Sexual Dysfunction After Traumatic Injury Corrected by Transcranial Magnetic Stimulation: A Case Report


 Background: Neurogenic sexual dysfunction (NSD) is a common problem in patients after spinal and pelvic trauma. New treatment is needed beyond medicine or psychological therapies. This study probes the potential for using repetitive transcranial magnetic stimulation (rTMS) for NSD rehabilitation, the insights of which can inform further research.Methods: In a 24-year-old man who fell from six floor building, with multiple spinal and pelvic injuries, we used rTMS to treat his subsequent NSD. The therapy lasted for 3 months. Motor and sensory conductivities, as well as sexual function, were evaluated before and after the treatment.Results: The rTMS regimen produced satisfactory improvement on patient’s nerve conductivities and sexual activity. Improvements in sexual function were confirmed at 1-year follow-up. Conclusions: rTMS delivered a positive treatment to this patient with NSD. Potential mechanisms by which rTMS regulate sexual function need to be further investigated.


Introduction
Neurogenic sexual dysfunction (NSD) often results from pelvic fracturesthat damage the lumbosacral plexus [1]. Affected patients may complain of impotence, premature ejaculation, low sexual desire, retrograde ejaculation, or coital pain during sexual activities. Current treatments on sexual dysfunction with medicine or psychological therapy are unsatisfactory [2]. Here, we report the outcome from a NDS patient who undertaking repetitive transcranial magnetic stimulation (rTMS) treatment. Case A 24-year-old man who fell down from a six-oor building was sent to the Emergency Department of the Second Hospital of Jilin University on October 13th, 2014. X-rays and computed tomography (CT) studies indicated multiple fractures in his head, spine, pelvis, and the extremities (Fig. 1A E). Physical examination found his lower limb sensation was also diminished, and he had di culty controlling urination or bowel movements. Six weeks after surgical care, patients' wounds and fractures were healed and he was discharged from hospital. Two months later, the patient returned to a community hospital for rehabilitation (physical therapy, acupuncture, and massage). This program lasted for 2 years. Gradually, he was able to walk and climb stairs. Control of urination and defecation also recovered largely, but his sexual dysfunction persisted, posing a threat to his marriage.
On July 4, 2018, the patient visited our department for further treatment. Electromyography (EMG) examination was performed ( Table 1). The Arizona Sexual Experience Scale (ASEX) was used to assess sexual function. He was marked of 27 points (weak sexual drive was, di cult sexual arousal, extremely di culty in penile erection and no orgasm) on the ASEX, signaling severe sexual dysfunction. He was diagnosed as sacral plexus injury and NSD. He was accepted for the rTMS (CCY-IA, YIRUIDE MEDICAL Inc., Wuhan, China) treatment to promote nerve repairment. The protocol of rTMS was revised from what we used for dysuria (TMS Manual for Clinical Practice, First Edition, 2017). Stimulation site was S 2 -S 4 , each course lasting 2 weeks. Treatment prescription is presented as Fig. 1F. Three courses of treatment were completed in 3 months. A 1-year follow-up was performed with EMG examination on July 13, 2019. Results (Table 1) suggested that conductivities of peripheral nerves had improved. The patient claimed a signi cant improvement on his sexual function. His ASEX score was18 points, where his sexual drive recovered to strong; sexual arousal rose up; penile erection was sucessed; orgasm was improved but not fully unsatis ed). His family life improved dramatically. On June 12, 2019, the patient's wife delivered a healthy baby.

Discussion
At present, treatments of NSD are mainly done by using medicine, psychotherapy and surgical treatment. However, current clinical e cacy and safety vary greatly [2]. So far, rTMS has been used for repairing of damaged peripheral nerves [3]. Some reported therapeutic effect on neurogenic bladder [4], and magnetic stimulation of the cavernous nerve was reported can induce penile erection [5]. However, there is no report of rTMS treating for NSD.
We found that rTMS signi cantly improved sexual function in the patient with sacral plexus injury. The underlying mechanisms may be multifacts. First, rTMS may facilitates repairment of somatic nerves related to lumbosacral damage then improve NSD. Second, rTMS may promote recovery of the affected autonomic nerves in lumbosacral damage [6]. Thrid, rTMS may revise local chemical transmitter levels (e.g. nitric oxide) to improve sexual function [7]. Nevertheless, the speci c mechanisms of rTMS treating for NSD has not yet been reported, and further researches would be needed.

Consent for publication
The participant has consented to the submission of the case report to the journal.

Availability of data and materials
The datasets used and analysed during the current study are available from the corresponding author on reasonable request.
The authors declare that they have no competing interests.

Fundings
This work was supported by grants from the Department of Finance of Jilin Province (3D518S603429) and the Jilin Provincial Health and Family Planning Commission (2020J028) in China.
Authors' contributions XQD and BZ contributed to the conception and design of the study. XW, YTK, XYL contributed to acquisition, analysis and interpretation of data. XW, XYL, WL, ZLL drafted, modi ed the text and prepared the gures. All authors read and approved the nal manuscript.