INTRAURETHRAL ALPROSTADIL FOR TREATMENT OF ERECTILE DYSFUNCTION IN PATIENTS WITH SPINAL CORD INJURY DONALD R. BODNER, CHRISTOPHER A. HAAS, BEVERLE KRUEGER, AND ALLEN D. SEFTEL ABSTRACT Objectives. To assess the efficacy of intraurethral prostaglandin E 1 (alprostadil, MUSE) in treating erectile dysfunction in patients with spinal cord injury (SCI). Methods. Intraurethral alprostadil was tested in 15 patients with SCI to evaluate its effectiveness in treating SCI-associated erectile dysfunction. All patients were at least 1 year after injury, and all had previously used intracavernosal injections successfully (Schramek’s grade 5 erection). The intraurethral drug was adminis- tered in the office, in the presence of a physician, with monitoring of blood pressure. If effective, the patient was then able to use MUSE at home. The first 3 patients underwent gradual dose escalation starting with 125 g, without the use of a constriction ring. Because of hypotension, the remaining 12 patients all used a penile constriction ring prior to intraurethral drug administration using 1000 g. The quality of the erection was compared with that achieved with intracavernosal injections using Schramek’s grading. Results. The dose escalation (titration) in the first 3 patients demonstrated that the 1000-g dose was the most effective in creating an erectile response. Transient hypotension was noted in these first 3 patients in whom the constricting band was not used. The highest dose of MUSE (1000 g) was, therefore, used in the remaining 12 patients, with the constriction band. The quality of the erection varied and appeared to be less rigid in all patients (12 patients with grade 1 to 3; 3 patients with grade 4) than that noted with intracav- ernosal injection therapy (15 patients with grade 5). There was no incidence of priapism. The 3 patients with grade 4 erections tried the MUSE at home. All 3 patients were dissatisfied with the quality of the erection and did not continue to use the MUSE at home and returned to intracavernosal injection therapy. Conclusions. MUSE appears to be somewhat effective in creating erections; however, these were less rigid erections than those obtained with intracavernosal therapy and provided less overall satisfaction. It should always be used in the patient with SCI after placement of a constriction ring to prevent hypotension. Its ultimate use depends on the patient’s level of satisfaction with the quality of the erection compared with intracavernosal injections. UROLOGY 53: 199–202, 1999. © 1999, Elsevier Science Inc. All rights reserved. P enile erection is a neurovascular event that in- volves nitric oxide-mediated relaxation of the penile cavernosal smooth muscle. 1,2 Spinal cord in- jury (SCI), at the local level, prevents the effective release of this prime penile neurotransmitter, nitric oxide, from nonadrenergic-noncholinergic nerves, preventing the initiation of erection. Treatment of erectile dysfunction in these men with SCI has moved to minimally invasive therapies. Injection of vasoactive medications into the corpora caver- nosum of the penis has been used for the restora- tion of erectile function in men with SCI for more than a decade. 3,4 Intracavernosal injection has been shown to be effective in creating erections in patients with SCI, by direct cavernosal vasorelax- ation, bypassing the neurotransmission signals requisite to initiate erection. 5 Small doses of these medications are often adequate to create a rigid erection in men with SCI because most of these men are young, have an intact arterial supply to the penis, and have a normal veno-occlusive mecha- nism. Other treatment options for restoration of erectile function in this group include penile pros- thesis insertion, which carries a significant risk of infection and erosion, and vacuum constriction de- From the Cleveland Veterans Affairs Medical Center, Case West- ern Reserve University, Cleveland, Ohio Reprint requests: Donald R. Bodner, M.D., Department of Urol- ogy, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106-5046 Submitted: June 5, 1998, accepted (with revisions): July 17, 1998 ADULT UROLOGY © 1999, ELSEVIER SCIENCE INC. 0090-4295/99/$19.00 ALL RIGHTS RESERVED PII S0090-4295(98)00435-X 199