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Background: There is a high incidence of erectile dysfunction after spinal cord injury. This can have a profound effect on quality of life. Treatment options for erectile dysfunction include sildenafil, intracavernous injections of papaverine/alprostadil (Caverject), alprostadil/papaverine/phentolamine ("Triple Mix"), transurethral suppository (MUSE), surgically implanted prosthetic device and vacuum erection devices. However, physical impairments and accessibility may preclude patient self-utilization of non-oral treatments., Methods: The costs and utilities of oral and non-oral erectile dysfunction treatments in a spinal cord injury population were examined in a cost-utility analysis conducted from a government payer perspective. Subjects with spinal cord injury (n=59) reported health preferences using the standard gamble technique., Results: There was a higher health preference for oral therapy. The cost-effectiveness results indicated that sildenafil was the dominant economic strategy when compared with surgically implanted prosthetic devices, MUSE(R) and Caverject. The incremental cost-utility ratios comparing sildenafil with triple mix and vacuum erection devices favoured sildenafil, with ratios less than CAN$20,000 per quality adjusted life year gained., Conclusion: Based on this study, we conclude that sildenafil is a cost-effective treatment for erectile dysfunction in the spinal cord injury population.

Objective: To compare the cost effectiveness of sildenafil and papaverine-phentolamine injections for treating erectile dysfunction., Design: Cost utility analysis comparing treatment with sildenafil (allowing a switch to injection therapy) and treatment with papaverine-phentolamine (no switch allowed). Costs and effects were estimated from the societal perspective. Using time trade-off, a sample of the general public (n=169) valued health states relating to erectile dysfunction. These values were used to estimated health related quality of life by converting the clinical outcomes of a trial into quality adjusted life years (QALYs)., Participants: 169 residents of Rotterdam., Main Outcome Measures: Cost per quality adjusted life year., Results: Participants thought that erectile dysfunction limits quality of life considerably: the mean utility gain attributable to sildenafil is 0.11. Overall, treatment with sildenafil gained more QALYs, but the total costs were higher. The incremental cost effectiveness ratio for the introduction of sildenafil was pound sterling 3639 in the first year and fell in following years. Doubling the frequency of use of sildenafil almost doubled the cost per additional QALY., Conclusions: Treatment with sildenafil is cost effective. When considering funding sildenafil, healthcare systems should take into account that the frequency of use affects cost effectiveness.

Using papaverine, papaverine/phentolamine, or prostaglandin E1 (PGE1), intracavernosal pharmacotherapy has been successful in treating erectile dysfunction. The limiting factor of using these medicines is intracorporeal fibrosis with the first two and a high cost with PGE1. Our experience with intracavernosal therapy in patients with impotence secondary to neurogenic disease has included 35 men, 30 of whom are spinal cord injured, 3 after radical prostatectomy, 1 with multiple sclerosis, and 1 with lower extremity weakness after surgery. Patients ranged in age from 22 to 59 years, with an average of 36.3 years; mean follow-up was 13.8 months. Intracavernosal therapy has been performed with a tri-mixture of papaverine hydrochloride (smooth muscle relaxant), phentolamine mesylate (alpha-adrenergic blocking agent) and alprostadil (PGE1- a vasodilator and smooth muscle relaxant). Of the patient population, all 35 patients were able to have adequate erections for sexual relations with minimal complications. Acting synergistically, the ingredients promote erectile activity using small doses and without a significant incidence of priapism or fibrosis. Techniques of injection, dosing and followup are discussed.