Sex, catheterization, and spinal cord injuries

Dear Wanting to be informed,

These are all great questions and deserve to be tackled one at a time. First, spinal cord injury (SCI) may affect a person's ability to have orgasms, erections, and to ejaculate, but the extent of its affect depends largely on the location and severity of the injury. You also mentioned intercourse with a catheter. Typically, it's recommended that a catheter be removed prior to sex to aid in the comfort of each partner, but more on this later. No matter the limitations that may result from an SCI, though, many men and women discover how best to give and receive pleasure and satisfaction. 

To begin: a quick erection tutorial! There are three types of erections:

• Psychogenic erections are the result of stimulation from seeing, thinking, or hearing something arousing. That stimulus is processed in the brain, which sends a signal down the spinal cord to dilate the blood vessels in the penis, causing an erection. A spinal cord injury higher up may interrupt this pathway and the ability to get an erection, but a lower spinal cord lesion may not: this is because the part of the spinal cord responsible for erections is located between thoracic nerve eleven (T11) and lumbar nerve two (L2) (the region roughly between the bottom of your ribcage and the small of your back). If the spinal cord is damaged lower down than L2, there’s still a direct connection between penis and brain and an erection may still be possible.
• Reflex erections happen from physical stimulation — such as contact with the penis, testicles, anus, nipples, or other erogenous zones. As long as the sacral nerves (nerves located at the base of the spine in the pelvic region) S2-S4 are intact, a person may be able to have reflex erections.
• Spontaneous erections are in response to an internal stimulus like your bladder being full. Some people may get an erection this way even after a SCI.

Your question about ejaculation is a good one because different parts of the nervous system are responsible for the penis and the ejaculate. While getting erect is mostly a function of sensing a stimulus and responding to it by dilating blood vessels, ejaculation requires a few different inputs and is slightly more complicated. Some research estimates that as many as 90 percent of people with SCI’s have difficulty ejaculating. One thing that can happen after an SCI is retrograde ejaculation — that is, damage to the spinal cord can interfere with the penis’s ability to close off the urethra while ejaculating, allowing semen to flow backward into the urethra to some extent. Additionally, a small percentage of people with SCI report the feeling of ejaculation but show no outward sign of semen.

As far as sex with a catheter, it’s recommended that it be removed before intercourse. This is because movement during sex could push the balloon of the catheter through the sphincter of the bladder, potentially resulting in serious damage. You also asked about discomfort, either for your friend, or their partner. On a literal level, once a catheter is removed, there is nothing there to cause discomfort for either person. If there is some worry about possible urine leakage, avoiding drinking fluids for an hour or two beforehand or urinating right before sex might be in order.

On a more philosophical level, concerns about getting and maintaining an erection, or concerns about coming or not may be worrisome to a person with an SCI. This is where the original aphrodisiac — open and honest communication — can play a role. Discussing what feels right, listening to fears as well as desires, and thinking together about how to find mutually satisfying pleasure (including considering the use of a huge range of things like sex toys or sexual devices) can form the basis of healthy and fulfilling sexual life. Your friend may also consider chatting with their health care provider about adaptive equipment, medical therapy for erection maintenance, or sperm banking. 

For more information on SCI, check out the Spinal Cord Injury Information on the National Institute of Neurological Disorders and Stroke website.