EFFECT OF SILDENAFIL ON ERECTILE DYSFUNCTION IN SPINAL CORD INJURED PATIENTS

1 Department of the nervous system and rehabilitation, faculty of medicine, university of Cocody, Abidjan; 2 UGECAM Aquitaine Centre de La Tour de Gassies – 33523 BRUGES Cedex, France ; 3 Service d’Anesthésie-réanimation, GH Pellegrin, Centre Hospitalier Universitaire -33076 Bordeaux cedex, France and 4 Service de Médecine Physique et de Réadaptation, Pôle de Neurosciences Cliniques GH Pellegrin & EA 4136 Handicap et système nerveux Université Victor Segalen Bordeaux2, Centre Hospitalier Universitaire F33076 Bordeaux cedex, France


INTRODUCTION
Care of spinal cord injured (SCI) patients is a major preoccupation regarding sexuality, motor and bladder dysfunctions.This is particularly so because of the increasing prevalence of paraplegic and tetraplegic subjects and the fact that these patients are younger, and sexually active.This increase in prevalence is directly related with the increase in life expectancy of these patients irrespective of the etiology.In fact, an inquiry conducted in France, in 2002, showed an incidence of 19.4/million inhabitants and a prevalence of 100-400/million regarding post trauma paraplegic and tetraplegic subjects. 1ectile and ejaculation disorders in these patients require effective management in order to improve their social and familial rehabilitation.This preoccupation, shared by many research and healthcare teams has led, in the past years, to the use of vasoactive drugs like Sildenafil in view of improving the sexuality of patients with erectile dysfunction. 2,3 he objective of this study was to determine the effects of Sildenafil on erectile dysfunction in SCI patients.

MATERIALS AND METHODS
The study was approved by the ethics committee of the University of Bordeaux.Informed patient consent was obtained prior to data collection.From January to March 2007, we conducted an inquiry in 16 SCI paraplegic and tetraplegic male patients who were either currently or previously admitted (2000-2007) at the Tour de Gassies Rehabilitation Center of Bordeaux/France.The inclusion criteria were male SCI patients who had been or currently treated by Sildenafil for erectile dysfunction.None SCI patients and those incapable of completing the questionnaire were excluded.
A questionnaire based on the concise version of the International Index of Erectile Function (IIEF-5) 4 was sent by ordinary mail to some patients while others received the questionnaire on site.This 5-item questionnaire has been validated by the National Institutes of Health Consensus Panel.Additionally we assessed patient satisfaction.The data was analyzed using the EPI info 2000 software.The results were expressed as mean and standard results were expressed as mean and standard deviation or range.

RESULTS
The mean age (range) of the patients was 32.75 yrs (21-53 yrs).The mean duration of their disability was 47.75 months (4 yr).Trauma was the etiology in 87.5% of the cases (44% were road accidents).12/16 patients were paraplegics (10 above T10) and 4 were tetraplegics (1 above C4 and 3 below C5).The mean duration of sildenafil treatment was 18.75 months (17 days-7 yr).70% of the patients were satisfied with their erection after treatment.However, 10/16 patients had concomitant treatment with alprostadil.

DISCUSSION
This study shows that sildenafil is an effective treatment of erectile dysfunction in SCI patients.The study population is comparable to other series including Tetrafigap, 1 Hulting 3 and Giuliano 6 with regard to young age and the fact that trauma was the major cause of the spinal cord lesion.However the evolution period of the disorder was shorter than in Tetrafigap's series.
In this study, sildenafil was mainly prescribed by physiotherapists.These specialists are more concerned with the sexual disorders of SCI patients.
In fact, the French Society of Urology recommended this approach with the physiotherapist in the frontline. 10owever, the important role of general practitioners could not be totally excluded.
The response to the IIEF-5 questionnaire corroborate to previous studies of Giuliano and Hulting. 3,6We used the IIEF-5 questionnaire because it is an auto evaluation form with a high degree of sensitivity and specificity in detecting the efficacy of treatment.It is not specifically designed for SCI patients.It consists of 5intems derived from 15 of the complete version.This questionnaire takes into account four of the five areas of sexual function: erection, orgasm, sexual desire. 4his concise version is simple and fast to use during consultation.The first item of the HEF-5 deals with the pretreatment status while the four other questions involve the post-treatment status of the patients.
We also added questions on global satisfaction so that the patients could compare their erectile conditions before and after sildenafil treatment.Despite the high satisfaction rate of our patients, 10/16 of them used other vasoactive drugs like alprostadil (edex).The main explanation for this was that sildenafil was not reimbursed by the French social welfare.The majority of the patients expressed their desire for the reimbursement of this drug in SCI patients.Patients who failed both the sildenafil and alprostadil were advised to consult our local multidisciplinary team of physiotherapists, neurosurgeons and anesthesiologists in order to determine whether they were suitable candidates for implantable sacral nerve stimulators.However, we did not assess the outcome of these consultations.
The results of this study are strictly in the hospital domain and could not be extrapolated to all SCI patients.Additionally, the sample size is too small to deduce any pertinent conclusions.However, our study provides further insight to the efficacy of Sildenafil on erectile dysfunction of SCI patients in corroboration with other studies. 2

Table 1
Clinical characteristics of the study population

Table 1 .
The prescription and distribution profiles of sildenafil are presented in Table2.The main responses of the patients are shown in Table3.

Table 2
Distribution and utilization of Sidenafil