Ejaculation: Still a Top Priority for Men with SCI

As a quad and a sexuality researcher and educator, I have devoted over 35 years to teaching health professionals and people with disabilities what they need to know about sex and relationships to optimize sexual response and pleasure after an illness or injury. After all these years of spending time in SCI-related forums, answering questions online, and coaching men with SCI, I can confirm that the No. 1 topic on the minds of the male SCI community remains ejaculation.  

A little over 25 years ago I published an article in New Mobility entitled Making Babies: Vibratory Stimulation and At-Home Insemination. I followed up in February 2016 with my article The Ejaculation Affirmation, now called Spinal Cord Injury and Ejaculation. That article was based on one of the most active threads in the CareCure Community’s Relationship and Sexuality Forum, “Electro Nut Busting.” 

My theory as to why we are so focused on ejaculation is threefold. I’ll start with explaining the term I coined, “ejaculation affirmation.” Ejaculation provides concrete proof of sexual satisfaction for partners. For most people who have sex with men, ejaculation provides the affirmation that they pleased their partner. Second, ejaculation affirms masculinity, as it is the defining moment of the typical male orgasmic response and is associated with the feeling of completeness or finishing. Hence the loss of the ability to ejaculate strikes at the core of a man’s sexual identity. The third reason goes beyond the personal: Ejaculation is a primal drive linked to procreation and species survival. The importance of ejaculation is clear, and while my work often focuses on exploring pleasure beyond it, I absolutely understand and support the desire to restore this fundamental function after an injury. 

A Three-Step Method for Ejaculating at Home 

Researchers at the Institut de Réadaptation Gingras-Lindsay-de-Montréal developed a protocol for eliciting ejaculation after SCI. During patients’ initial hospital stays, they are asked to explore their ability to ejaculate via natural options, including masturbation, intercourse or oral sex, as 5%-32% of men with SCI report the ability to ejaculate without assistive devices or medication, based on the type and completeness of the injury. 

If natural means are not successful, patients are encouraged to try penile vibratory stimulation, which often is an effective method if you have intact lumbosacral reflexes (typically those with thoracic-level SCI or above). Patients are trained in vibratory use, stimulation parameters and perceptual responses.  

Encouraging participants to focus on the sensations experienced during masturbation, regardless of achieving ejaculation or orgasm, is important to the process. While some sensations may be diminished following SCI, many people report experiencing increases in heart rate, respiration and sex flush — diffuse autonomic sensations that can evoke feelings similar to pre-injury orgasm.  

You can follow a similar method at home using commercial vibrators or specialized devices like the FERTICARE 2.0 or Viberect, designed to optimize stimulation for men with SCI. Studies have shown that the FERTICARE 2.0 can improve ejaculation success rates significantly. Additionally, using two vibrators simultaneously, known as the “sandwich technique,” has also yielded promising results. You can find more details on PVS in Spinal Cord Injury and Ejaculation. There is also good information on this site recommended by a member of the Facebook group SCI Locker Room. 

If your injury is above T6 or you are prone to autonomic dysreflexia — a significant increase in blood pressure in response to situations like pain, a full bladder or sexual arousal — it is essential to monitor your blood pressure during vibrostimulation and ejaculation because AD may not exhibit any symptoms. I use a convenient wrist blood-pressure monitor. While mild-to-moderate increases in blood pressure during ejaculation are common and not necessarily something to worry about, it’s crucial to assess and manage any risk of severe AD.  

If vibrostimulation alone doesn’t work, you can talk with your doctor about adding midodrine with vibration. Midodrine is an oral medication traditionally used to treat low blood pressure, which works by tightening blood vessels. It has been shown to increase the chances of ejaculation in men with SCI without severe side effects. This drug is typically taken 45 minutes before sexual activity. Note that while this article is about men, women with SCI can also benefit from this protocol.  

Electro Nut Busting: Ramping It Up 

Electroejaculation has historically been a medical procedure that uses a rectal probe to stimulate the pelvic nerves and induce ejaculation. It was typically used when vibratory stimulation wasn’t successful. Nowadays, many clinics treat male infertility by extracting sperm via a needle or a small incision in the testicle. Similarly, the rectal probe ejaculation procedure is usually performed by a health care professional in a clinical setting. Both are effective techniques for in vitro fertilization and reproductive purposes. 

Some men with SCI, however, discovered that they could trigger an ejaculation at home using a TENS unit — a device that is generally accessible and cost-effective to facilitate ejaculation. I explain this procedure in detail in Spinal Cord Injury and Ejaculation. 

Among those in the CareCure Community who have experimented with electrostimulation, 22 of the 26 men reported achieving ejaculation, with some individuals describing the experience as pleasurable. It is essential, however, to recognize that this experience carries certain risks, particularly for anyone who’s prone to AD as discussed above. 

PT-141: A Potential New Treatment for Erectile Dysfunction and Orgasm in Men with SCI 

I was recently asked by a sex therapist I supervise in Australia about the practice of men with SCIs injecting themselves in the abdomen with a peptide, PT-141. She has a few clients who have started using PT-141 for sexual dysfunction. These guys have cervical-level SCI. They are getting the product online from a supplier in Australia, self-injecting, and sharing the news with each other. She said the feedback is amazing.  

One of her clients self-injecting PT-141 noted experiencing erections and a heightened sexual desire akin to pre-injury sensations, albeit without ejaculation. Impressively, he rated his erectile function a perfect 10 of 10 and reported spontaneous erections over a period of up to 48 hours post-injection. However, she was curious about risks or side effects such as priapism — prolonged erections lasting over four hours — or reasons why this isn’t used more widely. The fact that she hasn’t seen it before highlights the need for further investigation into the safety and efficacy of this treatment. 

I hadn’t heard of this practice either but I knew a colleague, Jim Pfaus, Ph.D., who researched this peptide, otherwise referred to as bremelanotide, for the pharmaceutical company that took this drug through the FDA approval process. Pfaus expressed keen interest in these preliminary findings, suggesting that PT-141 may enhance the spinal reflex pathways responsible for erections, while also potentially influencing brain mechanisms related to sexual desire. According to Pfaus, “this dual action could represent a significant advancement in the therapeutic options available for men with spinal cord injuries, particularly given the limited efficacy of traditional erectile dysfunction medications in this population.” 

While bremelanotide was initially FDA approved for premenopausal women with hypoactive sexual desire disorder — low sex drive — its application in men, not to mention those with SCIs, remains largely unexplored in the literature. The current use of PT-141 for this purpose is considered “off-label,” and there are concerns regarding the quality control of products sourced online.  

Researchers at San Diego Sexual Medicine had been studying and prescribing bremelanotide since the FDA approved it for premenopausal women with hypoactive sexual disorder in 2019. They began prescribing it off-label for men with different types of sexual dysfunction in 2021. Based on their research, bremelanotide was safe and effective in both populations. They emphasized the importance of using medically approved formulations, citing that their clinic prescribes the FDA-approved version, Vyleesi, which is specifically designed for women but has been effectively used in male patients as well.  

The anecdotal evidence presented by users highlights a significant need for formal studies to validate these findings and assess the safety of PT-141 for men with SCIs. As researchers continue to explore the intricacies of sexual function and its restoration, PT-141 may pave the way for new therapeutic strategies that enhance quality of life for people with SCIs. 

Options Abound 

Despite decades of progress in sexual health for men with SCIs, the desire to achieve ejaculation remains a central focus. While the “ejaculation affirmation” reflects deep-seated psychological and biological drives related to masculinity, partnership and procreation, a range of approaches is available to those seeking to restore this function. From natural methods and penile vibratory stimulation, potentially augmented by medication, to the more complex electroejaculation techniques, options exist for many. Emerging treatments like PT-141 offer intriguing possibilities, though further research is crucial to validate their effectiveness and safety.  

While the pursuit of ejaculation remains paramount, it’s crucial to remember that it is only one aspect of a fulfilling sexual life. A balanced approach to sex after SCI acknowledges the significance of ejaculation while also exploring a broader spectrum of sexual experiences and pleasures.