SEXUAL REHABILITATION

NITIN MENON
 WHAT IS SEXUALITY

It is a means of expressing feelings towards

oneself and others
It is a means of procreation of species
 PROBLEMS IN DEALING WITH ISSUES RELATED TO
SEX

During medical crisis and chronic illnesses,

issues related to sex are ignored
Physicians are uncomfortable discussing sex
Patients are intimidated by their physicians
or there are cultural issues at play which
preclude them from bringing up their
concerns
 SEXUAL RESPONSE CYCLE

4 stage model of Masters and Johnson

Excitement
Plateau
Orgasm
Resolution
Men have only 1 orgasm per cycle, women
could have multiple orgasms.
 EXCITEMENT PHASE

MEN
Engorgement of corpora cavernosa
Testicular elevation & scrotal skin flattening
WOMEN
Clitoral enlargement
Vaginal lubrication
Constriction of lower 2/3rds and dilatation of
upper 1/3rds of the vagina
Uterine elevation out of deep pelvis
Nipple erection, areolar enlargement & deepening
of color
 PLATEAU PHASE

MEN
Increase in diameter of glans penis
Increase in testicular size
Drop of secretion from cowper’s gland appearing
at meatus
WOMEN
Further ballooning of vagina upper part
Clitoris and glans retract
Increase in breast size
BOTH SEXES
Increased muscle tone, HR, RR, sexual flush
 ORGASM

BOTH SEXES
Further increase in HR, BP, RR
Involuntary contractions of perineal muscles
MEN
Contraction of seminal vesicles, vas deferens,
prostrate  pooling & ejaculation
Closure of bladder neck
WOMEN
Contraction of uterus, vagina, vulva
Multiple orgasms can occur
 RESOLUTION PHASE

General perspiration
Reversal of above changes
Men  post ejaculatory refractory period
 KAPLAN’S MODEL OF SEXUAL RESPONSE

Phases
- Desire  experience of specific sensations
that motivate the person to initiate or become
responsive to sexual stimulation
- Under central neurophysiological control
- Excitement phase  genital vasocongestion
- Orgasm  reflex muscle contractions
 NEUROLOGY OF SEX

MALES
Dual innervation of the male sexual arousal
response
REFLEX ERECTION
- Excitation of the dorsal penile nerve 
transmission of the impulse to the sacral cord
via the pudendal nerve
- Sacral parasympathetic excitation of the
pelvic nerve  cavernosal nerve stimulation 
penile engorgement
 PSYCHOGENIC ERECTION

At the level of medial amygdala & medial preoptic

area of the hypothalamus, α 2 adrenergic receptor
mediated inhibitory pathways & dopaminergic
mediated facilitatory pathways regulate erectile
function
The neurologic pathways travel down the lateral
column of the spinal cord & connect to the
thoracolumbar sympathetic & sacral parasympathetic
pathways to produce psychogenic erection
Presence of intact sympathetic pathways in the
absence of parasympathetic supply is sufficient to
produce psychogenic erection
 EMISSION & EJACULATION

Emission
- movement of semen from prostrate, seminal
vesicles & vas deferens to the anterior urethra
- Also involves contractions of the above structures
- Mediated via thoracolumbar sympathetic
stimulation
Ejaculation
- Forceful propulsion of semen from the urethra
- Mediated by sacral parasympathetic and somatic
efferent stimulation, also involves closure of
bladder neck by sympathetic stimulation
 WOMEN

Similar dual innervation for vaginal lubrication

Reflex lubrication regulated via sacral cord
Psychogenic lubrication regulated via
thoracolumbar sympathetic nervous supply
 SEX AND AGING

CHANGES IN WOMEN
Decreased estrogen levels
Loss of labial fullness
Thinning of pubic hair
Increased friability of the vaginal mucosa
Smaller increase in breast size and loss of
flattening, separation & elevation of the major
labia alongwith decrease in genital
vasocongestion during the excitement phase
Decrease in myotonia and less muscular tension
during orgasmic contractions
 SEX AND AGING

CHANGES IN MEN
Longer time to achieve an erection
Scrotal vasocongestion is decreased
Testicular elevation occurs later and is
decreased
Longer time to achieve ejaculation
Less frequent orgasmic contractions
Ejaculatory fluid is decreased
Extended refractory period
 SEX AND AGING

EFFECTS OF AGING ON SEXUAL FUNCTION

Decrease in self-esteem
Fears about illness & death which can
decrease interest in sex
Depression
Medical problems which can affect sexual
functioning
Increased level of fatigue
Drugs
 DRUGS AND SEX

Antihypertensives Benzodiazepines
- Propranolol - Diazepam

- Clonidine - Alprazolam
- Clonazepam
- Methyl dopa
- Thiazides
Anticonvulsants
- Carbamazepine
Anticholesterol drugs - Valproate
- Clofibrate - Phenytoin
Antidepressants Antiarrhythmics
- Imipramine Digoxin
- SSRIs H 2 blockers
Baclofen – in high doses
 SEXUAL HISTORY AND EXAMINATION

 Chief sexual symptom

 Duration
 Pre-disability sexual functioning
 History of other medical illnesses or surgical procedures
 History of drug use
 Psychiatric illness, family relationships
WOMEN
 Presence & quality of menses
 Method of birth control
 Obstetric history
 Ability to be sexually aroused
 Ability to lubricate  psychogenically or reflexly or both
 SEXUAL HISTORY AND EXAMINATION

MEN
 Quality of erections  both reflex & psychogenic
 Ability to sustain an erection
 Ability to ejaculate in an anterograde manner
 Change in pattern of response
Examination
 General exam
 ROM at hips, arms, hands
 Neurologic deficits
 Presence of genital dryness
 Other genital lesions or pressure ulcers
 PYSCHOLOGICAL ISSUES RELATED TO SEX

Why to discuss?
 Sexuality involves interplay between the psychological and the
physical
 Sexual dysfunctions originate in reaction to psychological
processes or are psychological reactions to organic illness
What are these issues?
 Decreased self esteem
 Altered sense of self – ability to act and influence the world
 These have emotional consequences, affecting one’s adjustment
and sense of sexuality
 Disability and illness create stress can increase conflict in
relationships
 Feeling of inadequacy in the disabled partner
 Differing attitudes regarding intimacy
 SEXUALITY AND SCI

MEN WITH UMN COMPLETE LESIONS

- Reflex erections +
- Psychogenic erections –
- Anterograde ejaculations ±
MEN WITH UMN INCOMPLETE LESIONS
- Reflex erections +
- Psychogenic erections ± (if lat column spared)
- Anterograde ejaculations ±
MEN WITH LMN COMPLETE LESIONS
- Psychogenic +
- Reflex –
MEN WITH LMN INCOMPLETE LESIONS
- Reflex ↓
 SEXUALITY AND SCI

WOMEN WITH COMPLETE UMN LESION

- Reflex genital arousal +
- Psychogenic –
- Ability to perceive LT & PP in T11 to L2
dermatomes  psychogenic arousal +
WOMEN WITH COMPLETE LMN LESIONS
- Less likely to achieve orgasm
BOTH SEXES
- Frequency of the sexual act ↓
- Satisfaction ↓
REPRODUCTIVE CONCERNS IN MEN

Impaired fertility due to

- Inability to achieve anterograde ejaculation
- Sperm number and motility suboptimal
- Recurrent UTI
- Medications
Management
- Electroejaculation and electrovibration with
ART
- Penile vibratory stimulation
 REPRODUCTIVE CONCERNS IN WOMEN

PROBLEMS
 Post injury amenorrhea (av. = 5months)
 Decreased pregnancy rates
 Declining pulmonary functions (due to increasing
fetal size)
 Autonomic dysreflexia (Treat  epidural anesthesia)
 Altered perception of labor
- Spasms
- Ruptured membranes
- AD
Compensation  uterine palpation to detect labor
 SEX AND MS

Fatigue, tremor, muscle weakness, spasticity,

anxiety, depression, lack of interest
Decrease in exacerbations in pregnancy but
aggravated in childbirth
Treatment strategies
- Timing of sexual activity to be altered to
avoid fatigue
- Management of bowel & bladder
incontinence
- Treat spasticity in adductor muscles
 SEX AND STROKE

Problems
- Elderly
- Concomitant medical issues
- Drugs
- ED & PME common
- Decrease in libido
 SEX AND TBI

Problems
- Decrease in energy for sex, decreased drive
- Difficulties regarding positioning
- Altered cognition
- Impaired general arousal (brain stem injury)
- Precocious puberty, amenorrhea
(hypothalamic injury)
- Hypersexual behavior, changes in sexual
preference (limbic injury)
- Inability to fantasize (frontal lobe injury)
 SEX AND NEUROMUSCULAR DISEASES

Problems
- Loss of pulmonary capacity  loss of stamina
- Loss of strength in peripheral musculature
- Difficulties in positioning
 SEX AND CTD

 Joint stiffness, pain & fatigue

 Loss of mobility
 Depression
 Effect of medications
Cause
- Decreased libido
- Positioning problems
- Inability to use hands effectively\
Treatment strategies
- Proper positioning
- Avoid prolonged pressure on joints
- Premedication or use of heat before sexual activity
- Adapted erotic aids like vibrators for poor hand functioning
 SEX AND TJR

THR can impair sexual activity

Sexual intercourse can be resumed in about a
month or 2 after THR
Preferred positions include missionary for men
(eliminates excess motion at hips)
Side lying with non-operated side down for
women
TKR  avoid positions that increase stress on
the joint (excess flexing)
 SEX AND DIABETES

ED
- Occurs in 50% of men with DM
- Poor glycemic control causes autonomic neuropathy
- Slowly developing ED is more likely to be permanent
Retrograde ejaculation
- Internal sphincter does not close as a result of
autonomic neuropathy
Decreased vaginal responsiveness in women
Lower than expected rates of pregnancy due to
endocrine abnormalities
Gestational DM can cause macrosomia and birth defects
 SEX AND AMPUTATION

Positioning problems can arise

Compensations
- Positioning with pillows to maintain stability
in transfemoral amputees
- Side lying position for upper limb amputee
 SEX AND CARDIAC DISEASES

Problems in patients with cardiac disease

- ED
- Chest pain
- Deconditioning
- Decreased libido
- Anxiety about recurrence of MI (occurs more
in the resolution phase of the sexual response
cycle)
- Depression
- medications
 SEX AND CARDIAC DISEASE

Management
- Walking on a treadmill at 3mph at 5% grade or climbing 20
steps in 10 seconds  safely return to sexual activity
- True exercise stress test (should be able to perform 4-6
METs)
- General conditioning program
- Timing the sexual activity when not fatigued (morning)
- Foreplay (to gradually increase the HR)
- Avoid sex after heavy meal or alcohol intake
- Prophylactic NTG (avoid if patient is on sildenafil)
- Report if – rapid HR or breathing pattern persists after 7-
10 mins of orgasm, angina or extreme fatigue after orgasm
 SEX AND PULMONARY DISEASES

PROBLEMS
Dyspnea  decreased activity tolerance
Exacerbations of COPD due to rapid
breathing rate resulting in incomplete
expirations
Pressure of partner on chest  increase work
of breathing
Effect of medications
Deconditioning
Cystic fibrosis (azoospermia)
 SEX AND PULMONARY DISEASES

MANAGEMENT
- Avoiding sex on awakening (due to accumulated
secretions)
- Avoid physical activity before sex
- Use a bronchodilator prophylactically
- Avoid prolonged kissing and oral sex if they result
in dyspnea
- Side-lying and seated positions decrease work of
breathing
- Trying mutual masturbation rather than sexual
intercourse
- Microsurgical epididymal sperm aspiration and
intracytoplasmic sperm injection (for cystic
 SEX AND CANCER

PROSTRATE CANCER
- Surgery  ED (due to nerve damage)
- Decreased testosterone levels  decreased
libido, ED
TESTICULAR CANCER
- Retroperitoneal LN dissection  sympathetic
supply loss  retrograde ejaculation
PENILE CARCINOMA
- Penectomy  use penile implants
 SEX AND CANCER

BREAST CANCER
- Menopause (due to drugs)
- Vaginal soreness, dryness, hot flashes. Treatment  local
estrogen cream
OVARIAN CANCER
- Post coital bleeding
- Onset of menopause
- Surgical removal of reproductive organs
CERVICAL CANCER
- Fibrosis, pain with penetration, decreased lubrication,
vaginal stenosis
- Treatment  vaginal dilators, lubricants, alternative
position
 SEX AND CANCER

COLON CANCER
- APR  ED, ejaculatory dysfunction
- Colostomy can interfere with sex
BLADDER CANCER
- Retrograde ejaculation, ED
HEAD & NECK CANCER
- Disfigurement  image change
Effect of chemotherapy, radiation, hormone
therapy, effect of fatigue
 SEX AND CHRONIC PAIN

Pain
Depression
Weight gain or loss
Physical deconditioning
Loss of self image
Effect of drugs
 TREATMENT STRATEGIES

SEXUAL COUNSELING
Problems
- No specific training in the area of sexuality
- Sexuality is replete with personal values and
biases on the part of the physician
 PLISSIT MODEL

PLISSIT model
Permission
Limited information
Specific suggestion
Intensive therapy
Professionals should feel comfortable raising the
issue to permit discussion of the topic
Should possess enough knowledge to impart limited
information – should know their boundaries– refer to
more knowledgeable persons
Institutional commitment to train all personnel on
basic sexuality issues
 SCHOVER’S MODEL

Model for brief, problem-focused sexual counseling following

chronic illness
5 criteria for counseling
- Sexual dysfunction that predated the illness
- Relationship that is conflicted by the illness
- Sexual dysfunction because of poor coping
- Dysfunction because of changes in sexual self-image
- Adjustment to medical or surgical procedures
5 aspects of counseling
- Sexual education
- Changing maladaptive sexual attitudes
- Helping couples resume sex
- Overcoming physical handicaps
- Decreasing marital conflicts
 PHILOSOPHY OF SEXUAL COUNSELING

Sexuality is more than the act of sexual intercourse. It

involves the whole business of relating to another person;
the tenderness, the desire to give as well as take, the
compliments, casual caresses, reciprocal concerns,
tolerance, the forms of communication that both include
and go beyond words.
Sexuality includes a range of behaviors from smiling through
orgasm; it is not just what happens between two people in
bed.
The goal with couples in sexual counseling is to help them
expand their personal definition of sexuality. When their
definition of sexuality is broad and encompassing, they will
likely adjust more smoothly to the physical challenges in
their lives.
 EDS

Thorough history and physical exam

History of drug intake
Psychological history
Lab testing
- Serum testosterone
- Glucose levels
- Penile Doppler
- Nocturnal penile tumescence monitoring (to
differentiate neurogenic from psychogenic
sexual dysfunction)
 DRUG THERAPY

SILDENAFIL
- Selective inhibitor of cGMP specific PDE5
- Causes NO induced cGMP concentrations to stay elevated in the penile
corporeal muscles
- This causes vasodilatation and penile erection
ADR
- Do not use with nitrates
- Headache, nasal congestion, visual blurring
The drug does not help with baseline complete absence of both reflex and
psychogenic function
YOHIMBINE
- α2 adrenergic blocker
- Used in treating SSRI associated ED
PHENTOLAMINE
- Non specific, psychogenic or mild vascular dysfunction
APOMORPHINE
 VACUUM ASSISTED DEVICES

 Used in patients able to achieve an erection but not maintain it

 Device consists of a hard plastic cylindrical tube, at the end of
which is a smaller, soft plastic tube leading to a pump
 Manual or electric pump is used to generate a vacuum which
results in engorgement of corporeal tissues
 A constriction ring is placed on the base of the penis to
maintain the erection
Potential problems
- Penis will be wider than usual diameter
- Superficial veins will be dilated
- Abrupt lack of erection proximal to the constriction band
- Not to be used on patients taking anticoagulant
- Maximum time to place constriction band = 30 mins
 INJECTIONS

Intracavernosal injection therapy  relaxation of

smooth muscles  enhanced corporeal filling 
increased duration of erection
Papaverine, regitine, PGE1
Problems
- Penile pain
- Prolonged erections
- Priapism (treatment  aspiration & α agonist
injection
- Penile fibrosis
- Ecchymosis or hematoma
 PENILE PROSTHESIS

 Invasive therapy
 Prosthesis – malleable or inflatable
 2 erectile cylinders containing fluid reservoirs, inflation
pump at the tip, expansile chamber in the middle
implanted into the corporeal bodies
 Pumping causes erection without increase in diameter,
pressure on relief valve causes detumscence
Problems
- Mechanical failure
- Infections
- Extravasation of fluid
- Altered orgasm and ejaculation
- Scar formation
 HYPOACTIVE SEXUAL DISORDERS

Persistent or recurrent lack of sexual

fantasies and desire for sexual activity
Causes personal or interpersonal distress
Related to disability or illness or use of
medications
Treatment  counseling
 PREMATURE EJACULATION

 One of the most common sexual disorders

 Persistent or recurrent ejaculation with minimal sexual
stimulation before, on or shortly after penetration and before
the person wishes it
 Work-up for prostrate or UTI
Management
 Cognitive behavioral therapy
 New skills to increase man’s pleasure & decrease pressure to
perform
 Couple therapy to learn ejaculatory control by identifying point
of ejaculatory inevitability at which stimulation is stopped,
then resumed
 Alternative positions and movements
 SSRIs
 SEXUAL AROUSAL DISORDER IN FEMALE

Persistent or recurrent inability to attain or

maintain sufficient sexual excitement
expressed as a lack of subjective excitement
or genital or somatic responses
Management
Water based lubricants
Sildenafil
Cognitive therapies
Vibrators
Sexual counseling
 ORGASMIC DISORDER

Persistent or recurrent difficulty, delay in or

absence of attaining orgasm following sufficient
sexual stimulation and arousal which causes
distress
Determine whether problem was premorbid
Management
Learning about their bodies through stimulation
until they reach orgasm (learning to know what
feels good to them & teaching their partners)
Sex therapy
Use of aids to augment sexual response
 SEXUAL PAIN DISORDER

 Dyspareunia  recurrent or persistent genital pain

associated with intercourse
 Vaginismus recurrent or persistent involuntary spasm of the
outer vaginal musculature that interferes with penetration
 Noncoital sexual pain disorder  recurrent or persistent
genital pain induced by noncoital sexual stimulation
Management
- Search for co-morbidities like neuropathic pain
- Adequate lubrication
- Relaxation techniques
- Dilators
- Woman should be in charge of when and how penetration
take place
END