6.4a Treatment strategies


i) Treatment strategies

  • Low sex drive

  • Erectile difficulties

  • Ejaculatory difficulties

  • Sexual difficulties encountered by women

  • Sexuality and physical disability

  • Masturbation

  • Sex and incontinence



ii) Low sex drive

No treatments for low sex-drive after TBI have been documented or researched. Some of the following strategies can be helpful.

Stimulate interest

Practice – if things have changed sexually, it may take some practice to improve the quality of lovemaking and rekindle an interest.

Try to make love when there are no distractions, so that the person with TBI only has to concentrate on enjoyment.

Make sure that if things in environment turn the person off, that they are dealt with and are not going to get in the way during lovemaking (eg. open drawers, partner odour, etc.).

Use erotic videos, games, or erotic magazines, to help arousal. Relaxation or caressing parts of the body that the person finds sexually stimulating can also help.

Psychological factors

If the loss of interest is due to depression or anxiety, the treatment of those problems with a counsellor or doctor may help.

Medical options

If the problem is due to hormonal abnormalities, hormone replacement may be an option.

If it is due to particular medications, discontinuation or replacement of those medications could be discussed with a doctor.

If the loss of interest is due to chronic pain, then pain control techniques may assist.


iii) Erectile difficulties

There are a number of treatment approaches. No treatments for people with TBI have been published. The current approach has been to use existing treatment approaches.

See a doctor

A doctor may be able to help or refer on to an urologist for more specialised assessments.


If medication is the cause of the erectile difficulties, discontinuation or replacement of responsible medications may be an option.

Sexual counselling

Going to see a sexual counsellor. Research has suggested that even self-help strategies work more effectively with some contact with a sexual counsellor. Sexual counsellors can be found at local sexual health clinics, or by contacting ASSERT [Australian Society of Sex Educators, Researchers and Therapists] or the Family Planning Association.


Viagra can be a useful option for men. Clinically, a number of men with TBI have found it helpful. However, there have been no studies at this stage testing the efficacy of Viagra for men with TBI.

Constriction bands and vacuum erectile devices

Vacuum or constriction devices both assist the penis to become erect.

Penile injections

Either the person themselves or their partner can inject medication into the penis before the anticipated sexual activity. Scarring of the penis may be a long-term complication of this approach.

Surgical options

Men with irreversible erectile problems may be able to access surgical options, although this is rare. For example inserting a penile prosthesis into the penis using a simple surgical procedure. This penile prosthesis helps the penis to become erect when the person wants to have sex.


iv) Ejaculatory difficulties

There are three different ejaculation problems.

Premature ejaculation' is ejaculation either before or very soon after starting sexual intercourse.

'Retarded ejaculation' happens when a man has to have sex for a very long time before he ejaculates, or cannot ejaculate at all.

Retrograde ejaculation' is when the man feels he has had an orgasm, but no semen comes out of the penis, because it has passed backwards into the bladder.

Strategies for:

Premature ejaculation

Try to extend the time you can masturbate before ejaculating.

Think of non-sexual things while having sex.

Minimise thrusting, occasionally withdrawing altogether (stop/start technique). Speak to a sexual health counsellor or doctor.

Retarded ejaculation

See a doctor to make sure there are no physical causes why you can’t ejaculate. If there are no physical causes, learn to ejaculate first through masturbation. You can use erotic fantasies and/ or sexually stimulating magazines to help you masturbate. A lotion applied to the penis can also enhance sensations and reduce likelihood of soreness.

Retrograde ejaculation

You need to see your doctor.

Self-help book

These can be bought or borrowed from a library. Men and sex by Bernie Zilbergeld is a useful book for men experiencing difficulties with ejaculation.

Sexual counselling

Sexual counsellors can be found at: – Brain Injury Rehabilitation Unit, Liverpool Hospital – Local sexual health clinic – ASSERT [Australian Society of Sex Educators, Researchers and Therapists] – Family Planning Association – Australian Psychological Society have a list of psychologists who specialise in sexual counselling


v) Sexual difficulties encountered by women

Not reaching orgasm

Many women experience orgasm for the first time through masturbation. To learn more about this, see a sexual counsellor.

Vaginal dryness

This can be due to side-effects from medication. Check with your doctor about this. Lubricants can help with vaginal dryness and are available from the supermarket or the chemist. Look out for some of the newer water-based lubricants, that include fruit extracts and don’t get as sticky as some of the old water-based lubricants (eg. K-Y jelly)

Painful intercourse

Painful intercourse is sometimes, but not always, related to vaginal dryness. See a doctor or a sexual health counsellor for this problem.

Self-help books

These can be bought or borrowed from a library. Becoming orgasmic: A sexual and personal growth program for women by J.R. Heiman and J. LoPiccolo (Simon Schuster Australia, Sydney, 1988) is a useful book for women with orgasmic difficulties.


Many women find that after an injury, their menstrual cycle may stop for a while (eg. 4 – 6 months) and then starts again.

Some women may need assistance in using tampons due to cognitive problems, such as impaired planning, or physical problems, such as reduced fine motor skills or range of movement of the arm. Family members or carers may need to be trained to assist the women to address this area of her self-care.


vi) Sex and physical disability

Here are some physical impairments and strategies for managing them in relation to sexuality:

Weakness/paralysis on one side (hemiparesis, hemiplegia)
  • lying on affected side with pillow support if not painful can allow movement of unaffected arm or hand to caress partner and vaginal entry from side
  • male alternative is lying on back, although many men do not find this as enjoyable
  • women who have difficulty spreading their legs due to tight hip muscles, may find if they bend their knees and bring their feet up close to their body that this may help
  • firm mattress or larger mattress
  • consider alternatives to sexual intercourse
  • partner may take a more active role in love making
  • see material on positioning (see ‘back pain or other chronic pain’, below).
Muscle spasms
  • relaxing to try and avoid increasing spasms
  • try and ride the spasm out and incorporate it into the lovemaking
  • antispasticity medications such as Baclofen taken one hour before sexual activity can be helpful in alleviating spasms
  • positioning can help to reduce spasming.
Incoordination, restricted range of movement in hands, arms or legs due to spasticity or contractures
  • experiment with sex positions that incorporate the contractures
  • partner is encouraged to take an active role in helping the person
  • if hands weak or uncoordinated, use a vibrator to caress partner. If have trouble grasping objects, strap to hand.
  • use sexual positions that do not require strong supporting movements by weakened muscles
Tremor in arms or legs
  • if parts of the body tremble when movement is tried, allow partner to take more active role in love-making
  • find positions that support the part of the body affected by tremor
  • if parts of the body tremble when they are not active, then try and take a more active role in love making: trembling may decrease when you move that part of the body
  • look at whether mild restraint such as interlocking arms of partner may help control the trembling
  • check whether tremor is a side-effect of medication.
Back pain or other chronic pain
  • think of positions that are comfortable when doing other activities – this can help in finding positions for sex
  • use body positions during sex that place minimal strain on the person in pain
  • use body conservation exercises (BCE) learned for kneeling, sitting down and getting up to reduce stress on body. BCE aim to train people to move in ways that put least amount of stress on their bodies
  • avoid jarring movements or being too forceful – remember that smooth, flowing, gentle movements are less painful
  • let partner know when you are in pain and what increases pain
  • take gradual approach to rebuilding sexual activity
  • are there times of the day when pain is less, more relaxed, more interested in sexual contact
  • reduce your pain prior to sexual activity if possible by a hot shower, massage or stretches
  • if sex has been used for other things (eg. reconciliation after fights) – can these needs be met through other ways, to help reduce pressure on sexual performance
  • practice relaxation exercises 3 to 4 times daily to keep muscles/nervous system relaxed
  • back pain and sexual positioning – try extension positions for sex; flexion positions for sex, giving people options whether greater comfort arching back, inwards or outwards.
Changes to sensation
  • be aware of which body parts have new or reduced sensation and to what degree
  • make partner aware of the change to sensation
  • emphasise stimulation to other parts of the body where sensation is intact through experimentation, many people have found new parts of their body which can be sexually arousing (body mapping)
  • loss of sensation – more vigorous stimulation of penis
  • sensory disturbance – burning, tingling or pain. Sometimes symptom relief with prescription medication (Carbamazepine; phenytoin).

Oral and communication problems

  • use non-verbal communication such as touching and gesturing
  • use of Speech Therapy to improve communication or oral motor skills
  • for people with aphasia, lack of expression of emotions and sexual communication is a potential problem, however, keep in mind, research has shown that the physically intact person with aphasia, who had relatively good auditory comprehension and non-verbal communication ability, exhibited the least problems in sexual adjustment, irrespective of expressive language ability.

vii) Masturbation


People need to have privacy, whether this is done by knocking before entering a person’s room or by allowing set times during which a person will not be disturbed.

Uridome or pads

If a person is fitted with a uridome or pad at night, there may need to be some negotiation to allow for the opportunity to masturbate.

Non-dominant hand

If you have to use a non-dominant hand, or hand with a limited range of movement to masturbate, exercise the hand to build up co-ordination and strength.

Chronic pain

If you have chronic pain, make sure you are in a comfortable position. If energetic or rapid movements trigger pain, relax and continue the self-stimulation with gentle movements. Allow the time to stretch out – don’t hurry and you will be able to achieve peaks of pleasure.


If you have difficulty grasping or holding on to objects, a vibrator can be strapped to your hand to be used for self-stimulation. Modifications can be made to dildos to enable them to be used, even if you have physical disabilities. Find out if this is possible in your situation.

Assistance with masturbation

If there is no way of masturbating yourself, the other possibility is to organise someone else to do it for you, for example, your partner or a sex worker.

Loss of sensation

If you have experienced a loss of sensation to touch that you used to find arousing, experiment to see which parts of your body still respond to touch. People with disabilities have found other sensitive areas of the body. They can learn to experience touch in those areas as sexually arousing.


If you are unable to touch your body in places where it is arousing [not the genital areas] organising a massage can be another option.

‘Cleaning up’

If a man is not able to ‘clean up’ the ejaculate after masturbating, then some strategy to address this issue will need to be negotiated with family or staff.

viii) Sex and incontinence


People with incontinence problems need to communicate openly with partners about their needs and the possibility of leakage.


Medication can sometimes help manage incontinence by reducing spasms of the bladder and urethra. If vaginal dryness is experienced as a side effect of the medication, some water-based lubricant may be needed.

Intermittent catheterisation

Be catheterised before sexual activity. Keep towels handy if worried about leakage and protect the mattress. If there are only small amounts of leakage, this can be managed by a condom with a reservoir tip.

Suprapubic catheters

Use longer drainage tube to allow room to manoeuvre. Tape drainage tube to stomach to prevent excess pulling or pressure on catheter. Certain sex positions make it easier to keep drainage tube and collection bag out of the way. Ask doctor/nurse whether it is possible to disconnect the drainage tube and collection bag and clamp the catheter during sex.

Indwelling catheters

Sometimes possible to remove catheter occasionally for sexual activity – if this is possible make sure to empty bladder first. If there is a need to leave catheter in, the woman can bring the tube back up over the stomach. Men, once the penis is erect, can fold the tube down the penis, tape it on with non-stick tape, and place a condom over the penis. Additional lubrication may be needed to allow comfortable entry into the vagina.