| Abstract|| |
Fifty four male patients with spinal cord injury (SCI) with injury levels between D1 and L 3 were given intracavernous injection of papaverine to study its effects in the form of erection, rigidity, maximum duration of erection, possibility of ejaculation, coitus and psychological satisfaction. Fifty patients could be followed up. Of them 40 had full erection, eight partial and two had no erection. Mean dose given was 15 mg (range 10 - 30 mg). Duration of erection was 1 to 4 hour in 46 patients and in none it lasted for more than 5 hours. Eight patients had off and on ejaculation and semen analysis showed increased number of deformed and less motile sperms. Forty six patients were psychologically satisfied. Except for few minor complications like bruise (5), automatic dysreflexia (2) and intraurethral injections (4), no major complication occurred. Intracavernous papaverine therapy is safe, cheap and effective in paraplegics with erectile impotence. This mode of treatment may be used with confidence in socio-sexual rehabilitation of male paraplegics with SCI.
Keywords: Erectile impotency - Spinal cord injury-Intracavernous injection - Papaverine
|How to cite this article:|
Sharma S C, Singh R, Sangwan S S, Singh S. Role of intracavernous papaverine induced erections in sexual rehabilitation of paraplegic patients - A clinico psychological study. Indian J Orthop 2002;36:42-5
|How to cite this URL:|
Sharma S C, Singh R, Sangwan S S, Singh S. Role of intracavernous papaverine induced erections in sexual rehabilitation of paraplegic patients - A clinico psychological study. Indian J Orthop [serial online] 2002 [cited 2020 Jan 23];36:42-5. Available from: http://www.ijoonline.com/text.asp?2002/36/1/42/35928
| Introduction|| |
Sexual dysfunction following spinal cord injury constitutes a complex problem in the management of paraplegic patients.  Spinal cord injury (SCI) usually involves patients of such age group that is regarded in the society as the sanctional peak of sexual activity i.e. 18 - 45 years. Inability to obtain and sustain an erection sufficient for satisfactory intercourse is a frequent complaint of men with SCI.  As libido continues, the patients like normal individuals yearn to continue with his sexual functions despite physical disability. Therefore readjustment of the paraplegic to his sexual dysfunction and adequate supplementation of his sexual drive is essential for his successful domestic and social resettlement. Sexual rehabilitation in SCI patients has assumed an increasingly dominant role in the overall rehabilitative process. 
Although numerous articles have been written on altered physiology of sexual function after spinal cord injury, , genitourinary problem, , social studies dealing marriage and divorce,  statistical reviews of sexual competence, , and psychological aspects, , but very few articles discuss about the sexual rehabilitation of male paraplegics. ,
Pharmacologically induced penile erection have been used to treat patients with psychogenic and organic impotence. ,,, Intracavernous injection of vasoactive drugs to produce erection has gained widespread use since 1982 when Virag  reported that injection of papaverine, a smooth muscle relaxant, produced a fully rigid erection of the penis. Many authors have used papaverine alone or in combination in paraplegic patients and have reported that intracavernous injection works well with majority of the patients, is devoid of major side effects even on prolonged use and that it was easier and simpler for the patient to inject papaverine himself. ,,,
We have used intracavernous injection of papaverine in 54 impotent spinal cord injured men to evaluate the role of injection papaverine with regard to sexual rehabilitation of paraplegics.
| Patients and Methods|| |
In a prospective study, 54 young married male paraplegics with erectile impotence, who did not show any sign of improvement in neurological status after spinal cord injury were included. Duration of injury prior to inclusion in rehabilitation programme varied from 3 months to 5 years, with a mean of 3.2 years. After proper history and clinical examination details about the procedure was discussed with the couple and informed consent was taken.
The average age of the patients was 31.2 years (range 20 - 45 years). Highest level of vertebral injury was D 2 and lowest L 3 with maximum number of patients (26) having injury level between D 12 and L 1 . There were 36 complete and 18 incomplete lesions. All the patients were admitted during the initial period of rehabilitation programme. Under all aseptic conditions, initial dose of 15 mg (1ml) injection Papaverine diluted with 1 ml of normal saline (0.9 N) was injected intracorporally with 26 gauge needle and response was observed. The response was recorded as follows :
No response -No tumescence after 10 minutes of injection
Partial response - Some degree of tumescence without rigidity
Full response -Tumescence and rigidity, adequate for vaginal penetration
A dose titration of injection papaverine was done for each patient. The patients who did not respond or had a partial response were given increased dose of drug to a maximum of 30 mg in next sittings. Patients responding to a dose of 15 mg were given a decreased dose of 10 mg injection papaverine subsequently. In the first week, the method of injection application was taught to the patient and spouse. In second week, patient / spouse was asked to use injection under supervision. Only when the couple learnt the procedure, they were asked to use injection therapy independently at home 2 - 4 times a month, with a dose determined in the hospital. Concomitant management of associated problems like urinary traction infections (UTI), bed sores and flexor spasms was continued. Urinary bladder training was also an integral part of the study. All patients with catheter related problems were started on clear self-intermittent catheterization at regular intervals to manage their bladder. Follow up was done every month during initial 6 months and after every 6 months later on. On each follow up, psychological satisfaction, frequency, duration of act, ejaculation and complication (if any) were recorded; besides a through examination of patient and repeat liver function tests were also done.
| Results|| |
Out of 54 patients, only 50 patients could be followed up. Two patients did not use this therapy at home after having successful response during hospital stay, one patient had divorce and one patient was lost to follow up. At the initiation of the therapy, 21 patients had partially controlled and 12 uncontrolled bladders, 14 patients suffered burning during micturition and fever when they were on continuous indwelling catheter. Infection was treated with clean intermittent catheterization and appropriate therapeutic measures. Seven patients were having bed sores and 10 patients had flexor spasms.
Time taken for intumescence of penis varied from 1 to 10 minutes and two patients had no intumescence. Full response was obtained in 40 patients with a mean dose of 15 mg injection papaverine. Eight patients had partial and two patients no response. Lag period for the onset of rigidity of penis varied from 5 to 30 minutes (Average 9 minutes). The duration of erection for 46 patients was 1 -4 hours, none lasting more than 5 hours. Thirty eight patients reported having had sexual act twice during this period (range 1 - - 4). Except for two patients who did not respond to injection papaverine and two patients who were not happy with this form of therapy, even though they had good erections and performed sexual act, 46 were highly satisfied. In this series, 10 patients themselves and 40 spouses learnt the procedure successfully.
Eight patients had off and on ejaculation. Semen examination of these patients showed increased number of deformed sperms and motility of the sperms was also reduced drastically. None of the spouses of these patients conceived during study period.
After an average frequency of injection papaverine twice a month (range 1-6) and average follow up of 1.8 years (range 8 month to 4 years), no major complication was observed. Subcutaneous haematoma (bruise) in eight patients, autonomic dysreflexia in two and intraurethral patients, autonomic dysreflexia in two and intraurethral injection in four patients requiring no treatments were observed. No derangement in liver function test was noted.
| Discussion|| |
Rehabilitation plays a very important role in spinal cord injuries as most of the times these involve the younger age groups. The aim of rehabilitation of such patients should not aim towards an isolated problem but it must be an integrated rehabilitation programme including sex. Changes in sex life, anxiety about fertility, distorted body images and attitude of the society are the areas of concern in sexual rehabilitation. ,,
The presence of problems of uncontrolled or partially controlled bladder, urinary tract infections, bed sores and flexor spasms lead to the decreased sexual activity in our patients. Many patients are psychologically depressed. ,, Proper rehabilitation of the associated problems and psychiatric counseling not only improve their body image, but also facilitated sexual rehabilitation.
The erection is dependent on level of spinal injury, age, status of bladder, UTI and psychological status of patient. Although it has been reported that 80% percent of SCI men experience some erectile ability but the overwhelming problem pertains to the duration of erection. Tumescence and rigidity tend to fade away rather quickly leaving the patient unable to perform intercourse. 
Our experience of starting with a initial dose of 10mg in two patients was not good as the patients did not respond to it and were so depressed by first failure, that psychological counseling was required. Later they had erection with 30 mg of papaverine which was reduced to 15 mg during titration phase. This probably is because of the fact that psychology and mood following success or failure after first injection also effect the erection. Patients having full response or partial response were able to perform sexual act. Two patients not responding to 30 mg of papaverine were declared as unresponsive to such therapy. During erection lasting for between 1 to 4 hour, most of the patients had intercourse twice during one sitting assuring partner's satisfaction. Ninety two percent of the patients were psychologically satisfied with their sexual performance with this mode of sexual rehabilitation.
None of our patient had erection lasting for more than 5 hour (priapism), though this has been reported. ,, We used 26 gauge needle to inject the drug and none of our patients developed fibrosis, this is perhaps because of the lower dose of medication (average 15 mg), lower frequency of injection (twice a month)and thinner needle. Levine et al have reported that these effects are dose dependent. 
The presence of increased number of deformed and less motile sperms in semen may probably be explained on the basis of retrograde ejaculation, impaired spermatogenic functions secondary to sympathetic enervation and loss of testicular temperature regulation, due to hormonal changes and altered sperm fluid. ,, Stein has reported that pregnancy rate is lower when inseminating with sperm from SCI men compared with anonymous normal donor. 
Sexual functions are very complex and involve psychic, gonadal and neuromuscular activities. Psychology of the patient plays a vital role in any rehabilitative process. There seems to be definite role of psychotherapy and anti-depressive drugs as a part of treatment in these patients, before giving papaverine injection. Bailey  has also stressed that the psychological aspects of sexual counseling are as equally important as the physiological and anatomical aspects, and both patients and the partner require this counseling.
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S C Sharma
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