Sexuality and Intimacy After Spinal Cord Injury | The Practical Stuff: Making Sex Work in Real Life

A four-part blog series for unitedspinalga.org by Mitchell Tepper, PhD, MPH

Let’s talk about the things nobody wants to bring up but everybody wonders about: accidents, spasms, erections, medications, and safety. A little planning takes most of the worry out of it.

Bowel and bladder

Empty your bladder first and stick to your bowel routine before sex. Avoid intense genital or anal stimulation when your bowel is full.
Keep supplies close. Blue pads (chux), a towel, and a urinal nearby. Many couples keep absorbent towels discreetly stored under the bed. Being prepared lets you relax.
You can leave an indwelling catheter in during sex. It can be folded along the penis and held with a condom or tape. For women, a condom or tape can hold it against the lower abdomen. Use plenty of water-based lubricant.
Tell your partner ahead of time that an accident could happen. If it does, you’ve already agreed how you’ll handle it, and the moment usually passes quickly.

Lubrication, condoms, and protection

Use water-based lubricant for vaginal and anal sex, and for anything inserted, including fingers, toys, and vibrators. Skip petroleum jelly. It raises infection risk and breaks down latex condoms.
SCI doesn’t protect you from sexually transmitted infections or HIV. Use condoms for all types of intercourse. If hand function makes this hard, a willing partner can help.

Spasticity, positioning, and skin

Take anti-spasticity medication around the time you expect sex, as your doctor advises.
A warm room, a massage that includes inner thighs, back, and belly, and plenty of pillows or foam wedges can reduce spasms.
Try positions where you’re well supported, such as lying down or leaning on something. Experiment.
Watch your skin. Friction and prolonged pressure can cause sores, and sores can sideline you for weeks.

Erections: options from least to most invasive

Men with SCI have several choices. Always check with a doctor or urologist, ideally one familiar with SCI.

“Stuffing.” If you get reflex erections but they’re not firm enough for penetration, your partner can gently guide the penis in and use their muscles to keep stimulation going. Many couples are satisfied with this whether the erection holds or not.
Constriction rings. These help if you get an erection but can’t keep it. Use lots of water-based lubricant. Never leave a ring on longer than 30 minutes, so set an alarm and don’t fall asleep with it on.
Vacuum devices. These draw blood into the penis and are followed by a ring to hold it.
Oral medications (Viagra, Cialis, Levitra and similar). Often the first thing tried. They are generally well tolerated by men with SCI but must not be combined with nitrates, and some other medications can interact too, so your doctor needs to review everything you take.
Injections into the side of the penis. They work well for many men. Risks include bruising, scarring, and an erection that lasts too long (an emergency if more than four hours).
Surgical implants. These are the last resort because of higher risks.

If your desire has dropped or you’re only getting a partial erection, ask your doctor to check your testosterone. Men with SCI are more likely to have low levels, and it’s treatable.

For women, the main practical points are lubrication, positioning, vibrators and other devices (which many women with SCI use), and checking whether medications are getting in the way.

Check your medications

Some common medications can dampen desire, arousal, or orgasm. These include certain antidepressants, nerve pain drugs such as gabapentin and pregabalin, the spasticity drug baclofen, and some blood pressure medications. If you think a medication is affecting your sex life, don’t stop it on your own. Tell your doctor. Often the dose or timing can be adjusted, or another medication can be substituted.

Autonomic dysreflexia: know the signs

If your injury is at T6 or above, AD is a real risk during sex. It’s a sudden spike in blood pressure that can cause a pounding headache, flushing or sweating above the injury, a slow or irregular heartbeat, and in the worst case, seizure or stroke. Sometimes there are few symptoms until it’s serious.

Own a home blood pressure cuff and use it.
If AD hits, stop what you’re doing, sit up, lower your legs, and loosen tight clothing, including rings and straps. If it doesn’t ease within a few minutes, get medical help right away.
Talk with your doctor about prevention, including medication taken beforehand if you’re prone to it.
Try vibrostimulation first in a clinic where your blood pressure can be monitored, especially if your injury is at T6 or above. Never use electrical or mechanical stimulation on the penis without your doctor’s okay if you’re prone to AD.

Having a baby

Yes, many people with SCI become parents.

Women: SCI doesn’t physically stop you from conceiving. Periods can pause for six to eight months after injury, but pregnancy is still possible during that time, so use contraception if you don’t want to be pregnant. Pregnancy brings extra risks, such as bladder infections, pressure sores, and AD for injuries at T6 or above. All are manageable with a knowledgeable doctor. Many women deliver vaginally, and breastfeeding is possible.
Men: Ejaculation and sperm quality can be challenges. Vibrostimulation and electroejaculation can collect sperm, and fertility clinics that specialize in SCI can help. Ask your doctor for a referral.
Adoption is also a path to parenthood. An occupational therapist can help you find adaptive equipment like accessible cribs and changing tables.

Where to go from here

Ask your doctor, nurse, or rehab team about sexual health. If they don’t bring it up, you can. You have every right to expect respectful, informed answers. And if they say “give up on sex” or “just give it time,” ask for a referral to someone who knows more.
Contact the United Spinal Association Spinal Cord Resource Center (unitedspinal.org) and your local chapter’s peer support.
Visit DrMitchellTepper.com for the Sex and Paralysis video series and other resources.
Download the free PleasureABLE Sexual Device Manual for People With Disabilities and the PVA guide Sexuality and Reproductive Health in Adults with Spinal Cord Injury.

Sexuality spans the physical, emotional, social, and spiritual parts of who we are. It begins with how we feel about ourselves, and it grows through our connections with others. We are all sexual people, with or without SCI, and we have a right to a satisfying sexual life.

This series is educational and isn’t medical advice. Please talk with your own doctor about your individual situation.

Sources

Alexander MS, Courtois F, Elliott S, Tepper M. Improving sexual satisfaction in persons with spinal cord injuries: Collective wisdom. Top Spinal Cord Inj Rehabil. 2017;23(1):57-70.
Tepper M. Living Your Life: Sexuality Following Spinal Cord Injury. United Spinal Association; 2016.
Hollister Incorporated. Living Your Life: Love, Sex, and Becoming a Mother and Becoming a Father. 2011.