Algorithm for the Diagnosis and Management of Symptoms of Neurogenic Sexual Dysfunction

Artem Valeryevich Bershadsky, MD, PhD¹, Andrey Avgustovich Belkin, MD, DSc², Roman Vyacheslavovich Salyukov, MD, DSc³

1. Urologist at the Center for Medical Rehabilitation, Clinical Institute of Brain Berezovsky city, Russia
2. Professor, Department of Neurology and Department of Anesthesiology and Intensive Care, Ural State Medical University, Yekaterinburg, Russia; Ural State Medical University, Ministry of Health of the Russian Federation, Yekaterinburg, Russia
3. Professor, Department of Urology with Courses in Oncology, Radiology, and Andrology, Faculty of Advanced Training of Medical Workers, Peoples’ Friendship University of Russia, Ministry of Science and Higher Education of the Russian Federation; Associate Professor, Department of Medical Rehabilitation, Faculty of Continuing Medical Education, Pirogov Russian National Research Medical University, Ministry of Health of the Russian Federation; Research Fellow, Russian Scientific Center of Roentgenoradiology, Ministry of Health of the Russian Federation, Moscow, Russia

 

OPEN ACCESS

PUBLISHED: 30 April 2025

CITATION: Bershadsky, A.V., et al., 2025. Algorithm for the Diagnosis and Management of Symptoms of Neurogenic Sexual Dysfunction at the Rehabilitation Treatment Stage. Medical Research Archives, [online] 13(4).
https://doi.org/10.18103/mra.v13i4.6496

COPYRIGHT: © 2025 European Society of Medicine.
This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

DOI https://doi.org/10.18103/mra.v13i4.6496

ISSN 2375-1924

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ABSTRACT

Background: Neurogenic sexual dysfunction (NSD) is a frequent yet underdiagnosed consequence of neurological disorders such as spinal cord injury (SCI), multiple sclerosis (MS), stroke, and Parkinson’s disease (PD). Despite its significant impact on psychosocial well-being and quality of life, NSD remains insufficiently addressed in standard rehabilitation protocols.

Objective: To describe an original, context-adapted clinical algorithm for the diagnosis and management of neurogenic sexual dysfunction during the rehabilitation phase, based on the PLISSIT model and augmented by a structured feedback mechanism.

Methods: A modified diagnostic and therapeutic protocol was developed and implemented in a neurorehabilitation center in Russia, addressing systemic barriers such as the absence of sexual health professionals, lack of guidelines, and limited physician training. The model utilizes the first three stages of PLISSIT—Permission, Limited Information, and Specific Suggestions—and introduces a home-based feedback protocol to replace the Intensive Therapy phase. This protocol includes functional evaluation, educational counseling, environmental adaptation, and structured self-assessment after the first sexual attempt.

Results: All ten participants (aged 23–52) with chronic spinal cord injury and their partners completed the diagnostic protocol, including a structured feedback questionnaire. Sexual activity was conducted either in a home environment (8 couples) or in a designated guest room within the rehabilitation facility (2 couples). Among six male participants, five achieved erection and four reported successful penetration; two experienced orgasm, and one reported ejaculation. Among four female participants, three reported vaginal dryness and two reported discomfort during intercourse. Spasticity was noted in seven participants, and positioning difficulties were reported in six cases. Genital hypoesthesia or altered sensation was identified in nine participants. Eight participants reported post-activity fatigue, and two noted transient cardiovascular symptoms. All couples followed at least one clinical recommendation: lubricants were used in six cases and positioning aids in eight. Three male participants used phosphodiesterase type 5 inhibitors. Feedback forms were fully completed in all cases, with high adherence across physiological, emotional, and partner-related domains.

Conclusion: This adapted PLISSIT-based algorithm provides a feasible, replicable approach to the early diagnosis and treatment of sexual dysfunction within rehabilitation settings. The structured feedback loop enhances ecological validity, empowers patients, and facilitates targeted, multidisciplinary care. Further multicenter studies are warranted to validate its broader applicability.

Keywords: Neurogenic sexual dysfunction, PLISSIT model, spinal cord injury, rehabilitation, feedback protocol, patient-centered care, sexual health, multidisciplinary approach.

Sexual health is a fundamental component of overall well-being and personal identity, even in the context of severe neurological impairment. According to the World Health Organization, sexual health is a basic human right and integral to quality of life. However, sexual dysfunction of neurogenic origin (NSD) remains an underrecognized and underaddressed consequence of spinal cord injury (SCI), multiple sclerosis (MS), stroke, and other neurological disorders. Studies indicate that NSD affects up to 80% of individuals with neurological conditions, yet it is rarely addressed systematically in standard rehabilitation protocols¹²³.

Sexual dysfunction can be classified into three interrelated categories: primary dysfunction, resulting from direct damage to neural pathways; secondary dysfunction, associated with neurological sequelae such as spasticity, bladder or bowel dysfunction, and fatigue; and tertiary dysfunction, which encompasses psychological, relational, and sociocultural factors such as anxiety, altered body image, or reduced self-esteem⁴⁵⁶. These domains interact dynamically, complicating both diagnosis and treatment. Despite increasing awareness of its prevalence, NSD is often omitted from routine care due to barriers including lack of clinician training, discomfort with the topic, absence of clear guidelines, and limited access to sexual health professionals⁷.

A growing body of evidence highlights the importance of integrating sexual rehabilitation into multidisciplinary care for neurological patients. Interventions that combine education, pharmacological support, physical therapy, and psychosexual counseling have demonstrated improvements in patient satisfaction, adherence to rehabilitation, and psychosocial adjustment⁸. Among the tools available to guide clinical work in this domain, the PLISSIT model (Permission, Limited Information, Specific Suggestions, Intensive Therapy) has been widely adopted. It provides a structured, stepwise approach to addressing sexual concerns. However, in real-world settings—particularly in systems with constrained resources—the final stage of the model (Intensive Therapy) is frequently inaccessible.

In our clinical experience, many patients with SCI and other neurological conditions receive little or no guidance regarding sexual recovery, despite expressing significant concerns⁹. Additionally, hospital-based assessments often fail to reflect the lived experience of sexual activity, which depends on emotional readiness, partner interaction, and environmental comfort—factors not replicable in sterile or institutional settings.

To address these gaps, we developed an adapted diagnostic and therapeutic algorithm based on the first three levels of the PLISSIT model, enriched with a structured, real-world feedback protocol. This protocol is designed to assess sexual function not only from a physiological standpoint, but also through the lens of contextual, emotional, and interpersonal dynamics. Following preparatory counseling and individualized recommendations, patients and their partners are invited to attempt sexual activity in a familiar, emotionally supportive environment and complete a structured feedback questionnaire within 24 hours.

The aim of this study is to describe the implementation of this novel, feedback-informed PLISSIT-based model in a neurorehabilitation setting and to evaluate its feasibility, clinical utility, and acceptability among patients and their partners. We hypothesize that the use of structured feedback collected under ecological conditions will improve diagnostic precision, inform therapeutic decisions, and enhance partner engagement in the rehabilitation process.

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Materials and Methods

Study Design and Setting

This study was conducted as a prospective observational pilot within a neurorehabilitation program at Clinical institute of brain, aimed at evaluating the feasibility and clinical utility of a structured diagnostic and feedback-based algorithm for the assessment and management of neurogenic sexual dysfunction (NSD) following spinal cord injury (SCI). The protocol was based on a modified PLISSIT framework and incorporated structured sexual counseling, personalized recommendations, and post-coital self-assessment via a feedback questionnaire.

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Participants

A total of 10 adult patients (aged 23–52) with chronic consequences of traumatic spinal cord injury participated in the study. All individuals were undergoing rehabilitation and presented with varying levels of spinal lesions (cervical, thoracic, or lumbosacral), verified through neurological assessment and imaging. The time since injury ranged from 8 months to 4 years.

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Inclusion Criteria

Participants were eligible if they met the following criteria:

• Documented history of spinal cord injury with residual neurogenic dysfunction;

• Medical stability to engage in sexual activity;

• Absence of active infectious disease (e.g., urinary tract infection, decubitus infection, or systemic inflammation);

• Presence of a stable sexual partner willing to participate;

• Ability to attempt sexual intercourse either in a dedicated guest room at our institute or in home conditions with full adherence to provided recommendations;

• Consent to complete a structured feedback questionnaire within 24 hours after the attempted intercourse.

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Intervention Protocol

Each participant and their partner underwent:

1. Multidisciplinary functional evaluation involving a neurologist, urologist, physical therapist, and occupational therapist;

2. A semi-structured educational session led by a neuro-urologist, covering the neurophysiology of sexual function, expected challenges, and adaptive strategies;

3. Delivery of an individualized instruction sheet, including ergonomic recommendations, hygiene protocols, pharmacological support if applicable, and use of sexual aids (e.g., lubricants, pillows, vibrators).

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Feedback Collection

Following the sexual activity, both the patient and their partner independently completed a custom-designed feedback questionnaire. This tool included Likert-scale and open-ended questions on:

• Physical comfort, spasticity, and pain;

• Quality of erection and orgasm (in men), or lubrication and pain (in women);

• Emotional experience, confidence, and intimacy;

• Environmental and positioning factors;

• Suggestions for improvement and unmet needs.

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Ethical Considerations

The study was approved by the local Institutional Ethics Committee. All participants provided written informed consent. Personal data were anonymized, and couples were informed of their right to withdraw from the study at any stage without consequences to their medical care.

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Sexuality in Neurological Patients:

The Rationale for Integration into Rehabilitation Programs

Sexuality remains a fundamental aspect of human well-being and identity, even in the context of severe neurological disease. According to the WHO (2004), sexual health is a basic human right and an integral component of quality of life¹⁰. Despite this, sexual concerns are often neglected in clinical practice, particularly among patients with chronic neurological impairments. Neurogenic sexual dysfunction (NSD) is a prevalent yet underrecognized consequence of disorders such as spinal cord injury (SCI), multiple sclerosis (MS), and stroke. These conditions compromise sexual function through a combination of neurological disruption, somatic disability, and psychosocial maladaptation¹¹.

Contemporary classification distinguishes between primary, secondary, and tertiary components of NSD. Primary dysfunction arises from direct neurogenic disruption of afferent and efferent pathways controlling sexual response. Secondary dysfunction reflects comorbid neurological symptoms—bladder and bowel dysfunction, spasticity, fatigue, cognitive or sensorimotor deficits—that impede sexual activity. Tertiary dysfunction encompasses the psychological and sociocultural consequences of chronic illness, including loss of body image, anxiety, low self-esteem, and relationship disruption¹². These levels interact dynamically, compounding the clinical burden and contributing to reduced quality of life, emotional distress, and social isolation.

Findings from qualitative and quantitative research confirm the strong association between NSD and depression, anxiety, and decreased life satisfaction in both men and women. Common manifestations include reduced libido, erectile and orgasmic dysfunction in men, and anorgasmia, dyspareunia, and lubrication deficits in women¹³. These symptoms persist across all stages of disease progression and are often intensified by the absence of targeted medical or psychological intervention¹⁴. Notably, despite the high prevalence of NSD, most healthcare professionals do not address sexuality proactively during consultations. Studies cite lack of training, time constraints, and cultural taboos as common barriers¹⁵.

Integration of sexual health into neurological rehabilitation represents both a clinical need and an opportunity to improve outcomes. Evidence from neurorehabilitation studies indicates that incorporating sexual counseling, pelvic floor therapy, pharmacologic treatment (e.g., PDE-5 inhibitors, hormone therapy), and neuromodulation techniques leads to improved patient-reported satisfaction and psychosocial adjustment¹⁶. Moreover, addressing sexual function contributes positively to adherence with broader rehabilitation goals, particularly in the domains of intimacy, self-care, and interpersonal relationships¹⁷.

In rehabilitation practice, restoring pelvic autonomic function is a cornerstone of managing NSD. Multimodal interventions combining somatic rehabilitation with targeted neuro-urological approaches (e.g., sacral neuromodulation, electrostimulation, functional training) are especially promising. However, successful implementation requires trained personnel and a paradigm shift: from viewing sexual dysfunction as an ancillary concern to recognizing it as a core determinant of recovery and reintegration¹⁸.

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Early Diagnosis and Multidisciplinary Management of Neurogenic Sexual Dysfunction During Rehabilitation

Neurogenic sexual dysfunction (NSD) is a frequent and disabling consequence of neurological disorders, including spinal cord injury (SCI), multiple sclerosis (MS), and Parkinson’s disease (PD). Failure to recognize and address NSD in a timely manner leads to progression of symptoms, deterioration of emotional well-being, and a measurable decline in quality of life. Early identification and a coordinated, multidisciplinary intervention are critical at the rehabilitation stage to optimize functional outcomes¹⁹.

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Importance of Early Diagnosis

Accurate and timely diagnosis of NSD begins with a comprehensive clinical evaluation. This includes:

• Detailed sexual history, encompassing changes in libido, arousal, orgasmic response, genital sensation, and partner dynamics.

• Neurological examination, focusing on spinal and peripheral pathways involved in sexual reflex arcs and autonomic control.

Targeted physiological assessments, such as somatosensory evoked potentials (SSEPs), bulbocavernosus reflex testing, and electromyography (EMG) of the pelvic floor, to evaluate the integrity of neurogenic control mechanisms.

Although advanced diagnostic tools may aid in delineating the neurophysiological basis of dysfunction, diagnosis is often clinical and requires specialized expertise. The subtleties of NSD, particularly when overlapping with urinary or bowel symptoms, necessitate structured screening within routine neurological rehabilitation.²⁰

THE ROLE OF A MULTIDISCIPLINARY TEAM

Effective rehabilitation of NSD requires coordinated input from urologists, neurologists, physical medicine specialists, clinical psychologists, and sexual health professionals. Each discipline contributes to a holistic, patient-centered plan of care.²¹ Key components include:

• Personalized rehabilitation protocols, tailored to the degree and type of neurological impairment.

• Pharmacological therapy, such as phosphodiesterase type 5 inhibitors and hormone replacement, targeting vascular and hormonal contributors to dysfunction.

• Physical interventions, including pelvic floor muscle training and electrical stimulation, to restore motor and autonomic function in the pelvic region.

• Psychosexual counseling, addressing body image concerns, relationship dynamics, emotional adaptation, and expectations related to sexual recovery.

Integration of these approaches within the rehabilitation continuum enables a shift from symptom-oriented care to functional and psychosocial restoration.

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Neurophysiological Mechanisms of Sexual Function and Their Disruption in Neurological Disorders

Sexual function is governed by a complex integration of central, spinal, and peripheral nervous system pathways, involving both autonomic and somatic components. It is modulated by neurochemical signaling, hormonal regulation, and afferent feedback from genital and extragenital zones.²²

Disruption of these mechanisms at any level—cortical, subcortical, spinal, or peripheral—may result in neurogenic sexual dysfunction (NSD), frequently observed in patients with spinal cord injury (SCI), multiple sclerosis (MS), stroke, and other neurological diseases.

 

CENTRAL REGULATION

Key brain regions involved in sexual function include:

• Hypothalamus (especially the paraventricular nucleus), which integrates hormonal and autonomic control, and modulates erection and ejaculation via oxytocinergic pathways.

• Limbic system, notably the amygdala and hippocampus, which governs emotional and motivational aspects of sexual behavior. Bilateral amygdala lesions can result in hypersexuality, as seen in Kluver–Bucy syndrome.

• Prefrontal cortex, responsible for cognitive modulation of sexual responses, impulse control, and inhibition of socially inappropriate behavior.

• Thalamus and cingulate gyrus, which process sensory inputs relevant to sexual arousal and pleasure.

• Periaqueductal gray (PAG) in the midbrain, involved in balancing excitatory and inhibitory signals during sexual arousal and coordinating autonomic outflow.³

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SPINAL AND PERIPHERAL PATHWAYS

Peripheral sexual function is mediated by three main neural pathways:

• Parasympathetic (S2–S4):
  Mediates vasodilation and engorgement of erectile tissue via acetylcholine and nitric oxide (NO). Essential for penile and clitoral erection and vaginal lubrication.

• Sympathetic (T11–L2):
  Controls ejaculation, detumescence, and closure of the bladder neck to prevent retrograde ejaculation through noradrenergic signaling.

• Somatic (S2–S4, via pudendal nerve):
  Coordinates rhythmic contraction of the perineal muscles (bulbospongiosus and ischiocavernosus) involved in orgasm and maintenance of erection.²⁴

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IMPACT OF NEUROLOGICAL LESIONS ON SEXUAL FUNCTION

Cerebral lesions may impair sexual desire, arousal, and emotional regulation. Damage to the frontal lobes can suppress libido and affect behavioral inhibition. Amygdala involvement may trigger disinhibition or hypersexuality, while PAG dysfunction may impair autonomic balance and lead to sexual hypoactivity.

Spinal cord injury results in segmental disruption of reflexogenic and psychogenic sexual responses, depending on lesion level:

• Above T6: Reflexogenic erection is often preserved, but psychogenic pathways are disrupted.

• Below L2: Psychogenic input may remain, while reflex arcs are compromised.

• S2–S4 lesions: Both reflexogenic and psychogenic components are impaired, leading to severe erectile and ejaculatory dysfunction.²⁵

In women, analogous mechanisms affect vaginal lubrication, genital vasocongestion, and orgasmic response, with neurogenic disruption resulting in dryness, anorgasmia, and dyspareunia.

Understanding the neurophysiology of sexual function is essential for the accurate diagnosis and management of NSD. Clinicians should assess both psychogenic and reflexogenic components, integrating neurological, urological, and sexual histories. Functional neuroimaging (e.g., fMRI), electrophysiological tests (e.g., SSEPs, bulbocavernosus reflex latency), and urodynamic studies can help localize lesions and differentiate between central and peripheral dysfunction.

Sexual function is regulated by a hierarchically organized neural network involving cortical, spinal, and peripheral mechanisms. Neurological diseases frequently disrupt this network, leading to NSD. A thorough understanding of neurophysiological control and site-specific patterns of dysfunction is vital for accurate diagnosis and the development of individualized rehabilitation protocols. Incorporating electrophysiological and imaging tools enhances diagnostic precision and informs the design of targeted interventions aimed at restoring sexual health in neurologically impaired patients.²⁵

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Diagnosis of Neurogenic Sexual Dysfunction

The diagnostic approach to neurogenic sexual dysfunction is based on a standardized, stepwise evaluation that incorporates clinical history, neurological examination, functional testing, and patient-reported outcomes.²⁶ This comprehensive diagnostic framework is summarized in Table 1 and provides a practical guide for structured assessment in rehabilitation settings.

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Table 1

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Diagnostic Algorithm: Application of the PLISSIT Model in Neurogenic Sexual Dysfunction

A structured, phased approach is essential for the assessment of neurogenic sexual dysfunction (NSD), particularly in the rehabilitation context. The PLISSIT model (Permission, Limited Information, Specific Suggestions, Intensive Therapy), initially developed in behavioral sex therapy and now widely adopted in neurorehabilitation, offers a practical framework for addressing sexual concerns in patients with neurological disorders.²⁷

The model comprises four escalating levels of clinical engagement:

• Permission involves creating a safe, nonjudgmental space for patients to voice concerns regarding sexual function, validating their experiences as part of holistic care.

• Limited Information provides tailored evidence-based explanations of how neurological conditions and related symptoms affect sexual health.

• Specific Suggestions includes individualized recommendations for managing identified issues, such as strategies to improve arousal, positioning, or partner communication.

• Intensive Therapy refers to referral to specialized care—sexual medicine, psychotherapy, or neuropsychology—when complex dysfunctions exceed the scope of routine rehabilitation.

In NSD, where sexual impairment may result from a combination of central nervous system lesions, autonomic and somatic pathway disruption, cognitive deficits, and psychosocial factors, this model allows for stratified diagnostic clarity.²⁸ It facilitates the identification of barriers that patients may be reluctant to report spontaneously, and guides clinicians in adjusting interventions based on symptom severity and patient readiness.

However, real-world implementation of the PLISSIT model presents several challenges:

1. Initiating the dialogue:
   At the Permission stage, many clinicians feel unprepared or uncomfortable initiating conversations about sexuality. Cultural taboos, lack of formal training, and concerns about patient discomfort often contribute to silence around sexual health. Surveys indicate that even experienced neurologists and rehabilitation professionals seldom address sexual dysfunction unless patients raise the issue directly.

2. Knowledge limitations:
   At the Limited Information and Specific Suggestions stages, clinicians may lack adequate understanding of sexual neurophysiology, pharmacological options, or rehabilitative strategies. The absence of formal training in sexual medicine during core medical education contributes to inconsistent and superficial management of NSD.

3. Interdisciplinary coordination:
   Implementing Specific Suggestions requires integration of neurological, urological, gynecological, endocrine, and psychological expertise. This demands a multidisciplinary structure that may not be available in all rehabilitation settings.

4. Access to specialized care:
   At the Intensive Therapy level, access to qualified sexual health professionals is limited in many regions, especially in underserved or rural areas. This restricts the model’s final tier of care delivery, leaving complex dysfunctions inadequately addressed.

Despite these barriers, the PLISSIT model remains a validated and adaptable tool for structuring sexual health assessment. It empowers clinicians to address NSD systematically, build therapeutic trust, and guide patients toward appropriate interventions.²⁹

For patients with neurological impairment—such as those with spinal cord injury, multiple sclerosis, or Parkinson’s disease—who face multi-level sexual dysfunction, this model provides a nuanced diagnostic algorithm that aligns with the complexity of their clinical presentation.

To further investigate the diagnostic gap in routine clinical care, we conducted a local mini-survey at our neurorehabilitation center among patients with confirmed neurogenic sexual dysfunction. A total of 211 individuals undergoing inpatient or outpatient treatment completed an anonymous questionnaire.

Only 10% of respondents reported that a healthcare provider had initiated a conversation about sexual function during their hospital stay. At the same time, 58.2% of patients indicated a strong desire to discuss issues related to neurogenic sexual dysfunction with a medical professional.

The results of this survey are presented in Figure 1 and Figure 2 below and illustrate a marked discrepancy between patients’ informational and emotional needs and the current clinical practice. These findings further emphasize the urgency of integrating systematic sexual health assessments into neurorehabilitation and support the rationale for the present study.

Figure 1

Have you discussed your sexual function with a physician or rehabilitation specialist after the onset of your condition?

 

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