• Urinary symptoms:

  • –

    Storage symptoms (urgency, daytime frequency, nocturia, urinary incontinence), bladder sensations; whether incontinence is associated with urgency (urgency urinary incontinence) or effort/exertion (stress urinary incontinence), continuous (e.g., incontinence from chronic urinary retention), related to neurological disability (impaired cognition and/or mobility) or sexual arousal

  • –

    Voiding symptoms (how voiding is initiated, posture adopted during voiding, hesitancy, quality of stream (e.g., strength, whether interrupted), dysuria, abdominal straining when voiding, voided volumes, terminal dribble)

  • –

    Post-micturition symptoms (sensation of incomplete bladder emptying after voiding, double voiding, post-micturition incontinence)

• Onset and course of symptoms in relation to the neurological disease; extent of neurological disabilities
• Current and past treatment for urinary symptoms- treatment outcomes and any adverse reactions, use of continence products and appliances (e.g., pads or diapers, sheaths, catheters). If using a catheter, whether intermittent (frequency of catheterisation) or indwelling (urethral or suprapubic catheter)
• Any complications: (recurrent) urinary tract infections, haematuria, pain from the urinary tract, catheter blockages or bypassing
• Lifestyle factors: fluid intake and timing, type of fluid intake (e.g., alcohol, caffeine, fizzy drinks), smoking, alcohol and recreational drug use
• Sexual and bowel symptoms
• Medical, psychological and surgical co-morbidities both past and current- co-existent genitourinary conditions eg. prostate enlargement, stones or surgery; obstetric history.
• Impact of urinary symptoms on quality of life (patient and carer).
• Support at home; expectations of patient and carers from symptom management in the context of the neurological condition.
• Periodic review for new or changing urinary symptoms. In case of a recent deterioration, enquire about symptoms of a UTI, change in bowel movements, recent change in neurological symptoms or in medications

• Assessment of vital signs, including blood pressure and pulse rate in supine and standing positions, to detect conditions like orthostatic hypotension and bradycardia that could impact urinary symptom management (e.g., contraindications to alpha-blockers, antimuscarinic agents)
• Neurological assessment of cognitive, motor, and sensory functions including evaluating the sacral innervation (sensory changes in the sacral dermatomes (S2-5)), sacral cord mediated reflexes (anal, bulbocavernosus). Assess ability to undergo investigations or treatments (e.g., ability to perform self-catheterisation)
• External genitalia, if appropriate, to identify contributors to urogenital dysfunction; screen for local complications (e.g., atrophy, skin infection)
• Specialist referral when prostate pathology, pelvic organ prolapse or abnormal pelvic floor muscle function are suspected

• Chemical assessment of the urine using urine dipsticks detect pyuria, glucosuria, proteinuria, and haematuria, prompting further investigations if persistent and unexplained. Interpret results in the context of the patient's underlying condition [7, 15, 20]
• Positive leukocytes and nitrites have reported sensitivity (78%) and specificity (65%) to detect significant bacteriuria (≥ 10⁵ CFU/mL) in MS [23, 24]
• Urine dipsticks have a 50% positive predictive value and 98% negative predictive value for UTIs [24, 25] and are more useful to exclude UTIs. Formal urinalysis (microscopic assessment) and urine cultures are preferred for UTI diagnosis [7, 13-15]
• Significant leukocyturia is defined as ≥ 10 leukocytes per microscopic field in centrifuged urine samples [13]
• Collection methods include clean-catch midstream, freshly inserted sterile catheter, or catheter sampling port [7, 15]; avoid leg bags [15]

• Urine culture should not routinely be sent unless there are symptoms suggestive of a UTI, exceptions being: pregnancy, planned invasive urological procedures [13-15, 20, 26] and before the administration of immunomodulatory agents in individuals with MS and hypogammaglobulinemia reporting recurrent UTIs [26]
• Due to impaired sensations, not all individuals may report typical UTI symptoms. UTIs can present as worsening neurological (e.g., autonomic dysreflexia, motor symptoms, delirium) or urological (e.g., urinary frequency, urinary urge or urge incontinence) symptoms [7]
• Urinary bacterial colonisation is common when using a catheter, however the risk of progression to symptomatic UTI is low [7]
• Collection of urine samples should follow the clean-catch midstream technique. If catheterized, sample to be taken from a freshly inserted sterile catheter or from the sampling port of a catheter bag; avoid leg bags [7, 15]
• Significant growth in urine culture: > 10⁴ cfu/mL in clean-void specimens, > 10² cfu/mL in samples from IC, any detectable growth in suprapubic aspirates [13]
• Routinely sending urine for culture in the absence of UTI symptoms can lead to unnecessary antibiotic treatment and consequent risk of side effects and antibiotic resistance

• A diary spanning three consecutive days is considered optimal, though there is limited normative data from the neurological population [7]
• Record voiding times and voided volumes using a jug, sleep and wake times, timing and type of fluid intake and volume, severity of urgency incontinence episodes and timing of medications, eg. diuretics [15, 17, 27]
• The link https://iciq.net/iciq-bladder-diary provides an example of a bladder diary

• The PVR is most commonly expressed as an absolute value. Percentage of bladder emptying (voiding efficiency) can also be calculated as a percentage and is particularly relevant when the bladder is overdistended or has a small capacity [7]
• The PVR should be measured during the initial evaluation [7, 13-15, 20, 28, 29] of individuals who can void spontaneously, and rechecked at follow up if there is an unexplained change in urinary symptoms [7]
• PVR is preferably measured by ultrasonography, however in-out catheterisation can also be used [7]
• An elevated PVR suggests voiding dysfunction. Urodynamics testing is needed to assess the cause ie. from detrusor underactivity, anatomical or functional bladder outlet obstruction, or both [7]

• Assessing renal functions by measuring blood urea and serum creatinine levels, or more accurately estimating the GFR (eGFR), is recommended as routine during the initial evaluation, particularly for high-risk individuals [7, 20]
• Frequency of follow-up testing is individualised based on risk profile [7, 13]
• Measuring serum creatinine alone may underestimate renal dysfunction in individuals with significant sarcopenia, and in these situations 24 h creatinine clearance or cystatin-C based estimates of GFR would need to be considered for assessing renal functions

• Men experiencing urinary symptoms should be given information and time to decide on undergoing PSA testing, especially if their symptoms suggest bladder outlet obstruction due to benign prostate enlargement, abnormalities are found on digital rectal examination performed by the attending urologist or they are concerned about prostate cancer [30, 31]
• Shared decision-making is essential, considering the benefits of reducing metastatic prostate cancer and preventing prostate cancer-related deaths against potential screening and treatment harms. Men should be offered a PSA test every 2 to 4 years between the ages of 50 to 70 years, though this may begin at age 40 to 45 years for individuals at greater risk for developing prostate cancer, namely black ancestry, germline mutations, strong family history of prostate cancer. The decision to continue screening is based on patient preference, age, PSA, prostate cancer risk and life expectancy [30-32]
• PSA levels may be elevated in men with urethral indwelling catheters or prostatitis, and alternative assessments will be needed if prostate cancer is suspected

• The need for urodynamics testing is determined by stratification of risk for developing upper urinary tract damage [7, 20, 33]
• With suprapontine lesions, urodynamics testing is omitted as a first-line examination as PVR and bladder pressures are typically low [7]
• Urodynamics can help identify specialised management options if first line treatments fail
• Urodynamics is a first-line examination for moderate/high risk individuals with neurological disease eg. suprasacral spinal cord lesions, spina bifida
• Follow-up urodynamics testing should be individualised based on risk profile [7, 13]
• Individuals with neurological disease should be referred to a urology service for undergoing urodynamics testing

• Neurological disorders associated with a greater risk of upper urinary tract damage, such as spinal cord injury, spinal dysraphism, transverse myelitis, or advanced MS [7, 13]
• Recurrent UTIs, particularly with fever [13, 15, 17, 21, 34]
• Haematuria without an apparent cause [15]
• Loin pain is suspected to originate from the urinary tract [15, 34]
• Abnormal findings on ultrasonography, including hydroureteronephrosis, renal or bladder stones, bladder diverticulum, renal scarring, or renal parenchymal loss [7, 15, 21, 34]
• PVR volume > 100–150 mL [7, 17, 35]
• Renal impairment [7, 15]
• When urological lesions are suspected, such as urinary symptoms secondary to prostate enlargement in men or pelvic organ prolapse in women [34]

• Maintaining an optimal daily fluid intake (1–2 L for an average adult) [14] and avoiding certain beverages (caffeinated drinks, carbonated drinks, citrus products and alcohol) can improve urinary storage symptoms [21, 36, 37], particularly when going outside the home or at night [38, 39]
• For individuals in urinary retention, the volume of fluids consumed can also affect the frequency of intermittent catheterisation
• Individuals at risk of developing constipation [40], dehydration [41], or with geriatric multi-morbidities [41] should limit their fluid intake cautiously
• Restricting fluid intake may exacerbate symptoms of orthostatic hypotension in those with autonomic failure [42] and increase the risk for recurrent UTIs or stone formation [36]

• Bladder retraining is effective in individuals with neurological disease, however a certain level of physical and cognitive abilities are required to recognise the urge to void and to be able to adopt techniques to postpone voiding [13, 15, 17, 29, 33, 37, 41, 43-47]; hence unsuitable if there is cognitive impairment
• Symptoms recur after cessation of bladder retraining [46, 48]
• Not recommended for individuals with urinary incontinence who are unable to void spontaneously, such as following SCI [29, 41]

• Pelvic floor exercises should be offered only to individuals at low-risk of developing upper urinary tract damage for improving continence [13-15, 17, 27, 29, 33, 37, 49, 50]
• Pelvic floor assessment and treatment regimen should preferably be organised through a pelvic floor physiotherapist [14, 15, 41]
• For long-term benefits, exercises should be continued even after continence had been achieved [51, 52]
• Prerequisites for performing pelvic floor exercises include active patient cooperation and ability to contract pelvic floor muscles, ie. partially preserved neural control over pelvic floor muscles [14, 15, 29, 41]
• Additionally, biofeedback may improve incontinence due to external sphincter deficiency [49], and pelvic floor electrical stimulation may improve urinary urge incontinence [37] however should be considered on an individual basis [15, 51]; these techniques may not be feasible in those with impaired cognition or sensorimotor skills

• Individuals with voiding dysfunction can present in chronic urinary retention. This can manifest as urinary storage symptoms such as urinary urgency, frequency and incontinence, recurrent UTIs, bladder stones, and upper urinary tract deterioration [50]
• A threshold PVR volume at which to initiate IC has not been defined [50]. A figure of 100 mL has been suggested in MS [14], whereas 300 mL was a suggested definition for non-neurogenic chronic urinary retention [53]. The task force came to a consensus of 150 mL
• Individuals require adequate support when learning IC, and teaching should be undertaken by health care professionals who are proficient with the technique, aware of locally available catheter products and understand the neurological disorder [33]
• A clean or aseptic technique should be adopted, and care should be taken to minimise trauma [33, 54]
• Complications of IC include UTIs, urethra trauma, false passages, stricture, and autonomic dysreflexia for SCI above T6 level [13, 33, 54-57]
• Hydrophilic, gel-coated, disposable catheters may lower the risk of urethral trauma and recurrent UTIs [57]
• Regular follow-up may be required to monitor complications, typically on an annual basis. However more frequent monitoring may be required if experiencing problems like recurrent UTIs [14, 20, 33, 51, 54, 55, 57]

• Both urethral and suprapubic catheterisation help to reduce intravesical pressure, however long-term catheterisation can lead to complications such as biofilm formation and thereby increasing the risk of urosepsis, catheter encrustation and bladder stones
• Suprapubic catheterisation is preferable when a long term catheter is being considered, however there is a risk for developing complications such as intestinal perforation at the time of catheter insertion and wound site infection
• A urethral catheter is appropriate as a temporary measure for acute urinary retention until a management plan is formulated
• In-out catheterisation may be required in select situations, eg. individuals with delirium who forcibly remove an indwelling catheter [41]

• Long term antibiotic use is associated with a risk for developing side effects and bacterial resistance, and therefore the need should be re-evaluated at follow-up [14, 15, 57, 58]. The choice of antibiotics should take into account urine culture and sensitivity results, previous antibiotic use and recommendations in local antibiotic formularies as part of antimicrobial stewardship

• Routinely treating asymptomatic bacteriuria can lead to antibiotic resistance without improving patient outcomes [13, 26, 29]
• In pregnant women, asymptomatic bacteriuria can pose a greater risk for developing complications such as pyelonephritis and premature delivery, and therefore antibiotic treatment is indicated [20, 26, 57-59]
• Treating asymptomatic bacteriuria prior to invasive urological procedures or immunomodulatory therapy including corticosteroids has been recommended by some guidelines to mitigate potential risks [20, 26, 57-59]

• Individuals with neurological disease with catheters reporting UTI symptoms should undergo urine culture and antibiotic sensitivity testing before starting antibiotics
• Antibiotic therapy should follow recommended dosages for at least 7 days, however duration of treatment may vary depending on clinical status and recommendations from local antibiotic formularies as part of antimicrobial stewardship [20, 57, 59]
• If antibiotic treatment is being started empirically whilst awaiting the results of the urine culture test, the choice of antibiotics should be based on previous antibiotic usage and, if available, results of earlier urine culture and sensitivity tests

• Tibial nerve stimulation has been shown to improve urinary symptoms and urodynamic parameters in neurological disorders such as MS [60-62], PD [63-65], SCI [66, 67] and stroke [68], with demonstrable durable effects lasting over 12 months [69]. There is still uncertainty regarding the type of lower urinary tract dysfunction that best responds to tibial nerve stimulation [20]
• Adverse effects are generally mild and include pain [20], inflammation and bleeding at the treatment site (for PTNS)
• Avoid this treatment in individuals with pacemakers or implantable defibrillators or if pregnant or planning pregnancy. PTNS should be avoided for those prone to excessive bleeding

• Condom catheters are worn outside of the penis and can be used for men who can empty their bladder [14, 30, 33]. A specialist nurse should assess penile length and girth, skin health and manual dexterity and, if appropriate, caregiver support [30, 33, 36, 41, 54, 56, 59]. Complications can include skin irritation and infection; rarely penile necrosis, urethral diverticula and UTIs [20, 33, 41]. Complications can be reduced by adhering to instructions on use, maintaining hygiene, regular changes, and periodic specialist nurse reviews [33]. Silicone condom catheters are preferred [33]
• Urine flasks can be used by individuals with mobility impairment to facilitate bladder emptying [41], and reduces the risk for falls from nocturnal toilet visits
• Temporary containment products such as continence pads may be offered till a urinary symptom management plan has been formulated [30]
• External appliances should be avoided for managing overflow incontinence due to urinary retention

• Efficacy between different antimuscarinic agents has been shown to be similar [70]
• Combination therapy of two antimuscarinic agents, or an antimuscarinic agent and beta-3 adrenoceptor agonist, could be considered in cases of poor treatment response [13, 33, 50]
• The PVR volume should be measured before initiating antimuscarinic treatment [14] and in cases of poor response to treatment.
• Adverse effects of antimuscarinic agents may include constipation, dry mouth and eyes, blurred vision, tachycardia, drowsiness, dyspepsia [50]. Voiding difficulties may worsen, however the risk of developing urinary retention in neurological patients is low
• Studies have evaluated the relationship between antimuscarinic agent use and cognitive changes and the risk for dementia [71]. In individuals at risk for cognitive impairment, antimuscarinic agents with favourable physicochemical and pharmacokinetic properties that make it less likely to cross the blood–brain barrier and having no demonstrated cognitive risks should be considered, such as trospium chloride or darifenacin. The decision on starting an antimuscarinic agent should be shared with the patient [50]
• Contra-indications include uncontrolled angle-closure glaucoma, gastro-intestinal obstruction, myasthenia gravis, severe ulcerative colitis, significant bladder outflow obstruction, toxic megacolon
• Use with caution if susceptibility to QT-interval prolongation (specifically for solifenacin)

• Beta-3 adrenoceptor agonists show similar clinical efficacy to antimuscarinic agents, however less consistent improvements in urodynamic outcomes including first detrusor contraction volume and bladder capacity [13, 20, 72]
• They can be considered in cases of poor response to antimuscarinic agents, either as an alternative or in combination [72-79]
• They may be considered in place of antimuscarinic agents in cases of unacceptable side effects or contraindications [37], and are considered a first-line treatment for individuals with cognitive disorders or in the elderly [71]. They have less detrimental effects on cognition and lower incidences of dry mouth, urinary retention and constipation. Adverse effects of beta-3 adrenoceptor agonists may include a rise in blood pressure, palpitations, increased heart rate and the risk of developing atrial fibrillation. Worsening voiding dysfunction has been reported in individuals with bladder outflow obstruction due to benign prostate enlargement [80], however the risk of developing urinary retention in neurological patients is low
• Use with caution if history of QT-interval prolongation
• Contraindicated if blood pressure severely uncontrolled (systolic ≥ 180 mmHg or diastolic ≥ 110 mmHg)

• Side effects include abdominal cramps, vomiting, diarrhoea and bradycardia [13, 29]

• Taken at bedtime, desmopressin has been shown to reduce MS related nocturia [81] and overnight catheterisation frequency in SCI-related nocturnal polyuria [82]
• Fluid intake should be restricted for a few hours after taking desmopressin [49]; weight and blood pressure should be monitored
• Common side effects include headache, ankle oedema, nausea, dizziness and hyponatremia, typically occurring early in treatment.
• The risk for hyponatremia is higher in females [27] and the elderly [27, 83], and therefore the standard desmopressin formulations (0.2 mg tablets at bedtime) should not be used for individuals, especially women, above age 65 [27]
• Low-dose desmopressin may, however, be considered for non-frail elderly individuals [21]
• Sodium levels should be checked at baseline, repeated 4–8 days and 1 month after initiation, and then every 3 to 6 months depending on clinical need [27]
• Desmopressin should be discontinued in case of side effects [38]
• Contraindications for desmopressin use include congestive heart failure, polydipsia, and concurrent use of medications with a high risk for developing hyponatremia [27] and persistent ankle oedema

• When initiating treatment, individuals should be advised to take the medication at bedtime and when supine, particularly the elderly, and those with high-level SCI, PD, dementia with Lewy bodies, or MSA, to minimise the risk of developing orthostatic hypotension
• Caution is advised when α₁-adrenoceptor blockers are taken together with PDE5 inhibitors
• Ejaculatory dysfunction is a known side effect, especially with the more selective α₁-adrenoceptor blockers eg. tamsulosin and silodosin [84]

History taking should include the following [13, 85-90] (checklist presented in Table 5):

• Sexual dysfunction assessment should include inquiries about primary, secondary, and tertiary contributors to sexual dysfunction [91]
• Consider the importance of an individual's context and psychological framework when assessing sexual function
• Enquire about sexual desire, orgasms, genital sensitivity, and in males erectile dysfunction and ejaculation issues, and in females poor lubrication

Medical history is crucial for identifying the cause of sexual dysfunction, and include onset and duration

• Sexual orientation, gender, relationships, emotional status, past treatments, alcohol/smoking habits, and recreational drug use
• The assessment should include a review of psychological co-morbidities, past sexual trauma and STIs
• Current medications and their impact on sexual functions should be reviewed [92]
• Stroke survivors should have regular inquiries about intimacy and sexual function, with post-stroke counselling at 3, 6, 9, and 12 months
• Several validated questionnaires exist for assessing sexual function in individuals with MS and SCI

• Assessment of vital signs including blood pressure and pulse rate (supine and standing), and weight/height
• Bedside neurological assessment of cognitive, motor, sensory and autonomic functions to evaluate multidimensional contributors that can impact intimacy and sexual performance and management
• Pelvic evaluation includes assessment of sensations in the sacral dermatomes, anal sphincter tone and contractions and reflexes (cremasteric, anal and bulbocavernosus reflex)
• Individuals with suspected urological, gynaecological or endocrinological pathology should be referred for specialist advice

• Male individuals with neurological disease who report ED should undergo a screening assessment for vascular risk factors (fasting glucose, HbA1c, lipid profile)
• Routine measurement of testosterone in males with neurological diseases and sexual problems is not recommended unless there is suspicion of hypogonadism
• Screening for cervical, ovarian, uterine, breast, prostatic, and testicular cancers may be recommended on an individualised basis
• Screening for STIs, including HIV, when deemed appropriate for the individual patient

• Sensory functions:

  • ○

    Pudendal sensory evoked potentials

  • ○

    Dorsal penile nerve conductions

• Motor functions:

  • ○

    Electromyography of pelvic floor muscles including urethral sphincter, anal sphincter

  • ○

    Pudendal motor terminal latency

• Reflex testing:

  • ○

    Bulbocavernosus reflex

  • ○

    Anal reflex

• Unexplained urogenital dysfunction where a neurological cause is suspected (e.g., atypical parkinsonism, unexplained urinary retention in females, genital numbness)
• Further evaluation of abnormal MRI findings such as a thickened filum terminale when the clinical significance is unclear
• History of trauma including individuals with a history of pelvic or perineal trauma where neurological injury is suspected
• Medico-legal considerations involving cases with urogenital symptoms that necessitate evaluating pelvic somatic innervation

1. Pain or bleeding during sexual activity
2. Anejaculation
3. Priapism
4. Suspected anatomical changes such as penile curvature or plaque (in male individuals) or pelvic organ prolapse (in female individuals)
5. Suspected endocrinological causes of sexual dysfunction, such as hypogonadism
6. Inadequate response to standard treatments for sexual problems.
7. Male and female individuals seeking treatment for infertility
8. Significant psychological co-morbidities such as depression and anxiety
9. Psychosocial factors including past or current trauma that may impact intimacy or sexual performance

• Discuss the impact of sexuality and fertility on individuals' lives
• Explore how the underlying neurological condition affects relationships
• Review the effects of medications used for treating neurological symptoms on sexual functions
• Address the effects of alcohol, tobacco and recreational drugs on sexual response and fertility
• Highlight the influence of unhealthy eating habits and obesity on sexual function and fertility
• Emphasise lifestyle modifications, such as diet optimization and increased physical activity targeting weight loss, which may improve sexual function in men with ED
• Consider the use of educational media when appropriate
• Tailor education to meet individuals' needs, life contexts, feelings, and previous sexual experiences
• Involve partners in discussions about sexual dysfunction when relevant and appropriate
• Maintain professional boundaries during discussions and ensure any used educational media complies with legal standards and is suitable for the person

• Assess lubricant compatibility with condoms, sensitivity, and potential irritants
• Consider local oestrogen therapy for these symptoms when appropriate

• Note insufficient evidence for recommending specific products, but consider:

  • ○

    Water-based lubricants may dry quickly, causing discomfort

  • ○

    Oil-based lubricants are incompatible with condoms

  • ○

    Silicone-based lubricants are condom compatible and don't cause dryness

• Inform individuals with spina bifida about the higher risk of latex allergy
• Possible adverse effects include skin irritation, dermatitis

• Vibrators may enhance arousal and erectile function in individuals with SCI
• Consult healthcare professionals (nurse practitioners, physiotherapists, sex therapists, andrologists, gynaecologists, or midwives) for appropriate selection and usage guidance
• Note limited studies suggest potential negative impacts on partner-related sexual function
• Be aware of contraindications like autonomic dysreflexia in T6 or above SCI and risk of skin breakdown from friction

• Efficacy for satisfactory erections is high, up to 90%, with satisfaction rates between 27% and 94%
• Devices are cost-effective but require manual dexterity
• For female sexual arousal disorder, significant symptom improvement with vacuum devices was noted, with no adverse events [104].
• SCI individuals need a recumbent position for effective use.
• Individuals should be advised never to leave the constriction ring on for over 30 min
• Partner assistance may be needed, especially in tetraplegia
• Most adverse events are minor, including penile petechiae, discomfort, and difficulty with ejaculation
• Common complaints: unnatural erections, coldness, pain, lack of spontaneity
• Caution is advised for men on anti-coagulants, bleeding disorders, or priapism history

• Oral sildenafil is effective and well-tolerated for ED in individuals with SCI
• In individuals with MS, sildenafil and tadalafil showed significant improvement in ED in two studies, though another reported no benefit
• Individuals with PD experienced improved erectile function and significant IIEF-15 score enhancement with sildenafil 100 mg compared to placebo
• Effective PDE5 inhibitor therapy requires some residual nerve function to induce erection
• Side effects include headaches, flushing, nasal congestion, dizziness, and rarely vascular insufficiency and priapism
• PDE5 inhibitors might cause orthostatic intolerance or hypotension, especially in individuals with tetraplegia/high-level paraplegia, neurodegenerative diseases, (autonomic) neuropathies, or neurovascular diseases
• PDE5 inhibitors are contraindicated in individuals taking nitrates including glyceryl trinitrate, isosorbide mononitrate and isosorbide dinitrate
• Caution is advised when PDE5 inhibitors are coadministered with α₁-adrenoceptor blockers
• Contraindications include hereditary degenerative retinal disorders, history of non-arteritic anterior ischaemic optic neuropathy, recent history of myocardial infarction or stroke, systolic blood pressure < 90 mmHg, individuals in whom sexual activity is inadvisable

• A meta-analysis showed a 90% satisfactory erection response rate with prostaglandin injections in individuals with SCI
• Prostaglandin injections have proven efficacy for achieving satisfactory erectile rigidity and duration in individuals with SCI and MS through home administration
• Intraurethral application of alprostadil presents a less invasive, albeit less effective, alternative for those seeking other treatments
• Quality of erection with intraurethral prostaglandin is reported to be less rigid compared to intracavernous injections, highlighting a difference in effectiveness
• Side effects of intracavernous prostaglandin injections include injection site pain and penile scarring, the latter often detectable only via ultrasound after repeated use [13, 87]. Some studies have shown a 40% discontinuation rate
• The risk of priapism following intracavernous prostaglandin injections is considered low, under 1%, according to guidelines for individuals without neurological disease
• Contraindicated if sexual activity is inadvisable

Address multidimensional factors affecting sexual activity and intimacy in individuals with neurological diseases, including secondary factors (spasticity, fatigue, incontinence, cognitive co-morbidities, medication side effects) and tertiary factors (changes in self or body image), through regular discussions due to their dynamic nature [85, 87, 91, 106]

• Inform individuals with spasticity that its level may change during sexual intercourse, potentially impacting sexual activity
• Offer baclofen, tizanidine, or botulinum toxin to reduce limb spasticity in individuals with stroke, SCI, and MS, facilitating sexual movements
• Advise individuals with SCI about the possibility of bowel or bladder incontinence during sexual intercourse, which may cause anxiety and deter sexual relations. Recommend bladder and/or bowel care prior to sexual activity and establish a contingency plan in case incontinence were to occur
• Assess individuals with neurological disorders for depression or other psychological disorders that could affect libido. Treat co-morbid depression with psychological and medication interventions to potentially improve sexual desire. If depression is treated or ruled out, provide suggestions for managing stress and fatigue
• Promote a positive body image, as sexual function can be adversely affected by poor self-perception post-SCI. Encourage counselling and open discussions about body image, ensuring comfort with personal and medical equipment
• Several medications used in neurology practice may cause sexual dysfunction, necessitating a review and possible adjustment of medication [92]