Elena Andretta
Chronic neurological disease can have a tremendous impact on a woman’s health, self-image, and consequently on self-esteem [1]. One of the most important areas that could be impaired after the onset of a neurological disease is sexual function.
Lesions in any level of the central nervous system (brain, spinal cord, and peripheral nerves) could impact on sexual function and could diminish a woman’s libido and ability to become sexual aroused, finally preventing orgasm. Neurologic disease frequently negatively affects sexual experience in multiple ways. Nevertheless, because a woman’s ability to become pregnant and carry and deliver a child is largely unaffected following such neurological disease, such as spinal cord injury or multiple sclerosis, it was assumed, for many years, that her sexuality was similarly unaffected [2]. Therefore, for many times, female sexuality was equalized with childbearing, and scientific interest was confined to pregnancy and its complications [3].
Nevertheless, sexual dysfunctions are common including decreased or loss of libido, painful or uncomfortable genital sensations (burning, tingling, numbness), and/or altered orgasmic response in both women and men. Women may experience decreased vaginal lubrication and dryness, anorgasmia, and low sex desire [4, 5].
Secondary sexual dysfunction arises as a consequence of disability caused by poor bladder and bowel control, fatigue, muscle weakness, spasticity, immobility, tremor, cognitive impairment, and sensory problems [6].
Muscular weakness, spasticity, or insensibility may prevent movements and reduce mobility and pleasure during intercourse. Moreover, psychological and social factors could contribute to cause further sexual dysfunction as hypoactive sexual disorder.
15.1 Neuroanatomy and Neurophysiology
The innervation of the female genital tract is mediated through the somatic and autonomic nervous systems. Somatic innervation is conducted through the pudendal nerve. The first branch of the pudendal nerve, called the dorsal nerve of the clitoris, is a sensory nerve, without any motor functions.
It carries somatosensory impulses from the clitoris [1].
The second branch, called the perineal nerve, provides sensory branches to the perineum, labia majora, labia minora, and distal third of vagina [1].
Moreover the perineal nerve provides motor innervations to pelvic floor muscles. Sympathetic innervation is provided from the sacral portion of the sympathetic chain.
The uterovaginal plexus supplies the uterus, salpinges, ovaries, vagina, erectile tissue of the clitoris and vestibular bulbs, urethra, and greater vestibular glands [7].
The neurophysiology of sexual response in women is not well understood even in nonneurological patients. In determining the neural pathways involved in the control of sexual response, the study of persons with spinal cord injuries (SCIs) allows to test hypotheses regarding the role of specific spinal mechanisms [8].
Sipski et al., with their laboratory-based, controlled studies in patients with SCI, demonstrated that preservation of sensory function in the T11-L2 dermatomes is associated with psychogenically mediated genital vasocongestion.
Less than 50 % of women with SCIs were able to achieve orgasm, compared with 100 % of able-bodied women (p < 0.001). Only 17 % of women with complete lower motor neuron dysfunction affecting the S2-S5 spinal segments were able to achieve orgasm, compared with 59 % of women with other levels and degrees of SCIs (p = 0.048). Time necessary to achieve orgasm was significantly increased in women with SCIs compared with able-bodied controls (p = 0.049) [8].
The impact of SCI on sexual response depends on the degree of injury and its location in the spinal cord [9]. Most of the information available about male sexual response is based on questionnaire studies, whereas most of the data available about women comes from laboratory-based research [10].
For women with complete upper motor neuron injuries affecting the sacral segments, the ability for reflex but not psychogenic lubrication should be maintained [8]. This hypothesis has been tested in a laboratory-based analysis [8], and the results, although not conclusive, supported the hypothesis that lubrication occurs reflexively [8].
For women with incomplete upper motor neuron injuries affecting the sacral segments, it is thought that they may retain the capacity for reflex lubrication and may maintain the capacity for psychogenic lubrication [8].
Reflex lubrication and orgasm are more prevalent in women with SCI who had preserved the sacral reflex (S2-S5). For those with complete SCI of the sacral segment, arousal and orgasm may be evoked through stimulation of other erogenous zones above the level of lesions such as the breasts, lips, and ears [11].
15.2 Psychological Change After Neurological Diseases
Although various health conditions can affect sexuality, the sexual consequences of suffering a spinal cord injury (SCI) can be substantial, especially because the majority of SCIs occur during the years when reproductive and sexual capacities are at their peak [12].
The SCI women reported that the neurological disease caused many changes in their life and affected many aspects of their sexuality negatively. Some changes were of a physical nature (decreased, lost, or changed sensation; difficulties to achieve orgasm; bladder or bowel problems; and difficulties to move and position), whereas other changes were of a psychological nature (feeling unattractive or less attractive, having less self-confidence, and difficulties to meet or find a partner).
The main difference in sexual functioning between women with disabilities and those without can be accounted for by the difficulties women with disabilities have in finding a partner. Their level of sexual desire may be the same, but the level of activity is generally less because fewer women with disabilities have partners.
There are no changes after paralysis that prevent women from engaging in sexual activity. Positioning can be an issue but could usually be accommodated. Autonomic dysreflexia could be anticipated and controlled. Although women’s desire for sexual activity seems to decrease after injury, 46 % of women with SCIs indicated that sex was less important after injury, and 44 % of women with SCIs rated their level of desire as “none” to “low” after injury [13, 14]. Frequency of sexual activity is also known to decrease in women with SCIs.
Recent studies have tried to investigate the true incidence of sexual dysfunction in women affected by SCIs, with a special attention to the level and completeness of injury, time from injury, and age of the patients. Biering-S0rensen et al. have demonstrated, in a survey on 43 SCIs women, that nearly all (94 %) female participants reported not having problems with impaired vaginal lubrication [15]. Sixty- nine percent of the women reported being satisfied with their sexual life [15]. When comparing satisfaction with sex life and the amount of problems regarding bladder and bowel management, pressure ulcers, spasticity, or pain, there was no statistically significant difference (p=0.08), although there was a tendency toward the more problems reported, the less satisfied the women were likely to be with their sexual life [15]. No statistically significant difference was found in satisfaction with sexual life when comparing tetraplegic and paraplegic women, or in relation to the Frankel classification [15].
When comparing satisfaction with sexual life with age, it was found that the mean age was statistically significantly lower for the satisfied women compared with the unsatisfied women (45 vs 53 years). Likewise, those who were satisfied were younger at the time of injury (24 vs 31 years). There was no significant difference in mean time since SCI in relation to satisfaction with sexual life (21 vs 22 years). There was no significant difference in satisfaction with sexual life between those who had given birth to a child after SCI and those who had not (87.5 % vs 65.4 %) [15]. Other studies found that women with tetraplegia were less likely to have sexual intercourse than other women with SCI, due to the possible presence of autonomic dysreflexia and urinary incontinence [16].
15.3 Pregnancy and Spinal Cord Lesion
Unlike men with SCIs, the ability of women with injury to conceive is thought to be unchanged. Of the 231 women studied by Charlifue et al., 60 experienced an average of 5 months of temporary amenorrhea after injury. After this time period, the women’s fertility should have returned to normal levels [17]. Conception, pregnancy, and normal labor and delivery are possible virtually with little added risk [3].
Some of reported complications of pregnancy in SCI patients are autonomic hyperreflexia, when lesion is above T6 level, major urinary tract infections, anemia, respiratory problems, skin fragility, and increased risk of early delivery [18]. Some studies reported a high risk of assisted deliveries with forceps because of weakness of abdominal muscles during expulsive phase [19].
For this reason and other factors such as autonomic hyperreflexia, fear of higher incidence of cesarean deliveries was reported [19].
No other problems were reported, especially no problem in the babies, except lower average birth weights than the general populations [19, 20].
15.4 Therapeutic Options
There are no evidence-based therapeutic options to treat neurological women with sexual dysfunction.
Lombardi et al., recently, in a 2-year follow-up after permanent SNM, reported that 36.5 % of females with SCI and sexual dysfunction obtained positive effects on sexual response and showed a remarkable concomitant improvement through the Female Sexual Distress Scale (FSDS) questionnaire [6].
References
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