A 24-year-old man who fell down from a six-floor 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. 1AཞE). Physical examination found his lower limb sensation was also diminished, and he had difficulty 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, difficult sexual arousal, extremely difficulty 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 S2-S4, 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 significant 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 unsatisfied). His family life improved dramatically. On June 12, 2019, the patient’s wife delivered a healthy baby.
Table 1
MNCV and SNCV tests before and after rTMS treatment
|
Nerve and site
|
Latent time
(ms)
|
Amplitude
(mV)
|
Conduction velocity
(m/s)
|
| |
Before
|
After
|
Before
|
After
|
Before
|
After
|
|
Right femoral nerve
|
|
|
|
|
|
|
|
Below Inguinal ligament
|
5.950
|
5.300
|
14.76
|
30.54
|
|
|
|
Left femoral nerve
|
|
|
|
|
|
|
|
Below Inguinal ligament
|
5.700
|
5.700
|
21.54
|
24.05
|
|
|
|
Right tibial nerve
|
|
|
|
|
|
|
|
Popliteal fossa
|
-
|
-
|
-
|
-
|
|
|
|
Below buttocks
|
-
|
13.14
|
-
|
0.011
|
|
|
|
Left tibial nerve
|
|
|
|
|
|
|
|
Popliteal fossa
|
-
|
-
|
-
|
-
|
|
|
|
Below buttocks
|
-
|
12.04
|
-
|
0.037
|
|
|
|
Right peroneal nerve
|
|
|
|
|
|
|
|
Ankle
|
-
|
4.40
|
-
|
0.127
|
|
|
|
Fibula head
|
13.44
|
12.49
|
0.116
|
0.263
|
-
|
35.80
|
|
Left peroneal nerve
|
|
|
|
|
|
|
|
Ankle
|
-
|
5.35
|
-
|
0.064
|
|
|
|
Fibula head
|
-
|
10.29
|
-
|
0.038
|
-
|
52.52
|
|
Right sural nerve
|
|
|
|
|
|
|
|
Lower leg
|
1.866
|
1.533
|
0.310
|
0.679
|
83.03
|
88.04
|
|
Left sural nerve
|
|
|
|
|
|
|
|
Lower leg
|
2.366
|
1.933
|
0.741
|
1.049
|
42.25
|
80.17
|
|
Right tibial nerve H-reflex
|
|
|
|
|
|
|
|
M- Wave
|
4.625
|
3.62
|
0.572
|
0.710
|
|
|
|
H-Wave
|
33.37
|
31.25
|
0.028
|
0.057
|
|
|
|
Left tibial nerve H-reflex
|
|
|
|
|
|
|
|
M-Wave
|
4.00
|
3.75
|
0.337
|
0.735
|
|
|
|
H-Wave
|
37.25
|
35.12
|
0.028
|
0.047
|
|
|