Sexual function and cervical spine instability
Ross Hauser, MD
When assessing the degree of success of cervical spine treatment, we assess the quality of life standards the patient wishes to re-achieve and restore. One of those quality of life issues is the ability to be sexually active with their spouse or partners.
We often see patients who come in for a second opinion following a recommendation to cervical spinal surgery. We often see patients who have already had the surgery. These people have the familiar problems of cervical instability and diseases of cervical vertebrae that often manifest themselves in other symptoms and disorders of the body. For men, this is true with cervical instability, erectile dysfunction and retrograde ejaculation (you are ejaculating backwards into the urinary bladder). For women and men there is a fear of sex causing more cervical spine damage.
The ability to resume sexual activity is seen as a positive outcome of cervical spine treatment
Surprising there is not a lot of research on this important patient concern. Evidence presented is mostly empirical that is observational and discovered during a discussion of the patient’s medical history. We have found that the ability to have regular and unafraid intimacy with a spouse is very important to many patients. Having said this, this ability to resume intimacy is one of the important underlying factors of getting treatment. We do confess, that it is very rare that this will be the number one reason for seeking neck pain treatment.
Degenerative cervical myelopathy and the ability to have sex as a recovery priority
But how important is it to be able to have sex when you have been diagnosed and recommend to treatments for degenerative cervical myelopathy and symptoms related to compression of the spinal cord?
In October 2019, an international team of researchers lead by the University of Cambridge in the United Kingdom published a survey in the medical journal BMJ Open.(1) What the surgery asked was what were the most important symptoms that they wanted addressed in their cervical myelopathy related problems.
- Overall, pain was the most popular recovery priority (39.9%) of respondents,
- Walking (20.2%),
- Improvement in sensation (11.9%) and
- Arm and hand function (11.5%).
- Sexual function (5.7%),
- bladder and bowel (3.7%). Please see our article: Cervical spine problems, Vagus nerve compression, as cause urinary incontinence.
- and trunk function (3.5%)
In a clinic like ours, where we see many cervical spine patients. One out of 20 patients looking for improvement in sexual function as the main priority of their neck pain is a significant number.
Neurologists find erectile dysfunction, walking difficulties, urinary hesitation as curious aspects of neck problems
Many patients think sexual dysfunction, or in the case of men, erectile dysfunction, are seeming unrelated to their neck problems. For some this has been reinforced by their medical professionals who look at problems of the neck as problems of the neck and problems of erectile dysfunction a problem that needs to be recommended to a urologist. While the recommendation to a urologist is seen as a precautionary measure to rule out other problems, once the referral is made to the urologist and the report comes back that there does not seem to be a problem in this area, the problems of erectile dysfunction will then simply be dismissed or ignored.
A report in the medical journal Neurology (2) reveals how doctors are now seeing erectile and sexual dysfunction as components of a cervical spine, neck problem.
In this report a 51-year-old man went to University Hospital at the University of Athens in Greece. He had neck pain, right hand weakness, and progressively deteriorating gait. Onset of symptoms occurred 1 month before admission with cervical pain that worsened during neck flexion the movement of chin on chest). A few days later he noticed reduced dexterity and numbness of his right hand. During the following 3 weeks, his gait became increasingly unstable. Additionally, he reported erectile dysfunction and urinary hesitancy. No previous trauma was recalled. In other words he did not know how this started but it was getting worse fast.
This turned out to be a very complicated case. But for the purpose of this article the example is that this patient’s erectile dysfunction and walking problems were related to spinal cord compression and the the patient has excellent response to steroids, however the response was short-lived and the symptoms got that much worse.
Erectile dysfunction can be a problem of the cervical spine.
Does cervical surgery improve sexual function? Successful surgery likely yes. Unsuccessful surgery will make it worse
As is our habit, when we talk about the problems of surgery, we bring in the surgeons for their opinion.
Doctors at the University of California, San Francisco reported on sexual function problems in patients who underwent cervical spine surgery.
Writing in the Journal of Clinical Neuroscience, (3)
the UCSF researchers documented the following:
- They noted: Sexual function is an important component of patient-focused health related quality of life.
- In men, worse neck disability and the number of operated on cervical levels were associated with lower sexual function scores.
- In women, higher total number of medications and pain medications were associated with lower sexual function scores.
- 46% of patients reported difficulty performing a sexual position after surgery that they had previously enjoyed.
- Men and women who underwent cervical spine surgery had lower sexual function scores than age-matched peers, likely attributable to general mental health, regional neck disability, back pain, and medications.
- A large portion of patients reported subjectively worsened sexual function after surgery.
Cervical surgery and erectile dysfunction
Treating the problems of cervical instability can treat the problems of erectile dysfunction. In the above research, a myriad of problems for the patients resulted in lower sexual function because of post-surgical outcomes. In past research doctors found that successful cervical surgery, had as a side-effect, improved symptoms of erectile dysfunction.
In our opinion treating cervical neck pain can be effective in helping some patients restore erectile function, however while studies suggest a casual, indirect benefit of cervical surgery on erectile dysfunction, we believe the same results can be achieved with comprehensive Prolotherapy.
This could have been the result of the patient needing fewer pain medications as pain medication use has been associated with erectile dysfunction.
The role of opioids in low testosterone syndrome
In 2006 researchers looked at older men who had Cervical spondylotic myelopathy (neck pain).(4)
- A total of 22 patients with combined cervical spondylotic myelopathy and sexual dysfunction on admission were treated with surgery for their neck problems.
- Most of these patients had an abnormal psychogenic erection (18/22, 82%) before surgery. These are erection difficulties related to emotional and psychological problems such as depression and anxiety.
- but only few had an abnormal reflexogenic erection (4/22, 18%). This is the regular erection response to stimuli.
- The positive results with erectile dysfunction was attained post surgery because the patient had less depression and anxiety.
Waiting for surgery does cause depression and anxiety.
1 Davies B, Mowforth O, Sadler I, Aarabi B, Kwon B, Kurpad S, Harrop JS, Wilson JR, Grossman R, Fehlings MG, Kotter M. Recovery priorities in degenerative cervical myelopathy: a cross-sectional survey of an international, online community of patients. BMJ open. 2019 Oct 1;9(10):e031486. [Google Scholar]
2 Rallis D, Tsirigotis P, Arvaniti C, Sgouros S, Foukas PG, Oikonomopoulos N, Andronas N, Panayiotides IG, Kouloulias V, Papageorgiou S, Voumvourakis K, Stamboulis E. Clinical reasoning: a 51-year-old man with cervical pain and progressively deteriorating gait. Neurology. 2013 May 28;80(22):e230-4. doi: 10.1212/WNL.0b013e318294b2bf. PMID: 23713091; PMCID: PMC3716403.[Google Scholar]
3 Keefe MK, Zygourakis CC, Theologis AA, Canepa E, Shaw JD, Goldman LH. Sexual function after cervical spine surgery: Independent predictors of functional impairment. J Clin Neurosci. 2017 Feb;36:94-101. [Google Scholar]
4 He S, Hussain N, Zhao J, Fu Q, Hou T. Improvement of sexual function in male patients treated surgically for cervical spondylotic myelopathy. Spine. 2006 Jan 1;31(1):33-6. [Google Scholar]