Sexual function and cervical spine instability in men and women
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 qualities 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 for 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 backward into the urinary bladder). For women and men, there is also 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
Surprisingly there is not a lot of research on this important patient concern. The 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.
To be clear, erectile dysfunction or sexual dysfunction is typically not the primary, or in many cases the secondary concern that the patients we see have. These challenges are one of many conditions and symptoms that these people suffer from. If you are like these people your story may go something like this:
I have degenerative disc disease in my neck and low back causing me a lot of pain. I have blurred vision, balance and instability issues, chest pain without obvious heart problems, tingling sensation in my arms and legs, and erectile dysfunction.
In women, painful intercourse is often seen as a problem secondary to neck issues. Women who have vaginal issues including sexual and bladder dysfunction will also display symptoms and conditions of Hypermobility Ehlers Danlos Syndrome, Postural Orthostatic Tachycardia Syndrome and Dysautonomia, previous cervical neck surgeries or fusion, and other neurologic-like symptoms and conditions that can be connected to problems in the neck. Including headache, dizziness, vision problems, cardiac manifestations, tinnitus, emotional stress, and anxiety (neurologic-like and psychiatric-like).
I don’t like being touched, especially softly, it now hurts.
One such woman described her case:
I have a lot of strange symptoms. I have been to a chiropractor, optometrist, cardiologist, and gynecologist, and so far, nothing seems wrong with me, no one can find anything wrong with me. Some symptoms come and go, some are very extreme, and others are persistent.
I have had tinnitus, extreme migraines for a few days, eye pain, and blurry vision. I had fluctuating heart rate and blood pressure. The cardiologist said he couldn’t find the problem. One more thing bothers me. I have no sexual need or sensation, I don’t like being touched, especially softly, it now hurts.
Another woman, this way:
I have a complete loss of sex drive, a “vibrating” feeling in my pelvis, Pelvic Floor Dysfunction, Dyspareunia pain associated with intercourse), Dysuria (persistent urinary frequency and urgency intermittently.) They say they always felt like I was never getting enough blood flow to my brain to do anything productive. This person also described, neck pain, ocular migraines, heart palpitations, Presyncope, Idiopathic hypersomnia (extreme fatigue), Narcolepsy with Cataplexy (loss of muscle function when laughing hard or a state of excitability as in being angry or mad or frightened.
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 recommended treatments for degenerative cervical myelopathy and symptoms related to compression of the spinal cord either from acute injury or chronic degenerative injury? As you are reading this article it is probably important to you.
In October 2019, an international team of researchers led 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 to address in their cervical myelopathy-related problems.
- Overall, the 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, and urinary hesitation as curious aspects of neck problems
Many patients think sexual dysfunction, or in the case of men, erectile dysfunction, is seemingly unrelated to their neck problems. Generally, they see these problems as what we have described above, one problem in a constellation of 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 or sexual 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 and sexual dysfunction will then simply be dismissed or ignored.
A 51-year-old man went to the hospital with neck pain and erectile dysfunction
A report in the medical journal Neurology (2) reveals how doctors are now seeing erectile and sexual dysfunction as components of a cervical spine, and 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 a progressively deteriorating gait. The onset of symptoms occurred one month before hospital admission with cervical neck pain that worsened during neck flexion (the movement of the chin on the chest). A few days later he noticed reduced dexterity and numbness of his right hand. During the following three 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 patient has an excellent response to steroids, however, the response was short-lived and the symptoms got that much worse. The connection? 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 operating on cervical levels were associated with lower sexual function scores.
- In women, a 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.
Again. let’s point out that people do experience better sexual function after surgery. This was also suggested in an October 2018 paper in the European spine journal (x) which said: “Despite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery.”
Cervical surgery and erectile dysfunction
Providing that there is a good surgical outcome. An October 2018 (4) paper from The Ohio State University Wexner Medical Center researchers sheds light on this: “Sexual function is an important determinant of quality of life, and factors such as surgical approach, the performance of the fusion, neurological function and residual pain can affect it after spine surgery….. Despite limited evidence from high-quality articles, there is a general trend towards improvement of sexual activity and function after spine surgery.”
The paper ends with the suggestion that “future studies incorporating specific assessments of sexual activity will be required to address this important determinant of quality of life so that appropriate pre-operative counseling can be done by providers.”
We often find in medical history and examination that men do want to resume sexual activity stunted by cervical spine disorders. We do discuss this aspect with patients especially when there is an extensive history of painkillers and opioid use. Please see our article: Opioids and painkillers cause low testosterone syndrome.
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 a side effect, and improved symptoms of erectile dysfunction.
In 2006 researchers looked at older men who had Cervical spondylotic myelopathy (neck pain). (5)
- 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 a few had an abnormal reflexogenic erection (4/22, 18%). This is the regular erection response to stimuli.
- The positive results with erectile dysfunction were attained post-surgery because the patient had less depression and anxiety. Waiting for surgery does cause depression and anxiety.
In December 2013, doctors wrote in the Journal of Neurological Surgery. Part A, Central European Neurosurgery (6) noted that after treatment for cervical spondylotic myelopathy, patients usually experience an improvement in sexual function. The doctors then present a patient case of cervical disc herniation at the C3-C4 and C5-C6 level with erectile dysfunction but without myelopathy. The patient underwent anterior microdiscectomy and fusion with cages. Erectile dysfunction improved postoperatively.
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 non-surgically.
Tinnitus is a symptom of cervical spine instability, erectile dysfunction can be a problem of cervical spine instability. Is there a connection between ringing in the ears and sexual dysfunction?
Not every person we see with sexual dysfunction secondary to cervical spine instability suffers from tinnitus or “ringing in the ears.” If you have been diagnosed with tinnitus you have probably been subjected to many tests, scans, and other studies, have yourself researched the condition extensively, and have had more people look into your ears than you can count. Yet you still may suffer from ringing in the ears. For more information on tinnitus please see my article Tinnitus, cervical spine instability, and neck pain. Let’s now return to the problem of sexual dysfunction as being caused by cervical instability.
“With many previous studies indicating a higher prevalence of sexual problems in patients with tinnitus, the association between tinnitus and erectile dysfunction has become an interesting topic that warrants further research. In (this) study, (the researchers suggested) that tinnitus may be associated with erectile dysfunction and aimed to further explore the relationship between these two medical conditions.”
What did they find? A review of over 38,000 patients, (3.23%) received a tinnitus diagnosis within the year before the erectile dysfunction diagnosis and observed that patients were more likely to develop erectile dysfunction after a tinnitus diagnosis. The researchers concluded:
“Through our investigation, we have ultimately detected a novel (unique) association between erectile dysfunction and tinnitus and urge physicians to be alert to the possibility of the development of erectile dysfunction in patients treated for tinnitus.”
In other words, if you are a man, diagnosed with tinnitus, there is a risk that you will develop erectile dysfunction. How? One cause may be cervical spine instability.
We will often hear from women who have been diagnosed with many conditions who will also report that among their many issues they first developed tinnitus and then started experiencing a burning and tightness sensation in their vaginal area with problems of urinary frequency and urgency.
Vertigo and sexual dysfunction.
As mentioned above, many patients with secondary symptoms and conditions of cervical spine instability will report problems with vertigo. A 2019 paper published in the journal Frontiers in Neurology (8) suggested neurologic disorders, like those we see in neck instability patients, may be the result of blood and fluid flow blockage in the neck and brain. This is what they said:
“Like other physical activities, sexual intercourse increases the pulse rate, respiration rate, and blood pressure. Furthermore, the heart rate rises up to 110–180 beats per minute, and the respiration rate up to 40 breaths per minute during orgasm. These systemic and cerebral hemodynamic (blood flow) changes may explain the neurological disorders that occur in association with coitus (intercourse), which include coital cephalalgia (sex headaches), transient monocular blindness (you suffer from a temporary loss, or a slow fading out to gray, in the vision of one of your eyes), reversible cerebral vasoconstriction syndrome (sudden constriction of the arteries that supply blood to the brain), transient global amnesia (temporary memory loss), syncope (fainting), subarachnoid and intracerebral hemorrhage (blood leakage), and ischemic strokes (Please see our article Treating Vertebrobasilar insufficiency, vertebrobasilar artery insufficiency, rotational vertebral artery occlusion syndrome, or Bow Hunter Syndrome.)
Referring back to vertigo, the researchers noted: “. . . however, the characteristics, underlying disorders, and mechanisms of coital dizziness/vertigo have not been explored systematically in a large number of patients. The aim of this study is to draw the attention of physicians to this potentially important, but easily overlooked phenomenon.”
Here are the learning points of their study: Again we note the high collaboration with their findings and the possible association of cervical spine instability we see in our patients.
- Vertigo associated with sex can be caused by hormonal dysfunction. They noted a possible frequency of post-sex vertigo after hormone replacement therapy in patients.
- Peripheral vestibulopathy should be suspected in recurrent coital vertigo. (An imbalance in the ears. Please see our article When Cervical Spine Instability Causes Ear Pain, Ear Fullness, Sound Sensitivity, and Hearing Problems.)
- It is noteworthy that nearly half of the patients reported their vertigo also occurs during exercises requiring physical strains other than sexual intercourse. According to their observation, vertigo may be just an effect of coitus and orgasm rather than a direct effect of those. Indeed, it is common to encounter individuals with vestibular deficits who report exacerbation of their symptoms during physical or emotional stress.
- More than half (67% of the patients in this study) of exertional dizziness replicates symptoms during the tilt table and it is better explained by autonomic dysregulation. (Something is causing dysfunction in messages the nervous system is sending – cervical instability can be suspected.)
Surgical recommendation for degenerative disc disease may not address the patient’s real problems – cervical neck ligament damage
In our practice, we continue to see a large number of patients with a myriad of symptoms related to cervical neck instability including but not limited to severe neck pain, sexual dysfunction, problems of balance, headaches, and loss of mobility. These people are often confused, many times frightened by recommendations for complicated cervical neck surgeries they don’t understand.
Many of these people have been told that their problem is a problem of degenerative cervical disc disease. After years of prolonged pain and conservative care options such as chiropractic, massage, physical therapy, anti-inflammatories, pain medications, cortisone injections, and cervical epidurals that eventually fail, the only recourse, these people are told, is neck surgery.
Surgical recommendations are described in a way to the patient that seemingly makes sense as the only solution to their problems.
- The surgery will help, the patient is told because it will cut away the cervical vertebrae bone that is pressing on the nerves
- The surgery will fuse the cervical vertebrae in place so the vertebrae do not shift out of place and press on the nerves again.
- The cervical disc that has been flattened or herniated is replaced with an artificial implant or bone from the pelvis. Please see our article: Cervical artificial disc replacement complications.
In 2014 we (Caring Medical) published these findings in The Open Orthopaedics Journal. (8)
- The cervical capsular ligaments are the main stabilizing structures of the facet joints in the cervical spine and have been implicated as a major source of chronic neck pain. Such pain often reflects a state of instability in the cervical spine and is a symptom common to a number of conditions such as disc herniation, cervical spondylosis, whiplash injury, whiplash-associated disorder, post-concussion syndrome, vertebrobasilar insufficiency, and Barré-Liéou syndrome. (In some patients these concurrent symptoms can lead to sexual dysfunction).
When the capsular ligaments are injured, they become elongated and exhibit laxity, which causes excessive movement of the cervical vertebrae.
- In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.
- In the lower cervical spine (C3-C7), this can cause muscle spasms, crepitation, and/or paresthesia in addition to chronic neck pain.
- In either case, the presence of excessive motion between two adjacent cervical vertebrae and these associated symptoms is described as cervical instability.
Therefore, we propose that in many cases of chronic neck pain, the cause may be underlying joint instability due to capsular ligament laxity. Furthermore, we contend that the use of comprehensive Prolotherapy appears to be an effective treatment for chronic neck pain and cervical instability, especially due to ligament laxity. The technique is safe and relatively non-invasive as well as efficacious in relieving chronic neck pain and its associated symptoms.
Summary and contact us. Can we help you? How do I know if I’m a good candidate?
We hope you found this article informative and that it helped answer many of the questions you may have surrounding possible conditions caused by cervical spine instability. Just like you, we want to make sure you are a good fit for our clinic prior to accepting your case. While our mission is to help as many people with chronic pain as we can, sadly, we cannot accept all cases. We have a multi-step process so our team can really get to know you and your case to ensure that it sounds like you are a good fit for the unique testing and treatments that we offer here.
References for this article:
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 Malik AT, Jain N, Kim J, Khan SN, Yu E. Sexual activity after spine surgery: a systematic review. European Spine Journal. 2018 Oct 1;27(10):2395-426. [Google Scholar]
5 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]
6 Fotakopoulos G, Alexiou GA, Kotlia P, Pachatouridis D, Voulgaris S. Improvement of erectile dysfunction after surgery for cervical disk herniation. Journal of Neurological Surgery Part A: Central European Neurosurgery. 2012 Aug 16:e89-91. [Google Scholar]
7 Cheng YF, Xirasagar S, Kuo NW, Chung SD, Lin HC. Association of erectile dysfunction with tinnitus: a nationwide population-based study. Scientific Reports. 2021 Mar 26;11(1):1-7. [Google Scholar]
8 Lee SU, Kim HJ, Koo JW, Choi JY, Kim JS. Vertigo Induced During Coitus. Frontiers in neurology. 2019 Jan 11;9:1187. [Google Scholar]
9 Steilen D, Hauser R, Woldin B, Sawyer S. Chronic neck pain: making the connection between capsular ligament laxity and cervical instability. The open orthopaedics journal. 2014;8:326. [Google Scholar]
This article was updated August 6, 2023