Sexual Dysfunction and Infertility in the Male Spina Bifida Patient

Nanfu Deng; Nannan Thirumavalavan; Jonathan A. Beilan; Alexander J. Tatem; Mark S. Hockenberry; Alexander W. Pastuszak; Larry I. Lipshultz


Transl Androl Urol. 2018;7(6):941-949. 

In This Article

Relationship Between Level of Neurological Lesion, Hydrocephalus, and Infertility

Level of Neurological Lesion

In patients with spina bifida, level of spinal cord lesion determines the degree of deficits, sexual function and fertility. Therefore, it is expected that the degree of sexual dysfunction may be related to the level of lesion and other comorbidities. Numerous studies have associated lower spinal cord lesions with less severe neurological deficits and more intact sexual functions. Out of 52 post-pubertal males with spina bifida, Diamond et al. found that 64% of men with lesions at T10 or lower had erections while only 14% of men with lesions above T10 obtained erections.[29] Additionally, the likelihood of paternity was observed to be higher in those with lower lesions as 7 out of 8 men who achieved paternity in Decter et al.'s study had L5 or sacral lesions.[10] Studies have also suggested that infertility in spina bifida men with higher lesions may be attributed to more than just erectile or ejaculatory dysfunction as these men were also at an increased risk of azoospermia. In a preliminary study by Reilly and Oates that included ten spina bifida males with erectile dysfunction, all 10 were found to be azoospermic following electroejaculation, and their testicular biopsies revealed Sertoli cell only histology.[19] However, Hultling et al. found no association between level of spinal cord lesion and semen quality based on an examination of nine spina bifida men 22 to 39 years old.[18] In a study of 120 spina bifida men by Gatti et al., those with lesions at or below S1 reported more normal genital sensation (53.5% vs. 7.2% with intact sensation, P<0.05) and more frequent intercourse (30% vs. 14.3% with sexual contact, P<0.05) compared to those with lesions at or above L2.[35] It is important to note that the decreased frequency of sexual contact seen in men with higher lesions was found to be independent of their ability to form relationships.[35] However, patients with lesions at or below S1 were 4.2 times more likely to have been in a relationship and 3.4 times more likely to have had experience with intercourse compared to those with higher lesions.[35] Similarly, Lassmann et al. found that significantly more patients with higher lesions at thoracic and lumbar levels were not sexually active.[11] Using the SHIM to quantitatively evaluate overall sexual function, Lee et al. found that men with lower spinal lesions had higher sexual function as reflected by overall SHIM score (P=0.02), increased satisfaction (P=0.046), and higher erectile function score (P=0.02).[32] In fact, for each descending lesion level down the spinal column, the average SHIM score increased by 42% while the average erectile function score increased by 47%.[32]

Game et al. observed that erectile dysfunction was more common in those with impaired sacral reflexes, as seen on electromyography, associated with sacral nerve root lesions.[27] Similarly, Diamond et al. noted that in cases where the lesion occurred above the sympathetic outflow (T10), those with anocutaneous (sacral) reflexes were more likely to have erections compared to those without this reflex.[29] In a study of 12 spina bifida males, Cass et al. found that all males with intact sacral reflexes and urinary continence had potency.[8] In those without sacral reflexes, 64% of men with lesions below T10 were potent while rates of potency decreased to only 14% for those with higher lesions above T10.[8] These studies convincingly show that spina bifida men with lower lesions and intact sacral reflexes have the best chance at preserved sexual function and fertility potential. This data is summarized in Table 2.


Hydrocephalus affects more than 85% of infants with spina bifida and compromises development, learning and cognitive function.[36] Additionally, the presence of hydrocephalus is associated with worse sexual dysfunction and infertility. Verhoef et al. reported that patients with hydrocephalus were less likely to have a relationship, engage in sexual activity, and have normal sexual function compared to their counterparts without hydrocephalus.[34] Compared to those with hydrocephalus, patients without hydrocephalus were 3.2 times more likely to have a partner and 9 times more likely to have had sexual contact.[34] Males with hydrocephalus reported significantly more issues with sexual excitement, erection, orgasm, and ejaculation than those without hydrocephalus.[34] In Decter et al.'s series, all eight men who achieved paternity did not have VP shunts at time of conception.[10] Among the 33 patients with VP shunts, 61% obtained erections and 30% ejaculated.[10] On the other hand, out of 24 patients without VP shunts, 88% obtained erections and 83% ejaculated.[10] In a questionnaire study by Cardenas et al. on 121 spina bifida patients, no men with hydrocephalus fathered children while 15% of men without hydrocephalus achieved paternity.[12] In a questionnaire study of 76 spina bifida patients, 90% of those who were not sexually active had VP shunts.[11]