tions and failure to reach orgasm (especially in women with sacral injuries) (Benevento and Sipski, 2002). Women with spinal cord injuries benefit from sildenafil, which promotes increased subjective arousal (Sipski et al., 2000). In the trial, the drug worked most effectively when it was combined with manual or visual stimulation, and there were few adverse effects.

Fertility is generally preserved in women with spinal cord injuries (Charlifue et al., 1992), primarily because it does not rely on spinal circuits. Rather, fertility is controlled by the hypothalamic release of hormones that stimulate the ovaries. Pregnant women with spinal cord injuries tend to have babies with lower birth weights and tend to have more complications during pregnancy and delivery, including bladder and bowel problems, autonomic hyperreflexia, decubitus ulcers, urinary tract infections, edema, anemia, spotting, fatigue, cardiac irregularity, and preeclampsia (Charlifue et al., 1992; Jackson and Wadley, 1999).

Treatment of Bone Disorders

The reduced mobility and other pathological changes that occur in individuals with spinal cord injuries often lead to decreases in bone density (hence, a greater risk of bone fractures) and heterotopic ossification. The latter refers to the formation of bone in soft tissues near paralyzed joints. Bone density loss, particularly in the lower limbs, occurs during the first 6 months after the injury and then plateaus over the next 12 to 16 months (Demirel et al., 1998). The drug alendronate (Fosamax) has recently been found in a 2-year clinical trial to stop bone density loss at all bone sites at which measurements were taken (Zehnder et al., 2004). The drug, a bisphosphonate, works by inhibiting bone resorption by osteoclasts.

Heterotopic ossification can range from an incidental finding on an X-ray to massive bone formation surrounding a joint, producing total ankylosis. The most common location is the hips. Heterotopic ossification is treated with range-of-motion exercises, the drug etidronate, nonsteroidal anti-inflammatory drugs (NSAIDs), and irradiation. The use of NSAIDs, especially within the first 2 months of an injury, has been found to reduce the incidence of heterotopic ossification by a factor of 2 to 3 (Banovac et al., 2004). Severe cases are treated surgically, and the chance of recurrence may be reduced by the use of the nonsurgical therapies listed above.

Depression

Depression after a spinal cord injury is common and disabling. A key longitudinal study was conducted to track more than 100 individuals with spinal cord injuries for 2 years after discharge from the hospital (Kennedy and Rogers, 2000). It found that nearly 30 percent of the individuals were



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