Dr McBride and her colleagues (July 2003, JRSM1) describe a patient with spinal cord injury whose blood pressure rose threefold on sexual stimulation. We note the published correction2 concerning level of sympathetic outflow. The propensity of the sympathetic system to produce a mass response at varying intervals after the injury has been likened to development of spasticity in the motor system. Some people develop only mild dysreflexic symptoms, which they learn to associate with changes in the insensate part of the body such as a full bladder.3 Certain disabled athletes induce mild dysreflexia to enhance their achievements in sports, a phenomenon referred to as 'boosting'.4
A rise in blood pressure during sexual activity, especially at the time of ejaculation, has been well documented in both normal individuals and those with spinal cord injury (SCI), the magnitude of the rise being greater in the latter group.5 Hypotensive agents, such as glyceryl trinitrate spray or captopril, may be used when symptoms arise or prophylactically before sexual activity, to mitigate the resultant hypertension. Electroejaculation, a more painful procedure, is commonly employed in SCI individuals to obtain semen for assisted fertilization techniques. In our experience patients usually tolerate this procedure without need for medication (only 4 of 64 patients in our series who underwent assisted ejaculation developed dysreflexic symptoms, the symptoms settling without any pharmacological intervention in 3 and with glyceryl trinitrate spray in 1). It is also noteworthy that only 50% of patients who developed a vasomotor headache had a significant rise in blood pressure.6
The patient reported by McBride et al. had sustained his injury 36 years earlier and had engaged in sexual activity without headache until the onset of autonomic dysreflexia 3 years previously. The report does not make clear whether other neurological disorders were excluded—such as syringomyelia, which could manifest as new onset autonomic dysreflexia. The relation between the patient's erectile dysfunction and his autonomic dysreflexia is weak and both may reflect deterioration in neurological status.
Thus it is difficult to agree with the authors' conclusion that their patient with autonomic dysreflexia should abstain from sexual activity. The best course of action, in our opinion, would be a thorough investigation to exclude any neurological changes, followed by a full explanation and a trial of sexual intercourse with access to hypotensive medication such as glyceryl trinitrate spray to control the symptoms of autonomic dysreflexia should they arise.
References
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