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. 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. 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. Based on this study, we conclude that sildenafil is a cost-effective treatment for erectile dysfunction in the spinal cord injury population.

Background: Clinically silent autonomic dysfunction with bowel and bladder care, are postulated to contribute to cardiovascular disease after chronic spinal cord injury (SCI). Objective: We describe the frequency and severity of dysreflexic episodes, termed transient blood pressure elevations (T-BPE) over 48 hours in adults with cervical or high-thoracic motor-complete SCI. Setting: Tertiary SCI Rehabilitation Centre in Toronto, Canada. Participants: Individuals with chronic SCI, C1-T3 AIS A or B, >1 year post-injury, living in the community (n=19). Outcome Measures: Data were obtained via 48-hour ambulatory blood pressure (BP) and heart rate (HR) monitoring, with data captured at 10-minute intervals and a concurrent diary describing activities of daily living, and bladder/bowel routines. T-BPE were defined as a ≥ 40 mmHg elevation in systolic blood pressure (SBP) above the participant's supine baseline. Severe (≥ 60–79 mmHg) and Extreme ≥80 mmHg elevations in SBP were described. Results: Thirteen participants experienced T-BPE within the assessment period, with 7/13 experiencing “severe”, and 3/13 experiencing “extreme” SBP elevations. The median number of T-BPE was 8 (IQR = 3), and the mean ± SD SBP during T-BPE was 150 ± 16 mmHg, These T-BPE were verified as dysreflexic events using a conservative definition of a >40 mmHg increase in SBP, with a concurrent 10 bpm decrease in HR, above the 48-hour average SBP, yielding 12/19 participants with T-BPE. Conclusions: T-BPE were frequent, often with severe or extreme elevations in SBP, despite few reported symptoms. Recognition and management of these dysreflexic events associated with T-BPE are needed, which may ameliorate cardiovascular disease risk.

Introduction and Objectives: Technology has brought about changes to the sacral neuromodulation (SNM) therapy and has rendered it as a minimally invasive procedure. The presence of tined lead, smaller implantable pulse generator, and the different available patient programmers are the factors new modifications this procedure; however, no enough data are available about patient satisfaction comparing these different parameters. We therefore conducted our study among SNM-implanted patients, assessing factors affecting long-term satisfaction. Patients and Methods: We conducted a cross-sectional study with a survey questionnaire for all SNM-implanted patients from December 2011 to May 2012. The survey questionnaire included information on patient demographics, level of satisfaction, and the need for combined medical therapy for symptom control, type of programmer used by patient, and their ability to use it efficiently. Results: A total of 117 patients visited the clinic in that duration, and 71 patients filled up the survey questionnaire, with a response rate of 60.7%, diagnosis OAB 41 (57.7%), chronic non-obstructive retention 15 (21.1%) and frequency-urgency syndrome 15 (21.1%). Forty-nine (69%) of patients were on SNM therapy alone, while 31% patients needed other forms of therapy for symptoms control. The types of patient programmers used were old programmers in 10 (14.1%), new programmers in 44 (62%), and twin programmers in 4 patients. Patient SNM therapy satisfaction level was 95.8%, while 3 patients (4.2%) were not satisfied. SNM therapy satisfaction showed that it was correlated with the need for combined therapy for symptoms control (correlation coefficient 0.341, p value = 0.004), but there was no correlation with age, duration of therapy, complication, or programmer type. Conclusion: SNM satisfaction in patients is mainly correlated with the need for additional medications for symptom control.

As a potential new treatment for overactive bladder (OAB), we investigated the feasibility of non-invasively activating multiple nerve targets in the lower leg. In healthy participants, surface electrical stimulation (frequency = 20 Hz, pulse width = 200 μs) was used to target the tibial nerve, saphenous nerve, medial plantar nerve, and lateral plantar nerve. At each location, the stimulation amplitude was increased to define the thresholds for evoking (1) cutaneous sensation, (2) target nerve recruitment and (3) maximum tolerance. All participants were able to tolerate stimulation amplitudes that were 2.1 ± 0.2 (range = 2.0 to 2.4) times the threshold for activating the target nerve. Non-invasive electrical stimulation can activate neural targets at levels that are consistent with evoking bladder-inhibitory reflex mechanisms. Further work is needed to test the clinical effects of stimulating one or more neural targets in OAB patients.

The objective of this study was to describe our experience using sacral neuromodulation to treat urinary urgency, frequency, urge incontinence, and chronic urinary retention in patients with cardiac pacemakers. With the increasingly widespread use of InterStim for bladder function restoration, we are seeing more complex patients with multiple comorbidities, including cardiac conditions. Herein, we report 3 cases of individuals with cardiac pacemakers who underwent InterStim implantation to treat urinary conditions. This study is a case series of 3 patients with cardiac pacemakers who underwent sacral neuromodulation to treat refractory voiding dysfunction. The initial patient screening for InterStim therapy involved percutaneous nerve evaluation (PNE), in which a temporary untined lead wire was placed through the S3 foramen. Patients who did not respond to PNE proceeded to a staged implant. All patients in this study had a greater than 50% improvement of their urinary symptoms during the initial trial and underwent placement of the InterStim implantable pulse generator (IPG). Postoperative programming was done under electrocardiogram monitoring by a cardiologist. No interference was observed between the Inter- Stim IPG and the cardiac pacemaker. In this group of patients, sacral neuromodulation in the presence of a cardiac pacemaker appears to have been safe.

Sacral neuromodulation is an accepted therapy for various voiding dysfunction. We report a 71-year-old male with a history of BPH post TURP and overactive bladder. He was on anticoagulants for atrial fibrillation. He underwent uneventful percutaneous sacral nerve evaluation. Five days later, he showed no improvement. Temporary lead was removed in clinic without complications. On day ten, he developed lower abdominal, and genital skin bruising. CT scan showed presacral retroperitoneal hematoma. His Hemoglobin dropped. He was admitted, managed conservatively and discharged with a stable hemoglobin. Retroperitoneal hematoma post PNE is rare. Management is conservative. Angioembolization is reserved for unstable patients.