Introduction With the advances in penile vibrator stimulation (PVS), most spinal cord injured (SCI) men can self-ejaculate. Oral midodrine may further increase ejaculation success, while maintaining autonomy. Since most SCI men attempt ejaculation for sexual rather than reproductive purposes, self-ejaculation should be emphasized and sensations explored. Aims Explore (i) self-ejaculation success rate in SCI men; (ii) vascular parameters indicative of autonomic dysreflexia (AD) during sexual stimulation and ejaculation; and (iii) sensations associated with ejaculation. Methods Ejaculation was assessed on 81 SCI men with complete ASIA A (49%) and incomplete B to D lesions (51%), subdivided into tetraplegics (C2–T2), paraplegics sensitive to AD (T3–T6), paraplegics not sensitive to AD (T7–T10), paraplegics with lesions to the emission pathway (T11–L2), and paraplegics with lesions interrupting the emission-ejaculation pathways (L3–below). Natural stimulation was attempted first followed, if negative, by PVS followed, if again negative, by PVS combined with oral midodrine (5–25 mg). Main Outcome Measures Ejaculation success, systolic and diastolic blood pressure, and perceived physiological and orgasmic sensations. Results Overall 91% reached ejaculation, 30% with natural stimulation, 49% with PVS and 12% with midodrine plus PVS. Midodrine savalged up to 27% depending upon the lesion. Physiological and orgasmic sensations were perceived significantly more at ejaculation than sexual stimulation. Tetraplegics did not differ from paraplegics sensitive to AD on perceived cardiovascular and muscular sensations, but perceived significantly more autonomic sensations, and generally more physiological sensations than lower lesions unsensitive to AD. Conclusion Most SCI men can self-ejaculate and perceive physiological and orgasmic sensations. The climactic experience of ejaculation seems related to AD, few sensations being reported when AD is not reached, pleasurable climactic sensations being reported when mild to moderate AD is reached, and unpleasant or painful sensations reported with severe AD. Sexual rehabilitation should emphasize self-ejaculation and self-exploration and consider cognitive reframing to maximize sexual perceptions.

The rhythmic activity observed in the patient appeared related to the activation of a spinal pattern generator akin to what has been described in most animal species after complete spinal lesions.

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Objective: The objective of this study is to evaluate the efficacy of midodrine in the treatment of anejaculation in men with spinal cord injury (SCI). Study design: Prospective, double-blind, randomized, placebo-controlled pilot study. Method: Men with anejaculation associated with SCI (level of injury above T10) of more than 1 year in duration were approached. Those with no ejaculatory response to one penile vibratory stimulation (PVS) trial were assigned in a double-blind manner to one of the two following interventions once a week for a maximum of 3 weeks or until ejaculation occurred: oral administration of flexible midodrine (7.5-22.5 mg max) followed by PVS (group M), or oral administration of flexible sham-midodrine (placebo) followed by PVS (group P). Sociodemographic data, medical characteristics, and plasma desglymidodrine concentration were collected for all participants. Outcome measure: Ejaculation success rate in each group. Results: Among the 78 men approached, 23 participants (level of SCI: C4-T9) were randomized. Three participants abandoned the study and 20 completed the study; 10 were assigned to group M, 10 to group P. Ejaculation was reached for one participant of group M and for two participants of group P. Autonomic dysreflexia associated to PVS occurred in three patients. Conclusion: In this small sample study, treatment of anejaculation after SCI with midodrine and PVS did not result in a better rate of antegrade ejaculation in 10 men than in 10 men treated with a placebo and PVS.