Sacral Neuromodulation for Erectile Dysfunction
There is currently insufficient evidence to recommend sacral neuromodulation (SNM) as an effective treatment for erectile dysfunction (ED), and it should only be considered in highly selected cases after failure of established first- and second-line therapies.
Current Evidence Base
The available evidence for SNM in treating erectile dysfunction is extremely limited and of low quality. While SNM is well-established as a third-line treatment for overactive bladder (OAB) and fecal incontinence (FI), its application for ED lacks robust clinical validation.
What We Know:
- Small pilot studies have shown potential efficacy of SNM for sexual dysfunction, but these are preliminary findings without large-scale validation 1
- One small study of 22 patients with erectile impairment showed improvement in 7 patients (31.8%) following SNM, with better results in neurogenic patients 2
- A systematic review identified that high-evidence level studies for sexual dysfunction treatments in CNS disorders are rare, with no robust data supporting SNM for ED 3
Established Treatment Algorithm for ED
Current guidelines prioritize the following evidence-based approach for ED:
First-Line Treatments:
- PDE5 inhibitors (sildenafil, tadalafil, vardenafil, avanafil) - first choice for most patients 4
- Behavioral and psychosocial interventions 4
- Lifestyle modifications (weight loss, exercise, smoking cessation)
Second-Line Treatments:
- Intracavernous injection therapy with vasoactive drugs 4
- Vacuum erection devices (VEDs) 4
- Topical therapies
Third-Line Treatments:
- Penile prosthesis implantation for patients unsuitable for or unresponsive to other treatments 4
- Low-intensity shockwave therapy (LI-SWT) for mild vasculogenic ED 4
When to Consider SNM
SNM might be considered in very specific circumstances:
- Patients with concurrent lower urinary tract symptoms (LUTS) and ED, particularly those with neurogenic etiology 2
- Patients who have failed all established ED treatments
- As part of a clinical trial with appropriate ethical oversight
Limitations and Considerations
Several important limitations must be acknowledged:
- Limited Evidence: Current research on SNM for ED consists primarily of small pilot studies with short follow-up periods 1, 2
- Mechanism Unclear: The exact mechanism by which SNM might improve erectile function remains poorly understood 5
- Patient Selection: The few positive results have been primarily in neurogenic patients, suggesting very narrow applicability 2
- Cost and Invasiveness: SNM requires surgical implantation and periodic battery replacement, making it significantly more invasive than established ED treatments 4
Conclusion
While SNM is an established third-line treatment for OAB 4, 6 and fecal incontinence 4, its use for ED remains experimental. Patients with ED should be directed to evidence-based treatments following established guidelines, with PDE5 inhibitors as first-line therapy for most patients 4. For patients with spinal cord injury specifically, PDE5 inhibitors and intracavernous injections have shown the best performance and safety profiles 7.