Specific aspects of erectile dysfunction in spinal cord injury.

According to preliminary studies, the overall incidence of spinal cord injury (SCI; traumatic and medical) in Spain is estimated to be between 12 and 20 per million inhabitants, and almost 80% of these injuries occur in young men. SCI causes organic changes in men leading to erectile dysfunction (ED), impaired ejaculation, and changes in genital orgasmic perception. A vast majority of men with both complete and incomplete SCI will require treatment for ED, and the therapeutic options should include sexual counseling so that the patient can be informed about his disorder and can adjust his sexual behavior accordingly. The first-line treatment of choice is oral drugs, such as phosphodiesterase inhibitors (sildenafil, tadalafil, and vardenafil). Sildenafil has been shown to be highly effective and well tolerated in men with ED of various etiologies, including SCI. Data are also presented on sublingual apomorphine, which has limited indications for the treatment of ED in SCI, and on constrictive rings and vacuum systems. Second-line treatments include intracavernous injections of prostaglandin E(1), papaverine, and phentolamine, alone or in combination, which have been shown to be highly effective in the treatment of ED in men with SCI. Finally, for third-line treatments, the indications for surgical methods are given, including penile prostheses and neuroprosthesis of anterior sacral roots. These devices should be reserved for the cases when the above-mentioned methods have repeatedly failed. Historically, the treatment of ED among patients with SCI has been managed by clinicians in physical medicine and rehabilitation. Thus, the criteria for referral and the competencies of these specialists are established, and they should be included as an integral part of the rehabilitation program.