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This
section includes general definitions and
descriptions of common terms, conditions and
complications associated with spinal cord
injuries, as well as links to other available
spinal cord injury and disability resources. It
is intended for the purpose of educating people
about spinal cord injuries only and not for
medical diagnosis or treatment.
Bladder Conditions &
MANAGEMENT
Bladder
Conditions:
Normally, when the
bladder become full (about 1-2 cups for most
people), nerve endings in the bladder wall send
a message to the brain via the spinal cord. The
brain sends a message back to the bladder to
contract the detrusor muscles and relax the
sphincter muscles so you can void. If you can't
get to a toilet, the brain delays the messages
until you are ready to void. After a spinal cord
injury the bladder, along with the rest of the
body, undergoes dramatic changes. Since messages
between the bladder and the brain cannot travel
up and down the spinal cord, the voiding pattern
described above is not possible. Depending on
the type of spinal cord injury, the bladder may
become either "floppy" (flaccid) or
"hyperactive" (spastic or reflex):
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The Flaccid Bladder : A floppy bladder
loses detrusor muscle tone (strength) and does
not contract for emptying. This type of bladder
can be easily overstretched with too much urine,
which can damage the bladder wall and increase
the risk of infection. Emptying the flaccid
bladder can be done with techniques such as
Crede, Valsalva, or intermittent catheterization
(see "online resources" below). It is very
important that you do not let your bladder get
overfull, even if it means waking up at night to
catheterize yourself more frequently.
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The Reflex Bladder:
The detrusor muscles
in a hyperactive bladder may have increased
tone, and may contract automatically, causing
incontinence (accidental voiding). Sometimes the
bladder sphincters do not coordinate properly
with the detrusor muscles, and medication or
surgery may be helpful.
Bladder
Management
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Foley or
Suprapubic Catheter: A tube is inserted
through the urethra or abdomen and into the
bladder, where a balloon on the end holds it
in place. It remains in the bladder and drains
constantly, so the bladder is never full.
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External
Catheterization:
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Condom
Catheters: These collection devices are worn
by men for incontinence problems. They are
made of latex rubber or silicone that covers
the penis and attaches to a tube that drains
into a collection bag.
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External
Continence Device (ECD): An ECD is a method
of continence management that attaches only
to the tip of the penis using hydrocolloid,
a hypoallergenic adhesive commonly used in
wound and ostomy care. Urine is directed
into a collection bag and does not come in
contact with skin.
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Intermittent
Catheterization: You drain your bladder
several times a day by inserting a small
rubber or plastic tube. The tube does not
stay in the bladder between
catheterizations.
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Spontaneous
Voiding: The bladder muscles contract to
start the bladder-emptying process. This may
be under your control (voluntary) or not
(involuntary):
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Normal Voiding:
This is done under your control. When the
bladder gets full, messages are sent to the
sacral level of the spinal cord and carried
to the brain. The brain sends messages back
to the bladder to contract, and to the
sphincter muscle to open, so you can void.
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Spincterotomy:
This surgical process weakens the bladder
neck and sphincter muscle to allow urine to
flow out more easily. After this surgery,
you will urinate involuntarily, and must
wear a collection device.
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Condom Catheter:
These collection devices are worn by men for
incontinence problems or after
sphincterotomy. They are made of latex
rubber or silicone that covers the penis and
attaches to a tube that drains into a
collection bag.
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Stimulated
Voiding:
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Anal or Rectal
Stretch: This method for relaxing the
urinary sphincter is usually used along with
an abdominal corset and valsalva.
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Crede:
This method involves manually pressing down
on the bladder. Tapping The area over the
bladder is tapped with the fingertips or the
side of the hand, lightly and repeatedly, to
stimulate detrusor muscle contractions and
voiding.
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Valsalva:
This method involves increasing pressure
inside the abdomen by bearing down as if you
were going to have a bowel movement.
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Surgical
Alternatives:
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Mitrofanoff:
A passageway is constructed using the
appendix so that catheterization can be done
through the abdomen to the bladder. Bladder
Augmentation Surgical enlargement of the
bladder.
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Spincterotomy
See the description of this procedure in the
"Spontaneous Voiding" section.
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Bowel Conditions
With a spinal cord
injury, damage can occur to the nerves that
allow a person to control bowel movements. If
the spinal cord injury is above the T-12 level,
the ability to feel when the rectum is full may
be lost. The anal sphincter muscle remains
tight, however, and bowel movements will occur
on a reflex basis. This means that when the
rectum is full, the defecation reflex will
occur, emptying the bowel. This type of bowel
problem is called an upper motor neuron or
reflex bowel. It can be managed by causing the
defecation reflex to occur at a socially
appropriate time and place.
A spinal cord injury
below the T-12 level may damage the defecation
reflex and relax the anal sphincter muscle. This
is known as a lower motor neuron or flaccid
bowel. Management of this type of bowel problem
may require more frequent attempts to empty the
bowel and bearing down or manual removal of
stool.
Both types of
neurogenic bowel can be managed successfully to
prevent unplanned bowel movements and other
bowel problems such as constipation, diarrhea
and impaction.
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Cardiovascular
Disease
Cardiovascular
disease is a major long-term risk of spinal cord
injury. SCI individuals live in general rather
sedentary lives and are at higher risk for
cardiovascular disease than the able-bodied
population. Therefore, careful assessment of
cardiovascular function and the encouragement of
exercise programs are appropriate and necessary
long-term aspects of spinal cord injury
management and care. The prescription of upper
extremity exercise programs in spinal
cord-injured individuals are similar to those
used in other populations with the exception of
the use of adaptive equipment such as racing
wheelchairs or mono-skis.
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Online Resources:
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-Web
Link- |
"Heart Disease" - link to article on Craig
Hospital web site. |
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Deep Vein Thrombosis
(DVT) or pulmonary
embolism is a potentially severe complication of
spinal cord injury. There are changes in the
normal neurologic control of the blood vessels
that can result in stasis or "sludging". Deep
vein thrombosis in the lower leg is almost
universal during the early phases of recovery
and rehabilitation. Thromboses in the thigh,
however, are a great concern, as they are at
risk for becoming dislodged and passing through
the vascular tree to the lungs. A major
obstruction of the arteries leading to the lung
can potentially be fatal.
Deep vein thrombosis is a medical condition for
blood clotting. This is a process for formation
of thrombi that either partially or completely
block circulation in a deep vein, generally in
the lower extremities. Unlike the superficial
veins just below the skin surface, the deep
veins are surrounded by powerful muscles that
contract to force blood back to the heart.
One-way valves inside the veins prevent backflow
of blood between muscle contractions. The quick
and efficient return of blood to the heart using
the power of the leg muscles is a crucial phase
of the circulatory process. When the rhythm of
circulation slows down due to illness, injury,
or inactivity, there is a tendency for blood to
accumulate or "pool." A static pool of blood
provides an ideal environment for clot
formation.
Symptoms of DVT may
include pain, swelling, discoloration of the
affected area, and skin that is warm to the
touch. But up to 50% of deep vein thromboses
produce minimal symptoms or are completely
"silent." Because a number of other conditions,
like muscle strains, skin infections, and
inflammation of superficial veins (phlebitis),
display symptoms similar to those of deep vein
thrombosis, the condition may be difficult to
diagnose without specific imaging studies.
The major risk
associated with DVT is development of pulmonary
embolism (PE). A fragment of a blood clot breaks
loose from the wall of the vein and migrates to
the lungs, where it blocks a pulmonary artery or
one of its branches. Blockage of the main
pulmonary artery by one or more of these
migrating clots (emboli) may be life
threatening. Symptoms may include shortness of
breath, a feeling of apprehension, rapid pulse,
sweating, and/or sharp chest pain that worsens
with deep breathing. Some patients may cough up
bloody sputum. Others may develop very low blood
pressure and pass out. Anyone experiencing these
symptoms should call for assistance (don't try
transporting yourself) and get to the hospital
as soon as possible. A number of serious
conditions—including an evolving heart attack
and pneumonia—may mimic pulmonary embolism.
Although other
measures are sometimes used, the most common
form of treatment for DVT is the use of
anticoagulants, such as heparin and warfarin.
Therapeutic measures to reduce or eliminate the
risk for deep vein thrombosis include Ace
wrapping of the legs and the use of pneumatic
compression stockings.
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Online Resources: |
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-Web
Link- |
www.dvt.net - web site describing DVT
including risk factors, signs & FAQ. Requires
Flash 5 player. |
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Heterotopic
Ossification
Heterotopic
ossification is a condition not well understood
that occurs in acute spinal cord injury and
consists of the laying down of bone outside the
normal skeleton, usually occurring at large
joints such as the hips or knees. The primary
problem with heterotopic ossification, or HO, is
the risk for joint stiffening and fusion. Should
the hip or knee become fused in a certain
position, a surgical release is necessary to
allow range of motion to occur. Activities that
are used to prevent the development of HO
include range of motion programs and other
functional activities that move the joints
within a functional range.
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Online Resources: |
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-Web
Link- |
"Heterotopic Ossification" - Spinal Cord
Injury Fact Sheet from SCI Information Network -
University of Alabama. |
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HYPERTHERMIA/HYPOTHERMIA
Because of your
spinal cord injury, the temperature of your body
has an increased tendency to fluctuate according
to the temperature of the environment. If you
are in a hot room your temperature may increase
(hyperthermia); if you are in a cold
room, your temperature may decrease (hypothermia).
This occurs because of the altered function of
the autonomic nervous system. The higher the
level of injury, the greater the tendency for
fluctuations in your body temperature.
Hyperthermia
Hyperthermia
refers to an elevation in body temperature. For
example, it may occur on a hot day if you are
out-of-doors, sitting in a hot car, or covered
with too many blankets.
One or more of
the following symptoms may indicate
hyperthermia:
- Skin feels hot
and dry and appears flushed
- Feeling of
weakness
- Dizziness
- Visual
disturbances
- Headache
- Nausea
- Elevated
temperature
- Pulse is
generally rapid and may be irregular or weak
It is important
that you attempt to prevent hyperthermia when
exposed to an overheated environment.
Be familiar with
how long you can be in an overheated environment
without symptoms Drink lots of fluids Wear
protective, light-weight clothing (cotton and
light colors) Wear a hat
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Neuropathic/Spinal
Cord Pain
Neuropathic
(nerve-generated) pain is a significant problem
in some spinal cord-injured patients. Varying
types of pain are described in spinal cord
injury. Damage to the spine and soft tissues
surrounding the spine can cause aching at the
left of the injury. Nerve root pain is described
as sharp or may be described as having an
electric shock-type quality. Occasionally SCI
patients will describe phantom limb pain or pain
that radiates from the level of the lesion in a
specific pattern that is related to injury or
dysfunction at the nerve root or spinal cord
level. Various medications and nerve block
procedures have been described and are of some
use in the treatment of neuropathic pain
following spinal cord injury.
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Osteoporosis and
Fractures
The majority of
people with SCI develop osteoporosis. In people
without SCI, the bones are kept strong through
regular muscle activity or by bearing weight.
When muscle activity is decreased or eliminated
and the legs no longer bear the body's weight,
they begin to lose calcium and phosphorus and
become weak and brittle. The main risk of
osteoporosis is fracture. Once the bones become
brittle, they fracture easily. An osteoporotic
bone takes much longer to heal.
It is difficult to
totally prevent bone demineralization after
spinal cord injury. We know that individuals are
at higher risk for osteoporosis following SCI.
However, there is no “standard of care” to treat
this problem. Standard treatment methods for
osteoporosis have not been widely researched for
treating a person with spinal cord injury. Each
individual needs to be evaluated to determine if
treatment is warranted.
Exercise
Physical activity is
recommended to preserve or increase bone mass in
able-bodied individuals. A physical therapist
can recommend an exercise program. Various
activities are under study as forms of exercise
to build bone strength in individuals with SCI.
These include weight bearing using a standing
frame or harness; treadmill training; Parastep;
and functional electrical stimulation.
Extra calcium and
vitamin D
These need to be
included in one’s daily diet to help in
preventing osteoporosis. Calcium helps build
strong bones and vitamin D improves the
absorption of calcium, but for individuals with
SCI, high levels of calcium and vitamin D may
increase the risk of urinary stones. There are
no guidelines on the risks or benefits of
calcium and vitamin D supplements for
individuals with SCI.
Don't smoke
Smoking reduces the
body’s ability to absorb calcium. This in turn
can speed up bone loss in all populations.
Limit caffeine
Caffeinated drinks
act as a diuretic. They speed up the removal of
calcium from the body in the urine by about 10
mg per day.
Avoid drinking too
much alcohol
This is linked to
bone loss as well as poor nutritional habits.
Medications
A new class of
drugs, bisphosphonates, can help prevent bone
loss and increase bone density by 1 to 4%. These
drugs are approved for preventing and managing
osteoporosis in the general population.
Protect the bones
Individuals with SCI
need to protect their bones. When doing range of
motion exercises, limit movement to stretches
that are easily done. Do not force a joint or
muscle to move past what is comfortable. Check
with a physical therapist for exercises specific
to an individual’s needs and abilities.
Spasticity can put some force on the bones that
helps to strengthen them. However strong spasms
could cause a weak bone to fracture. Be cautious
when transferring. Remove feet from heel loops
or toe straps on the foot rests before
transferring. If a person’s balance or strength
is weak, he/she needs to ask for help to avoid
falling.
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Online Resources: |
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-Web
Link- |
"Osteoporosis" - link to article on Craig
Hospital web site. |
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Pneumonia,
Atelectasis, Aspiration
Patients with spinal
cord injuries above the T4 level of injury are
at risk to develop restriction in respiratory
function, termed "restrictive lung disease".
This occurs five to 10 years following spinal
cord injury and can be progressive in nature.
The quadriplegic individual as part of a health
care maintenance routine should have pulmonary
function studies at yearly or every-other-year
intervals between five and 10 years post injury.
As the medical treatment of spinal cord-injured
individuals continues to improve, respiratory
complications of SCI are becoming more
prominent. Adequate health maintenance and
protection from this complication are
appropriate and necessary as part of the
long-term care of the spinal cord-injured
individual.
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POSTURAL
(ORTHOSTATIC) HYPOTENSION
Postural
hypotension, also known as orthostatic
hypotension, is a condition which results in a
decrease in blood pressure when you sit or
stand. This can cause "light-headedness" or
"fainting". It occurs more commonly when you are
first injured, when you are fatigued, or after
any illness. You will have an increased tendency
for postural hypotension if your level of injury
is at T-6 or above, but it can occur in all
spinal cord injured individuals.
After your spinal
cord injury, the blood vessels do not decrease
in size, in response to lowered blood pressure,
due to the altered function of the autonomic
nervous system. Because of this, blood pools in
the pelvic region or legs while you are sitting
or sanding. Postural hypotension usually occurs
when you are initially placed in your wheelchair
or on the tilt table. To prevent this, wear
elastic hose and an abdominal support. It is
also helpful to come to a sitting or standing
position gradually.
If postural
hypotension occurs while you are in a
wheelchair, your attendant should firmly grab
the handles of the wheelchair and tilt you
backward, until your head and neck are nearly
horizontal to the floor. This will increase your
blood pressure and the "fainting" will quickly
disappear. You should then be gradually returned
to a sitting position.
Another problem that
may occur as a result of the lowered blood
pressure is a decrease in the amount of urine
produced by the kidneys. You may notice that
there is little or no urine in your urine bag.
After you recline, your leg bag may fill
quickly. This is a result of the increase in
your blood pressure that occurs when you lie
down. Watch your drainage bag closely after
changing positions to make sure it does not get
too full.
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RANGE OF MOTION
If the joints,
muscles, ligaments, and tendons are not
exercised they will contract or stiffen. Range
of motion exercises are used to keep these parts
loose. Basic exercises may include: heels, leg
rotation, hip extension, straight leg rise, and
trunk rotation. Quick motions may damage the
joints and all range of motion exercises should
therefore be done with smooth, controlled
motion.
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Online Resources: |
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-Web
Link- |
"Range of Motion" - link to article on
National Spinal Cord Injury Association web site
which describes examples of basic range of
motion exercises. |
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Respiratory
Dysfunction
Respiratory
complications and infection predominate as
post-SCI complications. When the injury involves
the upper thorax, the normal breathing pattern
is permanently altered. The diaphragm does most
of the work in quiet breathing. The chest wall
muscles (intercostals) are used primarily for
deep breathing or coughing. The abdominal
muscles also participate in coughing. When the
intercostal and abdominal muscles are paralyzed,
the entire load is taken by the diaphragm. This
results in poor coughing and a high risk of
pneumonia.
Pneumonia is one of
the most common complications of acute spinal
cord injury. Preventive measures are very
important to reduce the risk of pneumonia. These
include: percussion and drainage using gravity
to assist;
assisted
coughing (also termed "quad coughing");
abdominal binders (to increase the resistance
against which the diaphragm works); and early
mobilization (i.e.; getting the patient out of
bed as soon as possible).
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Sexual Function
Sexual function may
be affected in varying degrees by a spinal cord
injury, but how you feel about yourself may have
as much effect on your functioning as a sexual
person as the paralysis and sensory loss. Many
aspects of sexuality are the same after SCI as
they were before. Again, the effect on function
and movement will depend on the level of injury
and whether damage to the spinal cord is
complete or incomplete.
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Online Resources: |
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"Sexual Function for Men with SCI" -
Spinal Cord Injury Fact Sheet from SCI
Information Network - University of
Alabama. |
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"Sexuality for Woman with SCI" -
Spinal Cord Injury Fact Sheet from SCI
Information Network - University of
Alabama. |
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-Web
Link- |
"Sexuality in Spinal Cord Injury" -
link to University of Miami School of
Medicine section on sexuality & SCIs;
topics include: For Men - Erections;
Ejaculation, Orgasm & Coitus; Sexual Drive
& Activity; For Women - Orgasm; Fertility,
Childbirth, & Contraception; Sexual
Behavior & Activity |
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-Web
Link- |
"Sexuality and Spinal Cord Injury - Where
We Are & Where We Are Going" - article
from American Rehabilitation Magazine
which discusses the different effects of
an SCI on sexual ability for men and
women, as well as treatment of sexual
dysfunction and infertility. |
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-Web
Link- |
"Sexual Health Network" - web site
operated by Mitch Tepper PhD, a
quadriplegic, which provides easy access
to sexuality information, education,
mutual support, counseling, therapy,
healthcare, products & other resources for
people with disabilities |
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-Web
Link- |
Sexual Health & Fertility After Brain &
Spinal Cord Impairment - site by
International Collaboration On Repair
Discoveries & Vancouver Hospital & Health
Sciences Centre, covering topics related
to sexual health & fertility after spinal
cord injury |
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"Books &
Publications - Sexuality & Relationships"
- a listing in the Travis Roy Foundation
web site of available publications about
sex and relationships after an SCI,
including links to online retailers |
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FERTILITY
Women:
Women with
paraplegia or quadriplegia and of childbearing
age usually regain menses; nearly 50% do not
miss a single period following injury. Pregnancy
is possible, and if pelvic measurements are
adequate, most spinal cord injured women can
have normal vaginal deliveries.
A SCI woman may
be subject to certain complications of pregnancy
and should discuss these with her physician.
Among potential complications are premature
delivery in women in whom injury occurs during
pregnancy and above the T-10 level and autonomic
dysreflexia (high blood pressure, sweating,
chills, and headache) during labor. The problem
is also greater during pregnancy. Loss of
sensation in the pelvic area can prevent the
woman's knowledge that labor has begun. With a
low level injury, the woman can assist in
childbirth.
Choice of a
contraceptive method should be discussed with a
woman's physician, since there are some special
considerations related to the spinal cord
injury. Oral contraceptives are linked to
inflammation and clots in blood vessels and the
risk of these is greater SCI. Intrauterine
devices cannot be felt in the SCI woman, who has
lost sensation in her pelvis, and may cause
medical complications that would go undetected.
Use of diaphragms and spermicides can be
difficult for the woman with impaired hand
dexterity. Tubal ligation can be considered for
the woman who does not wish ever to become
pregnant.
Men:
Men with SCI
experience a change in their ability to
biologically father a child. The major factor
interfering with a man’s fertility is primarily
due to an inability to ejaculate as a result of
damage to the spinal cord. In fact, 90% of men
with SCI are not able to ejaculate during
intercourse; this is called anejaculation .
Another problem men with SCI may experience is
retrograde ejaculation. This occurs when semen
does not leave the urethra but travels back up
the tube and is deposited in the bladder.
One myth is that the
the number of sperm that a man produces
decreases the longer the time after injury.
There is no evidence that this occurs and should
not be a concern for men who want to
biologically father a child. However, the
motility (movement) of the sperm is of concern.
The average motility rate among men with SCI is
considerably lower than for the average man
without SCI. Recent research shows the average
motility rate of sperm in semen samples from men
with SCI is 20% compared to 70% in able-bodied
men.
Options are
available to assist men with spinal cord injury
improve their ability to father children. Men
who are interested in fathering a child should
get medical advice and treatment options from a
fertility specialist experienced in issues of
spinal cord injury.
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