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.

Precise diagnoses are seldom made upon complaints of sexual dysfunction by spinal cord injured men. The dysfunction is inevitably attributed to the neurological condition and available treatments are offered with little knowledge of the individual residual capacity or other contributing factors. Current practice emphasizes these treatment approaches, but the high rejection rate associated with the most widely used technique of intracavernous injections suggests that remaining sexual function should also be investigated. This study explores remaining function using physiological recording techniques and classifying the subjects according to the innervation of the reproductive system. The results show that, with objective measurements and proper classification of the subjects, 100% of individuals with high lesions maintain penile responses to reflexogenic stimulation and up to 90% of those with lower lesions maintain penile responses to psychogenic stimulation. These latter subjects also show naturally occurring emissions in 100% of the cases when they suffer from lesions to the conus terminalis and when they use psychogenic stimulation as a means of inducing erection and emission. Results from subjective reports reveal that spinal cord injured men underestimate their sexual capacity, while diagnoses based on clinical findings are better predictors.

pressure (BP) changes measured at baseline and at ejaculation (or on the last trial if the test was negative). Reported sensations were also recorded and compared during positive and negative tests. RESULTSOverall, 89% of the patients reached ejaculation with one mode or another of stimulation. When patients had a negative result with natural stimulation, 56% were salvaged by PVS, and when PVS was negative, another 22% were salvaged by midodrine combined with PVS. The mean systolic BP increased by 35 mmHg at ejaculation during PVS and by 11 mmHg after midodrine, and a subsequent 29 mmHg at ejaculation during PVS combined with midodrine. By contrast, negative tests showed a relatively stable BP; the difference in changes in BP during positive and negative tests was significant ( P < 0.01). Increases in BP during positive tests declined significantly more often within the limits of autonomic dysreflexia than negative tests ( P < 0.01).Study Type -Therapy (case series) Level of Evidence 4 OBJECTIVESTo explore the effectiveness of various sources of self-stimulation, including oral midodrine, in triggering ejaculation in men with spinal cord injury (SCI), and to document the systematic variations in blood pressure at ejaculation and consider a revised definition of autonomic dysreflexia. PATIENTS AND METHODSThe study included 62 men with SCI lesions from C2 to L2. Ejaculation potential was assessed with various sources of stimulation, beginning with natural stimulation, followed, if the test was negative, by penile vibrator stimulation (PVS) followed, if the test was again negative, by PVS combined with oral midodrine, started at 5 mg and increased in 5 mg steps up to 25 mg. The success rate of ejaculation was recorded, as were blood

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