Biomedical subjects
Publications and source records attributed to P A Chapelle.
Testicular biopsies and hormone profiles were obtained from 23 paraplegic patients who had sustained a complete spinal cord section. The hormone profiles were normal, but patients with a spinal lesion including the T10-L2 metameres showed a particular pattern of germinal cell abnormalities. The atrophy is multifactorial, but may well include destruction of the sympathetic innervation of the testis by the lesion.
This study was of 135 patients with a complete spinal cord section suffered from loss of ejaculation. The spinal cord injuries were classified following the upper and the lower limits of the lesion. The volume of the testes of the patients and of 13 normal control subjects were measured. Physostigmine allowed 75 patients to ejaculate and 15 of them procreated. The possibility of ejaculation after physostigmine mainly depended on the integrity of the T12-L2 metamers. The testicular volume was significantly smaller in patients with a lesion including the T12 metamer than in patients with a lesion sparing the T12 metamer. Six patients with a lesion including the T12 metamer had testicular atrophy. This suggests that T12 segment plays a role in testicular function in paraplegic patients.
The authors describe a new therapy for paraplegic anejaculation. Sub-cutaneous injection of Physostigmine with certain precautions and with selected methods of application can be used for patients where there is the same indication for the use of an intrathecal injection of Neostigmine. The T12-L2 myelomeres must be intact. The new treatment is easier to perform, and when the patient has experimented with three tests in our hospital without any problems, he is granted permission to apply this treatment at home, without any medical supervision.
The sub-cutaneous injection of physostigmine (Eserine), an indirect para-sympatheticomimetic by reversible anticholinesterase activity, is capable of provoking ejaculation. The result is therefore identical to that obtained with a spinal injection of neostigmine (Prostigmine), which is only effective by spinal injection. In 6 patients with lesions at T12, L1 and L2, the subcutaneous injection of physostigmine was always effective. When this injection does not provoke any adverse reactions, it can be repeated at home without medical supervision. When this injection results in ejaculation, the erection is improved in 80% of cases and the sexual act is made easier. The usual dose is 2 mg of Eserine. One woman is currently pregnant from such an ejaculation. This method can therefore be proposed in the outpatient treatment of sterility in couples in whom the man is paraplegic, until its oral administration has been perfected.
Basing themselves on 149 cases, the authors describe the spinal neurophysiology of ejaculation in spinal man, and put forward certain hypotheses. They suggest that the reflex of seminal emission is a lumbar reflex, which may be dependent on conductive factor originating in the upper neurological structures, and that the orthosympathetic system, which leaves the spinal cord through the thoracolumbar junction, could provide a highway for the psychological nerve impulses inducing seminal emission.
Three types of erection following complete spinal transection (at lower thoracic or thoracolumbar levels) in man are described. Reflex erection involves both corpus cavernosum and corpus spongiosum if the lower level of cord injury or lesional sector (LLLS) is cranial to T10/12, and involves only corpus cavernosum if the LLLS is caudal to T12/L2. Psychogenic erection may occur when the upper level of cord injury or lesional sector (ULLS) is caudal to T12 and when testicular sensation is normal. A mixed erection can occur when the ULLS is caudal to T10/12 and the LLLS cranial to S2.
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The authors made a detailed clinical analysis of 119 stabilized total paraplegics in order to define, as precisely as possible, the limits of the medullary segment which, for each patient, had lost all its functional value. The relationships between the affected segments and the sexual capabilities of these patients show that the segment must: --exclude the sacral spinal cord if reflex erections are to occur; --underly Th. IX at least, or better still Th. XI, for psychogenic turgescence to appear; the efferent pathways seem therefore, to emerge from the cord quite close to the level which receives testicular afferent pathways; --underly or overly Th. XII, L I, and L II for at least the greater part, for emission of sperm to occur; a true abrupt ejaculation probably requires the complementary integrity of the sacral spinal cord.
A case of successful pregnancy following artificial insemination following intrathecal neostigmine injection in the wife of a complete traumatic paraplegic (T7-T8 to T11-T12) is described.