Is it still clinically and economically viable in the UK to prescribe vacuum erection devices for patients with erectile dysfunction after radical prostatectomy?

Authors


In the UK, primary care trusts are reviewing prescription guidelines and treatment recommendations for numerous conditions managed within the NHS. An assessment by the ‘Solutions for public health, UK (http://www.sph.nhs.uk/) has concluded that vacuum erection devices (VEDs) are a low priority in view of limited evidence and cost effectiveness [1].

The current incidence of erectile dysfunction (ED) after radical prostatectomy (RP) can range between 14 and 89% [2]. The British Society for Sexual Medicine guidelines on erectile dysfunction management recommend phosphodiesterase-5 (PDE-5) inhibitors as well as a VED as first-line management for erectile dysfunction after RP. In the current literature, PDE-5 inhibitors are recommended because of their proven efficacy and cost effectiveness [3]. By contrast, the limited evidence for VED effectiveness in large-scale trials has raised doubts over their use [4]. Despite this ∼8000–10 000 VEDs are prescribed in the UK per year.

There is a lack of large-scale randomized controlled trials in the current literature to support the use of VED in erectile dysfunction after RP, but VEDs have a very high patient satisfaction rate of >80% [3]. The use of VEDs in penile rehabilitation without constriction rings after RP results in a 60% improvement in spontaneous erections, as well as a significant improvement in International Index of Erectile Function (IIEF) scores used early postoperatively [3]. Owing to a reduction in arterial inflow as well as venous flow, constriction rings are not recommended for use in penile rehabilitation [3, 4]. The study by Raina et al. [5] in 2006 showed that early use of a VED after RP resulted in 80% of patients successfully having intercourse, with a spousal satisfaction rate of 55%. Furthermore the mean IIEF-5 score improved from 4.8 before treatment to 16 after treatment at 9 months postoperatively. In that paper, 17% of patients had a return of natural erections sufficient for penetration, compared with only 11% without treatment [5]. In addition, daily use of the VED has been found to prevent loss of penile length occurring secondary to atrophy after RP [3-5].

When used in combination therapy with PDE-5 inhibitors, VEDs have good success rates. Studies have shown that a VED used for 5–10 min a day with tadalafil three times a week has a success rate of 90% when using the IIEF-5 at 1 year, compared with 60% in those not using the VED [6]. Another study showed that a VED combined with sildenafil after RP resulted in 30% of men reporting a return of spontaneous erections [4-6]. Patients on VEDs have also been found to have a reduction in the pain experienced with intracorporeal injections owing to improved tissue health, which was thought to be the result of penile tissue becoming used to filling and emptying [7].

We have calculated that the average cost of a VED device on prescription on the NHS is approximately £160 net of VAT. The average device life span of a VED device based on manufacturer specification is approximately 5 years. Patients on a VED device are advised to use a device atleast twice a week and may require two maintenance ring sets (3 rings per set) costing a total of £34. The combined dose of a VED device over five year is low at approximately £228 with VAT. When compared to the use of additional treatments for the post prostatectomy ED, the cost of patients on Caverject (Alprostadil Injections) at a dose of 40 micrograms / pack is £2589.50 (£21.58 per unit) over duration of 5 years.

In conclusion, there is convincing current evidence that VEDs are successful in the treatment of erectile dysfunction after RP, especially in combination with PDE-5 inhibitors, which appear to work synergistically to overcome the postoperative changes and to aid penile rehabilitation. Our calculations confirm that there is a cost benefit in prescribing VED when compared with additional adjuvant treatment options for erectile dysfunction after RP.

Conflict of Interest

None declared.