolved as well you know whenever I'm talking to patients I think Most patients are aware of Viagra um you know it was you know pretty much the first medication of its type to come out onto the market and it can be very very effective you know for patients that you know whether their reflexes are intact or they're not um I think those that still have their reflexes intact will possibly have a better outcome by using you know these medications but it's still worth trying Even those
that have called recliner syndrome um you know to try these medications as well because there are different degrees of how you know the nerve damage would impact on that individual so unless you try it you're not really going to know whether it's going to be effective or not but it's only what I found um over the years is that people might take the medication and it might not Necessarily be effective for them but I'd probably be asking the question you know are you taking it correctly it's not just a matter of you take that tablet
and then everything starts to happen certainly with medications like Viagra you know it must be taken on an empty stomach you know nothing to eat or drink an hour before or after you take it so it takes um takes away a bit of the spontaneity if you like so things do Have to be planned to a degree but you know the medications have evolved and things like Cialis Levitra um you know you can eat and drink with them they do stay in the system that much longer as well I think Viagra has still an approximate
shelf life is all eight to twelve hours which when I explain this to a patient you know I I've been asked the question so does that mean that I'll have an Erection for 8 to 12 hours it's like no no no you know the medication is in your system and so it will enable you to be able to achieve a better erection and maintain it while that medication's in your system and and it's the same with um you know the Levitra Cialis you know but that does stay in the system for you know a fair
while longer you know possibly 24 36 hours maybe even a tiny bit longer than that so it does enable that person To be a bit more spontaneous that you don't have to necessarily plan around it but the way that these medications work um they enable you know part of the penis the the Corpus cavernosum to be more engorged with blood so you know to stimulate the blood supply to the key area to enable interaction and it isn't as I've mentioned just in case if you take the tablet and then everything starts to happen these medications
they still they do Still rely on physical stimulation as well and it's little aspects like this they're very important to explain to the patient so you know they're not going to end up um taking the medication and feeling that it's not working for them but also as well you know the medications they come in various doses so for example you know Viagra it comes in 25 milligrams 50 milligrams 100 Milligrams quite often clinicians you know they'll start that patient on a lower dose because the lower dose might work quite effectively for that patient but if
it doesn't then you still got scope to increase it as well but from my experience patients they might have been given a lower dose but and it's not worked and then they've just thought well I've tried that medication it hasn't worked and then Feel like giving up on it but it's not until you're actually speak to them and say well what dose were you taking well I was taking 25 milligrams well you realize that you can increase the dose yeah they're not always told or you know did you take you on an empty stomach oh
no well nobody told me about that I think it always surprises me to a degree you know if I did a medication round that You'd be handing out these tablets the patients will just take them you could be giving them anything not that I ever would but you know often there is people don't always question what it is they're given you know they wouldn't always question you know how to take the Viagra um but maybe they're not told either so as Healthcare professionals you know it's very important that you know if we're suggesting any sort
of treatments you know we are explaining yeah how they Work you know how they work to their Optimum effect so that the tablets are probably the most popular form of um treatment for erectile dysfunction um on the bottom right hand side where you can see that penile injection um this is one called kavaject where I certainly when I've spoken to patients at the spinal unit this is the one that sort of tends to make their eyes water a little bit Because just the thought of you know putting an injection into the penis um can be
quite daunting but it is another option and you know again it can work quite um well you know for various individuals and it works in a similar way that you know encourages the blood supply to the penis I guess just one um word of warning if you like or just some You know note of caution you know certainly with the medications is that the way that they work by helping to dilate those blood vessels and they work in a similar way to other medications that a patient might be taking so if there's a patient that's
at risk of a condition called autonomic dysreflexia which is a unique condition and spinal cord injury and it's the body's way of um identifying whether There's any sort of pain or discomfort below the level of the spinal cord injury which causes the blood pressure to rise um the emergency medication which is often medications like glycerol trinitrate spray or nifedipine capsules the way that they work they dilate the blood vessels to reduce the blood pressure so these medications they do work in a similar way so again it's just another Note of caution that if we're talking
to patients about the treatment options if we're talking about Viagra or Cialis or the other um tablets that they are aware that if their risk of autonomic dysreflexia if they do need to take that emergency medication um that they just need to be very very cautious about that potential drop in their blood pressure um next slide please So you know there are various different treatments for erectile dysfunction and I think you know the use of a vacuum pump um you know is a treatment that's been around for a long long time essentially what you're doing
is you know the the vacuum pump goes over the penis and you're creating a vacuum and you know encouraging the blood supply to the penis and this can work Um effectively for you know any level of spinal cord injury or cord required but often for those patients with cord requirement where there often is no reflex to stimulate these are patients that often we would suggest have what we call a flaccid paralysis so they might not get that reflex or action so using something like a vacuum pump um is you know a potential option for Them
so once they've used the vacuum pump and um you know you've created that vacuum to encourage the blood supply to the penis to stop the blood from draining back into the body you use these um restrictor Rings which just cause you know a bit of mild compression around the base of the penis to stop the blood flow you know from traveling back and we all come in different shapes and Sizes you know the restrictor rings come in different sizes as well it is very very important that you know that patient is given advice to use
the right size restrictor ring because if it's too big it's not going to serve its purpose um if it's too tight it could cause additional trauma but you know it's very easy to get hold of vacuum pumps online um you know a lot of the equipment that um you know patients can access they can Just buy on online and perhaps without the right um you know sort of knowledge about you know the the safety and the efficacy of its use um next slide please so I don't once thought tread on Neil's toes um too much
so I'm just going to mention this you know very very briefly um and also partly because it's a technology that people don't generally see Um it's not very widely offered um and if you look at this you know the picture on the the left hand side you know with that control box and also that the picture of the patient that's using this system and I'll I will explain just a little bit about what it entails even the picture looks quite old because it is quite an old technology and you know there are a couple of
centers you know within the country now That are revisiting this type of technology and probably in a more refined way as well um but basically what this is this sacral anterior root stimulator or massazi for short um it's an electronic implanted device that is implanted under the skin and you've got these electrodes that are connected to the sacral nerve roots so those sacral nerve Roots as I mentioned that S2 3 and 4 these sacral Nervaries that can control bladder function and bowel function and sexual function this implanted device you know the idea is that you
can artificially trigger um you know fire off those nerve roots to Concord and to cause you know the contraction of the bladder to empty and to trigger a reflex erection to get the the bowels moving and what you have is um this external transmitter that's placed over the Implant and then it's a matter of just pushing the button so you know I'm not and I can't remember offhand you know which button um causes which reaction but say for example yeah number one might cause the bladder to contract number two might cause um that the peristalsis
of the bowels to start to move number three might trigger an erection um so it's very important that you do Push the right button at the right time to get the desired effect but this is a technology that um it is available um it's not available generally to new patients because the way that this process works is that you know basically you are causing permanent um disruption to those sacral nerve Roots so once this staple anterior root stimulates in place There is no potential then if there is the potential for nerve recovery you pretty much
um damage that by using this implanted device so there is a rough rule of thumb that um if somebody has the potential for neurological Improvement for those nerves to recover to a degree um often you will see that within the first six months quite more significantly but certainly within the First two years as well so I I would argue that this shouldn't really be given as an option to somebody if they're within the first two years of having a spinal cord injury you know if they have got that potential for that nerve recovery but you
know like I say there are a couple of centers that are revisiting this technology in a more refined way so this might become a more widely Um available option in due course excuse me um next slide please Tamsin so I think it's worth just talking a little about about fertility because you know when I first joined the spinal unit back in 1996 I think what we understood then is quite different to what we understand now um and you know I I saw patients that literally had come through the door at the spinal center Um trying
to take on board everything that they're being told about you know the degree of their spinal cord damage and one of the questions that they might get faced with is on top of that um because you've got a spinal cord injury you know the chances of you having children will be greatly diminished so um to give you the best opportunity in the future can we take a sperm sample From you and we'll freeze it yeah and you know for future use um and you know often that decision had to be made pretty pretty quickly because
the thought back then was that you know the sperm levels would just dropped to such a low point that you know the chances of them be able to um you know have children you know with sort of viable sperm would be very very slim but we now know that Um you know you can artificially stimulate ejaculation which in turn will hopefully you know bring up the sperm levels um to a much healthier degree and at the end of the day you just need one viable spam to be able to fertilize an egg but you know
you can increase you know the um you know the success rate by using things that can artificially trigger um not just an erection but ejaculation as well And the pictures on the right hand side are just two examples of piece of equipment that are available um so the one at the top right is called a 30k vibrator and you know certainly when I've been teaching patients previously yeah when I take this out of the box and um and it's probably about I don't know about 10 inches long you know the look on the patient's face
and you know I've had patients say well well where do you stick that well you don't Stick it anywhere it's got a vibrating plate on the end of it and it vibrates at a particular frequency which can be adjusted and that vibrating plate and goes against the glands of the penis so it can help artificially stimulate an erection but it can also artificially stimulate ejaculation as well and the picture on the bottom is a similar system called vibrate which has got two of these Um vibrating plates which um just very gently um sort of when
I say clamp around the glands to the penis but you know go in contact with the glands the penis and cause you know a similar effect it's just two different companies but a similar technology and patients that are under the care of spinal centers um I can I can only speak for you know Salisbury because that's you know where Um you know I came from that patients do have the opportunity to be able to you know try some of these treatments and see whether they are effective for them and you know but they are fairly
expensive pieces of equipment and I think off the top of my head I think the 30 care vibrator is about 600 700 pounds or thereabouts but um you know there are other charities um that you know have provided funding for piece of equipment like this because It might not necessarily be funded by the NHS um but you know for some people you know it is an effective um adjunct to you know the other treatments that they might be using um next slide please Tamsin and again I won't touch on this um a great deal because
you know I think you know this might be covered um to a certain degree you know with Neil but it's Um you know there are other ways um to support fertility you know by using things like an electro ejaculator which um I'm not entirely sure of you know the history behind you know how these were developed but I think you know my sort of loose understanding is that you know this technology was um developed for you know other animal species that are on the verge of Extinction so you know creatures like pandas um to be
able to you know artificially help them to ejaculate to be able to inseminate um you know other pandas to try and you know build up um their their population but you know basically what this Electro stimulator does is artificially cause that reflex ejaculation and you know just one note um worth mentioning is That patients with a spinal cord injury they don't always ejaculate in you know why I would say the normal way so ejaculating out through the penis some patients with a spinal cord injury might experience what we call a retrograde ejaculation where the semen
um sort of passes up into the bladder so that patient they might get the experience of orgasm they may not get the experience of orgasm Um often the majority of patients with a spinal cord injury probably won't ejaculate in a normal way but if they're not planning on having children they're of you know an age where you know their partner is of a child-bearing age and the advice would always be you know use contraception in you know a regular way because you know there will always be those unexpected pregnancies and you know you can't just
solely think well John said I'm not going to be able to ejaculate so I don't need to worry about contraception you know you absolutely do you know if you're not planning on um you know having children but it's just an a note worth mentioning that if somebody does experience a retrograde ejaculation they might not necessarily um be aware that it's happened but they may notice that their urine looks different But I guess just another point to mention as well and I did sort of touch on the fact about autonomic dysreflexia which is unique to spinal
cord injury and it's the body's way of um telling that there's some stimulus you know some discomfort you know um below the level of their spinal cord injury but orgasm can be a trigger for autonomic dysreflexia as well and because autonomic dysreflexia is a Life-threatening condition and I don't want to sort of sound dramatic but it is potentially fatal but the caveat is that if it's well managed um lots of patients you know very rarely experience autonomic dysreflexia because it can be managed but I guess the important point to make is that it is the
body's response to you know this um stimulus but at the point of orgasm Which you know for men just literally lasts for a few seconds it's not really something and to be overly concerned about but again it's just something else to make that patient aware of um so that you know they are as informed as they can be um about the impact of their spinal cord injury and how it affects them as an individual and final slide please Samsung so That's where I'm going to leave it for now unless anybody does have any questions at
all but hopefully that's just given you you know a very very brief snapshot of what some of the treatment options are but also the importance of actually discussing sexual function with somebody with a spinal cord injury and with cord recliner you know to try and normalize that conversation that it should be talked about in the same way that every other Aspect of the impact of a spinal cord injury is so thank you very much okay um thank you Damien for this nice uh overview um we have a remark in the in the chat or the
Q a I must say it's about somebody and and it's related to what you're saying about discussing things or not discussing uh this person was uh struggling to get a normal erection with a couple of tablets that he was given And he was not given really advice or information just in the tablets um so struggling do you do you do you know about it I mean have you any experience with this kind of treatment or lack of treatment or lack of discussion I have yeah so I I can only say What patients have told me
um rather than you know anything that I've actually observed in my time at the spinal unit but and um and it's not just You know these are patients across the whole of the country not just from where yeah I've worked but you know patients have said that they've just been given the tablets and it's not it might be by their spinal consultant it might be by their GP but you know here are some tablets these should help but not being given the advice about how to take them effectively and you know often that's where you
know patients that do try them and If they don't work then you know they're they're not um they don't have the confidence that it is going to work for them whereas what can you recommend in in in this situation or in these situations so I think you know firstly they could go back to their GP um you know often you know if the GP feels that um it's not an area that perhaps they feel confident to discuss Um the advice that I would give is to suggest to the GP they could either refer you know
to um especially a spinal consultant or they could refer to a urologist as well um urologists um often are very knowledgeable about erectile dysfunction um partly because it is those same sacral nerves that affect um your bladder control that affect erectile function as well So I've certainly referred many patients to urologists for that type of advice but I think you know in the context of spinal cord injury is yeah where do you go to in the first instance um you know the spinal injuries Association you know people can come to us for advice and then
we can direct them accordingly if they are under the care of a specialist spinal center Um they could go to their outpatient department where the staff there will be able to direct them as well right okay thank you yeah I I still think it's it's gonna remain a quite a problematic where to go to and how to discuss it and get to the right information from the right person but uh we have to move on to the to the next presentation times in your your own for abdominal stimulation thank you very much uh Thomas and
thanks Damian for really interesting overview of the area perhaps we could put uh just the contact details for the support line for the spinal injuries Association into that uh to answer that question so you could type that in and that person could then get in contact um with the spinal injuries Association to have a chat if other avenues they've tried hasn't worked yeah absolutely yeah I'll pop that into um the chat box brilliant thanks okay so Um I'm going to talk a little bit about abdominal electrical stimulation to improve sexual functioning just very early days
research that we've we've looked at so um if you'd like to get a more in-depth um kind of look at this area there's a publication in spinal cord Series in cases it's open access so it's free full text available if anybody wants to read a little bit more in depth about some of the the work I'll be talking about So what is abdominal electrical stimulation so AB Fest uses small electrical impulses to activate weak or paralyzed muscles by exciting the nerves that connect to the muscles we use self-adhesive patches or called electrodes which are placed
on the skin so here's the typical setup which is used for abdominal electrical stimulation that that we use there are other types of setups used for this similar sort of area but this is the Most common one that's kind of used in this area so the background to um how I got involved in this area um is came from doing work with bowel management I'm currently doing a clinical trial called the Bauman study which is funded by the Inspire foundation and it's an nhr portfolio um study and we hope to have some results in the
next couple of years or so so initially we started Um looking at the area of bowel management and using abdominal FES in this area of course when you do any research or you do any treatments with the bowel because of the proximity between the bowel the bladder and sexual functioning all around this sort of pelvic kind of area um there's a likely effect that you'll have some influence on the other areas so during the barman study we're looking at outcome measures to look at bladder And sexual functioning although the bowel is a predominant focus of
of this work abdominal life yes has also been used for Respiratory functioning if you're interested in this area there's a a good systematic review by McCarthy yatel um published back in 2016 and in spinal cord uh which where you can look at this more in depth so it's it's kind of an area which is which is quite quite an interesting area to do further working So um I'm just going to describe today a case study that we had which which kind of got me involved in looking at this area um so a 74 year old
man with a spinal cord injury with a C5 C6 is an incomplete spinal cord injury was referred for abdominal electrical stimulation for his bowel management so he's put on a course of a six-week treatment intervention to use the abdominal FES using the same electrode Setup that I showed you in the previous picture um for 15 to 30 minutes twice a day more or less every day but maybe not doing every single day um so at the end of the six week uh sort of trial we had a um a semi-structured interview to discuss um the
findings and and how he got on with using the the stimulator and he reported having some unexpected uh improvements in the strength and Duration of his erectile functioning after using the abdominal FPS roundabout after using it for about three weeks um at the time he was not taking any medications for sexual functioning um and he also reported not using so this is important for later on when we look at the cause but he reported not using electrical stimulation during sexual activity so this suggested it wasn't sort of a stimulus result of the electrical stimulation Um
helping to to activate and improve his sexual functioning during the time at all occasions he used the electrical stimulation at a different time to when he was he was engaging in sexual activity um prior to um uh reporting these improvements he was able to have something of a erectile functioning but he was unable to maintain the um the erection for for very long uh he Reported there was also an improved aesthetic appearance of the abdominal area um so helped to improve the muscles around that area uh possibly also reducing some of the bloating because he
um reported improvements in his bowel Management's a reduction in his overall bowel function he also uh reported improvements in self-esteem uh in his bladder functioning and as I said before abdominal strength So um what was going on here I suppose it's important to sort of think about it just threw up a lot of questions this is just was this just an isolated case what was electrode placement when was the electrical stimulation used so we already know he didn't use the electrical stimulation importantly during the sexual activity so it wasn't a sensory sort of stimulus in
terms of the electro placement which Is the other question to ask uh we asked him where he put the electrodes and he uh so if you remember the picture showed um the general Electro placement which we would normally use and we found he was using the electrodes the lower two electrodes from the picture if you remember and they were slightly lower down um than we would usually have placed them um and that may have had some um Activation of certain areas that may have helped to improve his sexual functioning in terms of innovation of nerves
that wouldn't have otherwise have been um implicated the next question would be the whether it was an isolated case or not were other people um experiencing this from using abdominal FPS for bowel management so from getting this information from him We were able to start ask other people um and to start to explore it as well as designing a research study for the future and we asked somebody else who was using it who also had a spinal cord injury a complete spinal cord injury and he'd also reported some improvements in his sexual functioning specifically his
ejaculatory functioning um and other people using it uh with multiple sclerosis uh who were who were Male um reported improvements in their sexual functioning so that was quite interesting but we didn't see an improvement in um the experiences for women or at least for the ones we asked again this is very uh limited because we only had a small sample of just a few people who are using the electrical stimulation for bile management at the time what's really interesting in terms of The potential um uh improvements that are going on and the causes of them
is that um for people who are non-neurological um uh who don't have a spinal cord injury um there's good evidence to suggest that using cardio exercises can help to improve erectile functioning so potentially there was some influence from improving the vascularization around the abdominal area Um potentially that may have contributed to improving erectile functioning for for these people who reported it also there was there's the Improvement in body image and self-esteem um which um our 74 year old reported was really important to him another really interesting area to look at is the potential of the
innovation of the nerves involved either directly or through the psychogenic pathways if you remember when Damien was talking about The different possibilities of how an erection can be produced um there's a couple of different Pathways so maybe we're able to tap into an alternative pathway through using this um this this abdominal FES okay and so just very quickly I'm going to talk about another use of abdominal Earth yes and that's combined with the vibratories uh with vibratory stimulation um so in Damon's talk he showed a Picture of the different types of vibratory stimulators that are
available um and there's a really there's a couple of interesting case studies uh which looked at combining that with abfast so a 37 year old man with a T3 complete spinal cord injury had reflex erections easily but these were poorly maintained without continuous stimulation so he experimented one day uh combining vibratory stimulation VBS uh with the ab Fest Um and at the same time and found that that facilitated um ejaculation um so he spoke to some researchers to the researchers about it and he said um and they said well let's let's see how many trials
you can score with and without so with VBS alone with the vibratory stimulation four out of 30 trials were successful but when combining it with the abdominal FES 31 out of 30 34 trials were successful for Ejaculatory functioning which was really interesting to see that difference this suggests that maybe in the future combining different types of treatments uh mixing and matching things might provide um an improved outcome in some situations the two further case studies with similar similar results um which found that combining the abdominal FES with the vibratory stimulation uh was was more effective
it Might be the case that combining these type of Technologies with certain types of medication might also be helpful in the future okay so just to conclude there's very early days with this sort of research larger studies are required to explore this area further and the current study um The Bowman study which I've mentioned is including measures on sexual functioning and we're looking at potentially writing some more studies to Look at this area further um thank you so I think I'll pass straight on to Neil and then if there are any questions we can take
them at the end okay thank you Townsend thank you Damon so I'm Neil I'm one of the doctors working down in Poole uh having worked with terms in the past I'm just going to go through a case report relating to male sexual dysfunction so in the next slide Please so I think Damian's covered this really well but um as we all know uh sexual functioning is really important for quality of life uh of course across people both in and not in the spinal cord population uh and the prevalence of sexual dysfunction is actually really high
amongst the son of quid injury population uh with a greater prevalence than both uh than bowel or bladder dysfunction And as Damon's talked about already ejaculation is the physiological culmination of the male sexual cycle our next slide these uh so why would we want to pursue research in this area well if if you survey the spinal cord population it it's very clear um that sexual functioning is is really important for feeling uh an intimate part of a relationship uh and despite sort of theories of darwinian Reproduction actually uh sexual functioning for fertility actually is a
sort of a low priority amongst that group so it should really reinforces the need to to look into the intimacy side uh for the general quality of life next slide please so going over what Damon's discussed already so uh primarily penile vibratory stimulation is effective amongst the population with a injury level around about T10 Uh as Damian mentioned briefly Electro ejaculation is a process of effectively harvesting spam but that's position LED usually an outpatient clinic um and that in itself comes with its own risks um it can sort of predispose to autonomous dysreflexia amongst those
patients uh next slide please oh yeah and again so this just goes through the current management for erectile dysfunction uh that uh Phosphodiesterase Inhibitors which you also down a field Group um you have a reasonably good mechanism um however they do experience a number of side effects and especially something called tachyphylaxis which is where through prolonged use there uh become less effective and as Damian was going uh discussing sort of from the Urology side um this is very much the domain of urologists when you talk about sort of The injectable um congenital medications they were
the predecessors for the for the oral medications um and something that they very much familiar with prescribing and using um the vacuolection devices um the sacral anterior root stimulators and then more recently as Tams has just mentioned the use of functional electrical stimulation um initially through the use of either Stimulating the pelvic floor muscles uh or more recently through the use of abdominal wall muscles next slide please so we're going to discuss a case report so this relates to a 46 year old gentleman with a spinal cord injury at the level of T4 it's a
complete injury at age array and prior to the injury happened eight years prior to what we're about to discuss uh he describes that he's able to generate a psychogenic correction Occasionally uh under reflexogenic eviction on demand and that's with the use of um standard fill uh he's available to maintain the direction for longer than five minutes um reported that he used AB Fest uh the abdominal electoral stimulation to improve his erectile function and degenerate ejaculation um but described that despite being able to produce an eviction um Through uh they were unable to ejaculate uh or
achieve orgasm with either manual stimulation or the penile vibration stimulation and next slide please so they've used Electro functional actual stimulation device called the neurotrac myoplus they've developed their own electrodes using four millimeter conductive rubber tubing and the diagram describes the layout that they've used so they place the anode um on the around the base of the penis Which was shielded from the body and the cathode was connected around the penis immediately below the glands and touching them our next slide please so they've described that they use the device at home um and they reported
their reptile functioning ejaculatory function and they're orgasm were using a self-reported diary their body position was supine so laid on their back with Their head raised by pillows initially interestingly we'll go on to other positions that they've attempted and they started at a low power and gently increased it until they felt some ejaculation was going to occur or evidence that it had happened um if the ejaculation didn't occur within the first two minutes it was stopped and then after 10 minute break was attempted again next slide please Uh so as you can see here there
are six different um methods that are utilized uh A variation of Channel usage and then later on uh variation in their positioning moving from their lying on the back Supine position to kneeling and then an addition or variation in their positioning of their an open cathode next slide please so looking at the results um if we look at initially Um the selection of attempts using a single Channel we can see that although ejaculation uh was created or developed um stimulated in all groups um we can see that the sensation of orgasm was achieved only when
the position was changed from supine Dunedin I also see that they reported that the spasticity increased immediately after ejaculation and dissipated later on uh take the next slide please and then we look when we look at sort of The side effect profile of using this using uh the single Channel um at a higher frequency uh we're using jawtown uh predisposed to Ultimate dysreflexia uh otherwise uh or this reflexia was was seldom wasn't reported any other mechanism used and we can see that using uh different positioning so the kneading position not only produced the sensation of
orgasm but also develops this at a at a much lower power required and was more often successful In the first attempt requiring mineral second attempts uh next slide please so why is this relevant so the potential benefit of using fraction electrical stimulation to generate the sensation of ejaculation so the sanitation of orgasm but also to generate ejaculation um using the settings towards lower Power Ranges which reduce the risk of generating Automotive with a shorter refractory period between attempts and I Suppose most interestingly really as well not only is the use of a different totality rule
so that showing the importance of variations in body positioning which impacts an ability to ejaculate moving from the Supine position to the kneeling position and generating the sensation of orgasm uh next slide please and then achieving ejaculation um associated with with that leading position so I suppose moving on about Whether or not using uh this device or this this layout of electrodes um with a larger sample size and to give us a better idea of how that accounts or how it the variation sits and that's different members of the spinal cord injury population and with
different levels of injury and preference uh finally you know where you would you go next with this area of research or Interest I suppose patient public involvement is something intelligence you're really involved with the spinal injury Association um and then so I suppose as Damian described earlier about you know who who is this sit under I suppose it sits under the domain of both the Spinal Rehab consultants and also the the urologists and finally you know another big area that that is of equal importance in research is female Neurogenic sexual dysfunction all right uh and
then sorry and then the last slide just like to thank um any for their input with this project as well that's me done okay I I think um that was a that was a good discussion um I think we need to close we we ran out of time uh we took a letter on already a little bit too much time of You uh some people need to move on uh having dinner or other things to do tonight uh so I would like to uh thank the speakers uh Damien Thompson and Neil for um for their
presentations and the discussion and I would like to uh thank Ken and uh Mikhail for their uh technical support to make this possible and I would like to thank the audience for being here uh still we haven't discussed everything uh we didn't have Enough time it takes a lot more time and so we will continue and maybe in the next uh webinar we will um further discuss this this topic if you have any suggestions please let us know and hopefully we'll see you next time Thompson is there anything else just uh just as a sort
of questions for people who are interested in uh participating in further research or if anybody has any questions for me Damien or Neil Um we'll send out an email with some contact details to get in touch uh with with lots of details so if you're interested in research or getting in touch with the Sia or have any questions that you you want to talk or discuss um uh I know it's not the easiest Forum to talk online with with a webinar that's being recorded so uh we'll provide that um shortly after the webinar thank you
and um just finally um just to say that I have provided the support line telephone number that went into the the chat function and our online referral form so if there are any queries you know from today's webinar and by all means do get in touch with us that way all right well thank you uh so much everybody and um you have all have a good evening [Music]
