Mechanisms of Disease: new insights into the cellular and molecular pathology of Peyronie's disease

Cavernosopatía traumática crónica. Un nuevo síndrome de fibrosis peneana

Introdución La llamada genéricamente «enfermedad de Peyronie» es un diagnóstico que explica un porcentaje de ciertos estados de fibrosis peneana grave, pero se queda corta para abarcar la amplia gama de grises de la fibrosis peneana secundaria a microtrauma sexual repetido.

Objectivo Describir un nuevo síndrome por trauma repetido en el pene al que se propone denominar «cavernosopatía traumática crónica» (CTC), con 4 componentes: fibrosis (leve, moderada o grave), disfunción eréctil, curvatura y fugas venosas peneanas.

Materiales y métodos Se realizó un estudio de corte transversal en una base de datos de 128 pacientes que tenían al menos una ecografía de pene con vasoactivo y en los que se había detectado algún grado de fibrosis cavernosa según la clasificación de Levine. Se evaluó la presencia de disfunción eréctil, curvas y fugas venosas según el grado de fibrosis. El estudio contó con la aprobación del Comité de Ética en Investigación.

Resultados Se estudió a 128 pacientes con fibrosis, con 51,3 años de edad promedio (DE = 13). El grado de fibrosis fue leve (Levine 1) en 30 (23,43%), moderado (Levine 2) en 23 (17,96%) y grave (Levine 3) en 75 (58,6%). Se demostró que, a mayor fibrosis, mayor disfunción eréctil, 66,6; 83,6 y 96% para Levine 1, 2 y 3, respectivamente (p ≤ 0,0001). La frecuencia de curvatura secundaria (n = 71) fue de 0; 4,2 y 95,7% para Levine 1, 2 y 3, respectivamente (p ≤ 0,0001). La frecuencia en los 44 pacientes con fugas cavernosas fue de 9; 20,4 y 70,4% (p = 0,0060) y en los 15 de fugas dorsales fue de 80; 13,3 y 6,6% (p < 0,0001) para Levine 1, 2 y 3 respectivamente. El grupo de 79 pacientes (64,03%) con mayor posibilidad de CTC, con presencia de 3 o 4 criterios que incluyeran curvatura secundaria y fuga cavernosa, tuvo un promedio de edad de 59,2 años (DE = 8,7), comparado con 41,7 años (DE = 11,7) en el grupo de menor posibilidad, diferencia estadísticamente significativa (p ≤ 0,0001).

Conclusiones Proponemos que existe un síndrome de microtrauma repetido en el pene, que puede denominarse CTC, análogo a la encefalopatía traumática crónica, con 4 componentes: fibrosis cavernosa, disfunción eréctil, curvatura peneana y fugas venosas. La fibrosis es un continuum que el paciente recorre por fases leves y moderadas, a menudo inapreciables para los clínicos. Las curvaturas secundarias y las fugas cavernosas están relacionadas directamente con el grado de fibrosis y con mayor riesgo de disfunción eréctil. La edad empeora algunos factores de la CTC.

Devices for penile traction: the long and winding road to treating Peyronie's disease

INTRODUCTION

Penile traction therapy (PTT) is increasingly being recognized as a viable nonsurgical approach to Peyronie's disease (PD). The goal of this article is to review the current literature on PTT with attention to traction protocols, devices, and outcomes.

AREAS COVERED

Literature on the pathophysiology of PD, PTT as primary and adjunctive treatment for PD, perioperative use of PTT, and vacuum erection devices are all reviewed. Pertinent literature was obtained from the PubMed database. The key words 'penile traction,' 'mechanotransduction,' and 'Peyronie's disease' were searched and results were narrowed down based on relevance to the review.

EXPERT COMMENTARY

PTT appears beneficial but the true magnitude of effect is difficult to discern. Most studies are not randomized, have small sample sizes, lack control arms, or have varying traction protocols. Patient compliance is critical and new devices and traction protocols are needed to maximize the benefit of PTT.

Prospective study to evaluate the clinical outcome of intralesional interferon-α2b in the management of Peyronie's disease

Context:

Interferon (IFN)-α2b in Peyronie's disease (PD).

Aims:

This study aims to evaluate clinical efficacy of the IFN-α2b in both subjective and objective manner for the treatment of PD and compared with previously used intralesional verapamil in terms of cost-benefit analysis.

Settings and Design:

Prospective study.

Materials and Methods:

A prospective study conducted from January 2013 to July 2016 in the Department of Urology, Government Medical College, Kota, Rajasthan, India. We included patients with identifiable Peyronie's plaque with or without pain, curvature ranging between 30 and 90 degrees. We excluded patients with a calcified plaque and the ventral location of the plaque, any infective foci over the penis, erectile dysfunction due to other etiologies and patients who had received previous intralesional therapy. Patients were evaluated by clinical history, physical examination including plaque location, size, consistency, and penile curvature. Patients received intralesional IFN-α2b in a dose of 3 × 10⁶ IU. Patients completed the visual analogue pain (VAS) score for pain, and International Index of Erectile Function-5 (IIEF-5) questionnaire at first visit as well as at follow-up of 1 month and 3 months.

Statistical Analysis Used:

Comparisons were performed using the paired Student's t-test and Chi-square tests as appropriate. Patient's objective and subjective clinical characteristics were described as a means (standard deviation).

Results:

We included 86 patients in this study. Patients had a mean age of 48.6 years, mean plaque volume 256 mm³, and disease duration of 15.2 years. After 1 month of treatment, there was a significant change in plaque volume 256–60.8 mm³; P < 0.01) and penile curvature 34.8–24.6°; P < 0.01). The patients reported significant improvement in pain score VAS and IIEF-5.

Conclusions:

IFN-α2b, as minimal invasive (intralesional) options for the treatment of PD, demonstrated significant improvement in plaque volume, penile curvature with minimal complications. Patients subjectively reported significant improvement in pain on erection and sexual activities. IFN-α2b and verapamil had an almost similar clinical outcome, but verapamil at much lower cost.

Inflatable Penile Prosthesis Placement, Scratch Technique and Postoperative Vacuum Therapy as a Combined Approach to Definitive Treatment of Peyronie's Disease

PURPOSE

Peyronie's disease is a devastating condition resulting in penile malformation, erectile dysfunction, pain and emotional distress. In this prospective, 2 institution study we evaluated a multimodal surgical and mechanical combined approach to the definitive treatment of Peyronie's disease and concomitant erectile dysfunction.

MATERIALS AND METHODS

A total of 145 select patients underwent endocavernous disruption of Peyronie's disease plaques via the scratch technique, followed by inflatable penile prosthesis insertion. Postoperatively patients were assigned to vacuum device therapy for 3 minutes twice daily to continue penile curvature correction. Followup continued for 1 year after surgery. Anatomical and functional results were assessed.

RESULTS

Patients with plaques in the proximal third, middle third and subcoronal areas of the penis had a mean ± SD postoperative residual curvature of 21.5 ± 4.5, 17.3 ± 4.8 and 14.1 ± 3.1 degrees, respectively. After 24 weeks of vacuum therapy the mean penile curvature deviation decreased to 8.7 ± 2.5, 9.1 ± 2.9 and 7.7 ± 0.9 degrees, respectively. The mean IIEF-5 (International Index of Erectile Function) score was 9.8 ± 2.3 preoperatively, 18.9 ± 3.1 at 6 months (p <0.001) and 24.1 ± 3.6 at 1 year (p <0.001). The mean EDITS (Erectile Dysfunction Inventory of Treatment Satisfaction) score at the end of followup was 64.6 ± 11.8. Operative and postoperative complications were minimal.

CONCLUSIONS

Our novel combination of intraoperative and postoperative therapies in the treatment of patients with Peyronie's disease and an inflatable penile prosthesis was safe and efficacious with excellent functional outcomes. Penile curvature corrections were statistically significant and complications were negligible.

Extracellular matrix alterations after blood instillation in tunica albuginea of rats

The cause of Peyronie's disease (PD) is still not completely understood. The objective of this study, therefore, was to analyze the histological and biochemical alterations that occur after the instillation of blood in the tunica albuginea (TA) of rats with an emphasis on the remodeling process of ECM. Thirty male Wistar rats were divided into 4 groups: two control groups with instillation of distilled water in TA followed by penectomy after 15 days or 45 days, respectively and two experimental groups with instillation of blood in TA followed by penectomy after 15 days or 45 days, respectively. Histological, immunofluorescent and immunohistochemical analyses were performed. The higher presence of fibrotic tissue in rats injected with blood demonstrated alterations in TA similar to inflammation found in PD. The increased expression of TGF-β, MMP9, HPSE, and biglycan associated with the decreased expression of syndecan-1 and aggrecan in the experimental groups suggested an enhancement in the remodeling of ECM. The results contribute to show that blood instillation on TA appears to trigger alterations in the ECM similar to the ones found in inflammatory diseases such as PD.

Inhibition of penile tunica albuginea myofibroblasts activity by adipose-derived stem cells

The activation of tunica albuginea myofibroblasts (MFs) serves an essential role in Peyronie's disease (PD). Increasing evidence has reported that adipose tissue-derived stem cells (ADSCs) have been demonstrated to attenuate the symptoms of PD in animal models. However, the mechanisms of the antifibrotic effects of ADSCs in PD remain to be fully elucidated. In the present study, the inhibitory effects and possible mechanism of ADSCs on the activation of MFs derived from rat penile tunica albuginea were investigated. ADSCs were obtained from the paratesticular fat of Sprague Dawley rats. MFs were transformed from rat penile tunica albuginea fibroblasts through stimulation with 5 ng/ml tumor growth factor-β1. Transwell cell cultures were adopted for co-culture of ADSCs and MFs. Western blot analysis was used to assess changes in the expression levels of α smooth muscle actin (αSMA), collagen I, phosphorylated (p)-SMAD family member 2 (Smad2), Smad2, ras homolog family member A (RhoA), Rho associated coiled-coil containing protein kinase (ROCK)1 and ROCK2, caspase3, caspase9, and matrix metalloproteinases (MMPs). Collagen gel assays were used to assess cell contractility. Additionally, the concentration of hydroxyproline in the culture medium was detected using commercially available kits. It was demonstrated that ADSCs reduced the expression of αSMA and collagen I of MFs. Furthermore, p-Smad2, RhoA, ROCK1 and ROCK2 expression was significantly reduced in the MFs+ADSCs group compared with that in the MFs-only culture, while the expression of MMPs (MMP2, MMP3, MMP9 and MMP13) and caspases (caspase3 and caspase9) was upregulated. In addition, ADSCs were able to downregulate the concentration of hydroxyproline in the culture medium of MFs and reverse the contraction of MFs. Collectively, these results suggested that ADSCs inhibited the activation of MFs, decreased collagen production, and suppressed the contraction of myofibroblasts, via Smad and RhoA/ROCK signaling pathways. Furthermore, ADSCs reduced the deposition of collagen and promoted the apoptosis of MFs via MMPs, and caspases. Accordingly, the application of ADSCs may provide a novel therapeutic strategy for PD.

Rationale of combination therapy with antioxidants in medical management of Peyronie's disease: results of clinical application

Peyronie's disease (PD) is a connective tissue disorder involving the tunica albuginea of the corpora cavernosa of the penis. We have published several studies describing a "combined therapy" for PD patients, but the present study aims to clearly demonstrate how the association between various antioxidants in PD treatment can significantly increase the likelihood of therapeutic success. We used the following substances: silymarin, ginkgo biloba, vitamin E, bilberry, topical diclofenac sodium, and pentoxifylline (PTX). We analyzed the therapeutic impact and possible side effects of one or more antioxidants in patients with early-stage PD. To clearly prove that it is possible to achieve better results when combining more than one agent, we designed this study with five treatment groups, corresponding, respectively, to the administration of a single oral antioxidant; two oral antioxidants; three oral antioxidants; five oral antioxidants + local diclofenac; and five oral antioxidants + local diclofenac + PTX by perilesional injection. One hundred and twenty patients were assigned to five groups of treatment designed according to the abovementioned study aim. Outcomes after 6 months of treatment showed that combined antioxidant therapy is effective in treating PD. Statistical analysis showed significant differences between the treatment groups with regard to: improvement and disappearance of penile pain; percentage of reduction in the volume of penile plaque; reduction in penile curvature; recovery of erectile function in patients with erectile dysfunction; increase in the International Index of Erectile Function score; and reduction of psychosexual impact. Furthermore, we observed that the clinical efficacy of combined therapy is greater when topical use of diclofenac gel and perilesional injection of PTX are added to oral treatment with more than one antioxidant. Although several articles have already been published reporting the effectiveness of combined treatment in PD, this is the first study clearly proving how, as the number of substances used in treatment rises, a proportionally greater therapeutic effect is achieved.

Evidence-Based Management Guidelines on Peyronie's Disease

INTRODUCTION

Despite recent advances in our knowledge and treatment strategies in Peyronie's Disease (PD), much remained unknown about this disease.

AIM

To provide a clinical framework and key guideline statements to assist clinicians in an evidence-based management of PD.

METHODS

A systematic literature search was conducted to identify published literature relevant to PD. The search included all relevant articles published up to June 2015, including preclinical studies and published guidelines. References used in the text were assessed according to their level of evidence, and guideline recommendations were graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Owing to the paucity of larger series and randomized placebo-controlled trials with regard to surgical intervention, guideline statements are provided as clinical principle or expert opinion.

MAIN OUTCOME MEASURES

This literature was discussed at a panel meeting, and selected articles with the highest evidence available were used to create consensus guideline statements for the Fourth International Consultation on Sexual Medicine guidelines on PD.

RESULTS

In addition to existing Third International Consultation on Sexual Medicine guidelines on PD, seven new summary recommendations were created.

CONCLUSION

A greater understanding of the scientific basis of PD is greatly needed to address our understanding of the pathophysiology, clinical epidemiology, psychosocial, and diagnostic assessment as well as treatment strategies.

Stem cell therapy for the treatment of Peyronie's disease

INTRODUCTION

Like other fibrotic diseases, the cause of Peyronie's disease (PD) is still obscure. Since there is now increasing evidence for the role of Mesenchymal Stem Cells (MSCs) as potential treatment to fibrosis, it is crucial to determine their possible efficacy in the treatment of PD. Areas covered: In this review, the authors summarize the emerging data and published studies regarding the use of SCs for the treatment of PD. The authors provide particular focus on the three-first experimental studies for the use of SCs in rat models as well as the sole two studies undertaken in humans. Expert opinion: It seems evident in experimental settings that SCs in general (Adipose Derived SCs in particular) provide a feasible, safe and effective therapy for PD. The potential limits of the rat models used initially have been somewhat overcome with the inception of studies in men. However, further prospective studies are needed in humans to further elucidate the therapeutic potential of stem cell therapy in PD.

Understanding the cellular basis and pathophysiology of Peyronie's disease to optimize treatment for erectile dysfunction

Erectile dysfunction (ED) is a common condition that significantly impacts a man’s physical and psychological well-being. ED is often associated with Peyronie’s disease (PD), which is an abnormal curvature of the penis. Delayed treatment of or surgical invention for PD often results in ED and therefore unsatisfied patients. The pathophysiology of PD is incompletely understood, but has been studied extensively and based on our current understanding of PD physiology, many medical treatment options have been proposed. In this paper, we will review what is known about the pathophysiology of PD and the medical treatment options that have been trialed as a result. More investigations in regards to the basic science of PD need to be carried out in order to elucidate the exact mechanisms of the fibrosis, and propose new, more successful treatment options which should be implemented prior to the onset of ED.

Nonsurgical treatment options in Peyronie's Disease: 2016 update

Peyronie's disease (PD) is an inflammatory condition of penile tunica albuginea which commonly ends with penile curvature and difficulty in vaginal penetration. Unfortunately, the pathophysiology of PD has not been completely understood. In this paper, we will review what is known about the pathophysiology of PD and the nonsurgical medical treatment options that have been trialed as a result. In the last 5 years, commonly used oral medications left their places to intralesional therapies. Clostridium collagenase, which is the only Food and Drug Administration (FDA) approved treatment for PD, is now the most prescribed intralesional therapy in the last years. Clostridium collagenase is advised for patients whose penile curvature is > 30° and < 90°. Because of its side effects, patients should be counseled before intralesional Clostridium collagenase treatment. Until finding best treatment solution for PD, more investigations in regards to the basic science of PD need to be carried out in order to elucidate the exact mechanisms of the fibrosis.

A mathematical model to predict the loss of length in patients undergoing plication corporoplasty for Peyronie’s disease

Introduction:

Peyronie’s disease affects three to nine out of 100 men and can have significant emotional and sexual effects on patients and their partners. Treatment options vary but once the disease becomes quiescent they are predominantly surgical. The type of surgery adopted is dependent on the degree of angulation although no single procedure is without its disadvantages. Plication corporoplasty is one approach but patients experience and often complain of loss of penile length. We set out to devise a mathematical model that would allow us to predict the loss of length based on erect penile dimensions.

Methods:

By considering the bend in the erect penis as an arc, utilising the degree of curvature and the penile circumference at maximum angulation, we have been able to derive a simple equation using parameters that are easily obtained in the clinic.

Results:

Where L=length lost, C=circumference at point of curvature, Y=angle of curvature as measured by a goniometer: L = CY/180. We have then been able to create a quick reference table based on the average penile circumference (12–13 cm±5 cm).

Conclusion:

This formula provides a more scientific and accurate means to predict potential loss of penile length in patients undergoing plication corporoplasty. Although we recognise that applying a rigid mathematical model to a biological non-uniform pathology creates inaccuracies this is somewhat better than ‘by sight’ estimates, and will allow more informed counselling and consent for patients. As far as we are aware this is the first attempt to create a mathematical model to aid counselling for plication corporoplasty.

A meta-analysis of extracorporeal shock wave therapy for Peyronie's disease

The efficiency of extracorporeal shock wave therapy (ESWT) for Peyronie's disease (PD) has been controversial for a very long time. We aimed to evaluate the efficiency of ESWT for PD and provide possible evidence on the basis of a meta-analysis of existing comparative studies. All controlled studies, including randomized controlled trials (RCTs), cohort studies and case-control studies, that focused on the efficiency of ESWT for PD, were prospectively identified through comprehensive searches of PubMed, the Cochrane Library and Embase databases. We conducted a meta-analysis of these studies. Six studies including 443 patients were selected for the meta-analysis. Pooling data of these studies showed that ESWT could significantly increase the percentage of men with lessening of penile plaques (odds ratio (OR) 2.07, 95% confidence interval (CI) 1.11-3.85, P=0.02), relief of pain (OR 4.46, 95% CI 2.29-8.68, P<0.0001) and complete remission of pain (OR 5.86, 95% CI 2.66-12.92, P<0.0001). However, insignificant differences were found in improvement of penile curvature (OR 1.88, 95% CI 0.97-3.65, P=0.06) and sexual function (OR 2.22, 95% CI 0.69-7.11, P=0.18) between ESWT and placebo groups. Further, similar results were shown for sensitivity and publication bias analysis when only RCTs were included. However, sporadic complications caused by ESWT were reported, but no patient needed additional treatment aside from conservative observation. ESWT may be an effective and safe treatment for lessening of penile plaques and relieving pain for men with PD, but not for improving of penile curvature and sexual function.

Intralesional Injection of Hyaluronic Acid in Patients Affected With Peyronie's Disease: Preliminary Results From a Prospective, Multicenter, Pilot Study

Introduction

Hyaluronic acid has been shown to be efficacious in decreasing scar formation, inflammation, and oxidative stress.

Aim

To assess the efficacy of intralesional injection of hyaluronic acid in patients affected by Peyronie's disease.

Methods

In this prospective, single-arm, self-controlled, interventional, multicenter pilot study, 65 patients underwent a 10-week cycle of weekly intraplaque injections with hyaluronic acid (0.8% highly purified sodium salt hyaluronic acid 16 mg/2 mL; Sinovial, IBSA, Lodi, Italy). Patients were re-evaluated 2 months after the end of therapy.

Main Outcome Measures

Plaque size (millimeters), penile curvature (degrees), International Index of Erectile Function (IIEF-5) score, visual analog scale (VAS) score for sexual satisfaction, and Patient's Global Impressions of Improvement (PGI-I) score.

Results

Median age was 57 years (range = 23–70). At baseline, mean plaque size was 10 mm (range = 3–30 mm), mean penile curvature was 30° (range = 0°–50°), and mean IIEF-5 score was 20 (range = 0–25), with slight to moderate erectile dysfunction (IIEF score < 21) in 36 of 65 patients (55%). A median VAS score of 6 (range = 2–10) was found. Mean follow-up was 12 months (range = 6–24 months). Statistically significant post-treatment improvements were detected for plaque size (before treatment = 10 mm [3–30 mm], after treatment = 8 mm [1–30 mm], P < .0001), penile curvature (before treatment = 30° [0°–50°], after treatment = 20° [0°–40°], P < .0001), IIEF-5 score (before treatment = 20 [11–25], after treatment = 21 [15–25], P < .0001), and VAS score (before treatment = 6 [2–10], after treatment 8 [2–10], P < .0001). After treatment, the rate of patients with an IIEF score lower than 21 decreased from 55% (36 patients) to 40% (25 patients). Overall improvement on the PGI-I questionnaire was 69%.

Conclusion

Intralesional treatment with hyaluronic acid can improve plaque size, penile curvature, and overall sexual satisfaction and seems preferably indicated in the early (active) phase of the disease. Furthermore, it is easy to perform and well tolerated.

Comparative Analysis of Tunical Plication vs. Intralesional Injection Therapy for Ventral Peyronie's Disease

INTRODUCTION

Approximately 10% of Peyronie's disease (PD) patients present with ventral curvatures and, as such, there is a paucity of data describing the optimal approach for treatment.

AIM

This study aims to compare the outcomes of surgery (tunical plication [TP]) and intralesional injection (ILI) therapy (interferon-α2b) in men with ventral PD.

MATERIALS AND METHODS

Retrospective data were collected from two centers: Tulane University (ILI) and Technical University of Munich (TP). Collected variables included patient demographics, pre- and post-treatment sexual function, rigorous penile measurements (curvature, length, and penile vascular findings), and post-treatment outcomes.

RESULTS

A total of 35 patients with ventral PD (21 ILI and 14 TP) were included in the study. There were no significant differences between the two groups prior to the interventions. There was a significantly better improvement in mean curvature with TP (46.4 degrees) as compared with ILI (9.3), P < 0.0001. TP was also associated with a significantly higher rate of ≥20% improvement in curvature as compared with ILI (100% vs. 67%, P = 0.027). Although there was no significant difference in post-treatment change in Sexual Health Inventory for Men (SHIM) scores between the groups, 36% of the ILI patients noted an improved SHIM score as compared with none in the TP group. Erect penile length was preserved or improved in 67% of the ILI group vs. 14% of the TP group, P = 0.005.

CONCLUSIONS

TP confers a better overall improvement in penile curvature as compared with ILI in patients with ventral PD. Preserved or improved erect penile length and SHIM scores may be observed in patients undergoing ILI. 12:2492-2498.

Estradiol attenuates the TGF-β1-induced conversion of primary TAFs into myofibroblasts and inhibits collagen production and myofibroblast contraction by modulating the Smad and Rho/ROCK signaling pathways

The transformation of tunica albuginea-derived fibroblasts (TAFs) into myofibroblasts plays an important role in the pathological progress of Peyronie's disease (PD). However, no treatment which addresses this transformation is currently available. Estrogen has been shown to inhibit the progression of fibrosis in a number of fibrotic diseases. The aim of this study was to determine whether estrogen [17β‑estradiol (E2)] suppresses the diffentiation of primary rat TAFs into myofibroblasts in vitro. TAFs obtained from male Sprague‑Dawley rats were stimulated with either transforming growth factor‑β1 (TGF‑β1) or E2. Western blot analysis and immunofluorescence staining were used to assess changes in the expression levels of α‑smooth muscle actin (αSMA). The expression levels of additional proteins (GAPDH, p‑Smad2, Smad2, Smad4, RhoA, Rac1, ROCK1 and ROCK2) were also measured by western blot analysis. We used collagen gel assays to assess cell contractility. Additionally, the concentration of hydroxyproline in the TAF cell culture medium was detected using commercially available kits. We found that E2 reduced αSMA expression which was induced by TGF‑β1. E2 also suppressed the TGF‑β1‑induced increase in the concentration of hydroxyproline (a marker of collagen) in addition to suppressing the contraction of TAFs. The key processes affected by TGF‑β1 treatment included the phosphorylation of Smad2, ras homolog gene family, member A (RhoA) and Rho‑associated, coiled-coil containing protein kinase 2 (ROCK2); this increase in phosphorylation was inhibited by treatment with E2. Collectively, these results demonstrate that by modulating the activation of the TGF‑β1‑Smad and RhoA‑ROCK2 signaling pathways, E2 inhibited the transformation of TAFs into myofibroblasts, decreased the expression of collagen and suppressed the contraction of myofibroblasts in response to TGF-β1 stimulation.

Collagenase Clostridium histolyticum for the Treatment of Peyronie's Disease: The Development of This Novel Pharmacologic Approach

INTRODUCTION

The conception of collagenase Clostridium histolyticum (CCH) as treatment for Peyronie's disease (PD) was a vital first step in providing a nonsurgical, minimally invasive FDA-approved treatment for men with PD.

AIM

To review the origins, clinical research history, and ultimately FDA approval of collagenase as PD treatment.

METHODS

A PubMed search using (Peyronie's or Peyronie) AND collagenase, and limited to clinical research studies, returned nine papers that were examined in the current review.

RESULTS

Collagenase as a PD treatment arose in response to a lack of effective nonsurgical treatments and the incomplete understanding of underlying PD etiology. Awareness of dense collagen in PD scarring and parallel initial exploration of collagenase to treat herniated lumbar discs coincided with and inspired laboratory-based investigation of collagenase effects on excised PD plaque tissue. The foundational conceptual work and the critical development of purified injectable collagenase allowed the pursuit of clinical studies. Progression of clinical studies into large-scale robust trials culminated in two important outcomes: development of the first validated, PD-specific measure of psychosexual function, the Peyronie's Disease Questionnaire, and the first FDA-approved treatment for PD.

CONCLUSIONS

Collagenase therapy began as an attempt to modify the structure of PD-related tunica albuginea scarring, despite the lack of a fundamental understanding of the scar's origin. If we wish to advance PD treatment beyond this first effective step, the future needs to bring us full circle to the starting point: We need a greater understanding of the control of collagen deposition and wound healing in men with PD.

Pharmacologic therapy for Peyronie's disease: what should we prescribe?

INTRODUCTION

Peyronie's disease (PD) is a wound healing disorder of the penis with a myriad of proposed treatment options reported in the literature. Evaluating the available data and therapeutic management of PD can be challenging and confusing, even for the most experienced treating physician. This review provides a comprehensive overview of pharmacologic treatment options for PD, focusing on the best available evidence.

AREAS COVERED

A comprehensive literature search for published articles evaluating oral, topical, and injectable pharmacologic agents for PD was completed. Prospective, controlled trials were given precedence for inclusion.

EXPERT OPINION

Although a multitude of oral agents have been proposed and evaluated in PD patients, results vary widely and a reproducible objective benefit has not yet been strongly established for any single oral agent. Well-designed, large-scale, randomized controlled trials evaluating oral agents in PD patients are lacking. Consistent objective benefit from injectable agents has been supported for years by various non-controlled trials. Recently, injectable collagenase Clostridium histolyticum became the first pharmacologic agent to obtain FDA approval for use in PD patients, supported by data from a large-scale, Phase III randomized controlled trial. Further elucidation of the genetic and mechanistic pathways involved in the development and progression of PD will help define future therapeutic targets.

All about Peyronie's disease

Peyronie's disease (PD) is an acquired connective tissue disorder of the tunica albuginea of the corpus cavernosum, characterized by excessive fibrosis and plaque formation. PD can result in significant physical and psychological morbidity; as it may prevent intercourse and cause adverse impacts on partner relationships. The exact etiology and pathophysiology remain unclear, and many misconceptions about the disease associations, course and treatment exist.

The disease has two distinct stages. The acute stage is characterized by pain, and disease may progress during this stage. Non-surgical managements at this stage aim to alleviate pain and stabilize the disease. Results for non-surgical treatment are often conflicting. The chronic stage occurs 6–12 months later, where pain disappears and the deformity stabilizes. Surgical treatment is reserved for significant deformity or with inability to penetrative intercourse. The choice of the surgical technique depends on the length of the penis, degree of deformity, erectile function, patients' expectations and surgeon's preference.

PEYRONIE'S DISEASE: A REVIEW OF ETIOLOGY, DIAGNOSIS, AND MANAGEMENT

Peyronie's Disease (PD) is a superficial fibrosing disorder of the penis resulting in plaque formation and penile deformity. Once considered rare, PD has more recently been found in up to 13% of men, and can negatively affect sexual and psychosocial function of both patients and their partners. While the etiology of PD is unclear, it is thought to result from an inciting traumatic event followed by aberrant fibrosis or dysregulated wound healing. The evaluation of men presenting with PD includes a detailed history and physical exam, focusing on the penis in both the flaccid and erect states. PD is often associated with erectile dysfunction (ED), as well as several other comorbidities. Laboratory testing is not needed to diagnose PD, although given the associations between PD and systemic diseases including hypogonadism, diabetes, and cardiovascular disease, screening and work-up for these conditions in men with PD may be warranted. Treatment modalities for PD are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Oral, topical, and mechanical therapies generally have little evidence supporting their efficacy. Several intralesional therapies, including interferon α2b and collagenase Clostridium hystiolyticum have demonstrated efficacy in the treatment of PD. Surgical treatment, indicated in men with significant, stable deformity, includes plication of the tunica albuginea, plaque incision/excision and grafting, and placement of inflatable penile prosthesis (IPP) with or without additional maneuvers to achieve desired results, and has high success rates.

Prospects of stem cell treatment in benign urological diseases

Stem cells (SCs) are undifferentiated cells that are capable of self-renewal and differentiation and that therefore contribute to the renewal and repair of tissues. Their capacity for division, differentiation, and tissue regeneration is highly dependent on the surrounding environment. Several preclinical and clinical studies have utilized SCs in urological disorders. In this article, we review the current status of SC use in benign urological diseases (erectile dysfunction, Peyronie disease, infertility, and urinary incontinence), and we summarize the results of the preclinical and clinical trials that have been conducted.

Peyronie's disease and autoimmunity—a real-life clinical study and comprehensive review

INTRODUCTION

Although heavily investigated over the last decades, Peyronie's disease (PD) pathogenesis remains unclear.

AIM

We sought to investigate the association between PD and autoimmune diseases (ADs) in men seeking medical help for sexual dysfunction in the real-life setting.

METHODS

Complete sociodemographic and clinical data from a homogenous cohort of 1,140 consecutive Caucasian-European men were analyzed. Health-significant comorbidities were scored with the Charlson Comorbidity Index and ADs were stratified according to International Classification of Diseases, Ninth Revision classification.

MAIN OUTCOME MEASURES

Descriptive statistics and multivariate logistic regression models tested the association between ADs and PD.

RESULTS

PD was diagnosed in 148 (13%) of the 1,140 men; of PD patients, 14 (9.5%) had a comorbid AD; conversely, the rate of ADs in non-PD patients was significantly lower (χ(2) = 24.7; P < 0.01). Both patient age and AD comorbidity achieved multivariable independent predictor status for PD (odds ratio [OR]: 1.05; P < 0.01 and OR: 4.90; P < 0.01, respectively).

CONCLUSIONS

Our observational findings showed that ADs are highly comorbid with PD in a large cohort of same-race individuals seeking medical help for sexual dysfunction in the real-life setting.

Psychosexual Symptoms and Treatment of Peyronie's Disease Within a Collaborative Care Model

INTRODUCTION

Peyronie's disease (PD) can be emotionally and sexually debilitating for patients and may negatively impact partner relationships.

AIMS

This study aims to present an ongoing collaborative care model for patients with PD and to discuss the critical need for integration of patient care among sexual medicine physicians and mental health practitioners or sex therapists.

METHODS

PubMed searches using the terms "Peyronie's disease" and "natural history," "treatment," "psychosexual," "depression," "relationship," and "partner" were conducted. Expert opinion based on review of the relevant published literature and clinical experience was used to identify meaningful treatment targets for patients with PD within a collaborative care model.

MAIN OUTCOME MEASURE

Characteristics of PD, medical treatment, and important assessment and treatment targets, including physical, emotional, psychosexual, and relationship concerns, from peer-reviewed published literature and clinical experience.

RESULTS

PD can result in significant patient and partner distress and relationship disruption. Sex therapy interventions may be directed at acute emotional, psychosexual, and relationship problems that occur during the initial diagnosis of PD, the period following minimally invasive or surgical treatment for PD, or recurring problems over the lifelong course of the disease. Sex therapy to improve self-acceptance, learn new forms of sexual intimacy, and improve communication with partners provides comprehensive treatment targeting emotional, psychosexual, and relationship distress. Ongoing communication between the mental health practitioner and physician working with the patient with PD about key assessments, treatment targets, and treatment responses is necessary for coordinated treatment planning and patient care.

CONCLUSIONS

Men with PD are more likely now than in the past to see both a sexual medicine physician and a mental health practitioner or sex therapist, and the integration of assessments and treatment planning is essential for optimal patient outcomes.

The role of intrinsic pathway in apoptosis activation and progression in Peyronie's disease

Peyronie's disease (PD) is characterized with formation of fibrous plaques which result in penile deformity, pain, and erectile dysfunction. The aim of this study was to investigate the activation of the intrinsic apoptotic pathway in plaques from PD patients. Tunica albuginea from either PD or control patients was assessed for the expression of bax, bcl-2 and caspases 9 and 3 using immunohistochemistry and by measurement of apoptotic cells using TUNEL assay. Bax overexpression was observed in metaplastic bone tissue, in fibroblasts, and in myofibroblast of plaques from PD patients. Little or no bcl-2 immunostaining was detected in samples from either patients or controls. Caspase 3 immunostaining was very strong in fibrous tissue, in metaplasic bone osteocytes, and in primary ossification center osteoblasts. Moderate caspase 9 immunostaining was seen in fibrous cells plaques and in osteocytes and osteoblasts of primary ossification centers from PD patients. Control samples were negative for caspase 9 immunostaining. In PD patients the TUNEL immunoassay showed intense immunostaining of fibroblasts and myofibroblasts, the absence of apoptotic cells in metaplasic bone tissue and on the border between fibrous and metaplastic bone tissue. Apoptosis occurs in stabilized PD plaques and is partly induced by the intrinsic pathway.

Outcomes of surgical treatment of Peyronie's disease

The aims of the present review were to assess the literature on published outcomes and complications associated with surgical treatments for Peyronie's disease (PD) and to assist clinicians in the effective management of PD by increasing understanding and awareness of the outcomes associated with current surgical treatment options. A PubMed literature search was conducted to identify relevant, peer-reviewed clinical and review articles published between January 1980 and October 2013 related to outcomes of surgical correction of PD. Search terms for this non-systematic review included 'Peyronie's disease', 'outcomes', 'complications', 'erectile dysfunction or ED', 'patient expectation', and 'patient satisfaction'; search terms were searched separately and in combination. Case studies and editorials were excluded, primary manuscripts and reviews were included, and bibliographies of articles of interest were reviewed and key references were obtained. Assessment of the study design, methodology, clinical relevance and impact on the surgical outcomes of PD was performed on the sixty-one articles that were selected and analysed. Currently, there are several investigational minimally invasive and non-surgical treatment options for PD; however, surgical treatment remains the standard of care for patients with stable disease and disabling deformity or drug-resistant erectile dysfunction. Each of the different surgical procedures that are used for treatment of PD, including tunical shortening, tunical lengthening (plaque incisions or partial excision and grafting), and use of inflatable penile prostheses, carries its own advantages and disadvantages in terms of potential complications and postoperative satisfaction. Because of the variety of ways that PD may present in affected patients, no single, standard, surgical treatment for this disorder has prevailed and multiple variations of each type of procedure may exist. Surgical outcomes of the most commonly used procedures are not substantially different; therefore, the appropriateness of each treatment option may often depend on disease and patient characteristics (e.g. deformity and erectile function). Surgical algorithms have been published to guide surgeons and patients through the selection of surgical procedures in the absence of conclusive, long-term outcome data. Accumulating data on outcomes associated with established procedures, modifications to these procedures, and new surgical techniques and materials may serve to further guide practice and refine evidence-based selection of the surgical approach.

Systematic review of the non surgical management of Peyronie's disease

This systematic review shows the “Status quo” on medical treatment for Peyronie’s disease (PD). PD is a connective tissue disorder, characterised by the formation of a fibrotic lesion or plaque in the tunica albuginea, which leads to penile deformity. The aetiology of PD is unknown. Nowadays the most widely accepted hypothesis proposed by Gonzalez-Cadavid et al, is repetitive microvascular injury or trauma to the tunica albuginea. Physicians have proposed several medical alternatives for treatment of this disease with few effective results. Nevertheless, as of today nonsurgical options are currently available, and some of them are able to stabilize or even reduce deformity while improving pain relief and sexual function. A systematic literature search throughout the Medline database was carried out. The controlled vocabulary of the medical subject headings database employs the specific term “penile induratio” for PD. A total of 50 articles on PD were found. Studies were selected based on clinical relevance. The recommended standard of care for PD involves an initial treatment in the acute phase. Several non-operative treatment options have been used. Unfortunately no further substantial, quality evidence on the use of medical therapy currently exits. There is, however, an increasingly enhanced interest in this disorder and basic scientific and clinical research will eventually lead to a more effective methodology to study the disease.

Is transforming growth factor-β signaling activated in human hypertrophied prostate treated by 5-alpha reductase inhibitor?

Background and Aim. It is well known that androgen deprivation relates to penile fibrosis, so we hypothesize that long-term treatment with 5-alphareductase inhibitors (5ARIs) may increase the risk of fibrosis of prostate. Patients and Methods. Thirty-two BPH patients who underwent transurethral resection of the prostate were enrolled. The patients were divided into two groups: group one, 16 patients underwent TURP who had been treated with tamsulosin for 2 years; group two, 16 patients underwent TURP who had been treated with combination of tamsulosin and dutasteride for at least 1 year. We evaluated the expressions of nNOS, iNOS, eNOS, TGF-β1, TGF-β2, phosphorylated-Smad2/3 (p-Smad2/3), E-cadherin, N-cadherin, and α-smooth muscle actin in the resected prostate tissues by western blotting, and the TGF-β concentration was determined by ELISA kit. Results. The expressions of 3 isoforms of NOS were significantly increased in group 2 except of eNOS in lateral prostate, and the expressions of TGF-β1, TGF-β2, and p-Smad2/3 increased about 2-fold compared with group 1. In group 2, the E-cadherin expression decreased while N-cadherin expression increased significantly. Conclusions. The overexpression of nNOS may contribute to prostate smooth muscle relaxation; however, long-time treatment with 5 ARI increases the risk of fibrosis of prostate.

The pathophysiology of Peyronie's disease

OBJECTIVE

To review the contemporary knowledge of the pathophysiology of Peyronie's disease (PD).

METHODS

Medline was searched for papers published in English from 2000 to March 2013, using the keywords 'Peyronie's disease' and 'pathophysiology'.

RESULTS

More than 300 relevant articles were identified for the purpose of this review. Unfortunately only a few studies had a high level of evidence, and the remaining studies were not controlled in their design. Many theories have been proposed to explain the cause of PD, but the true pathogenesis of PD remains an enigma. Identifying particular growth factors and the specific genes responsible for the induction of PD have been the ultimate goal of research over the past several decades. This would provide the means to devise a possible gene therapy for this devastating condition. We discuss present controversies and new discoveries related to the pathophysiology of this condition.

CONCLUSION

PD is one of the most puzzling diseases in urology. The pathogenesis remains uncertain and there is still controversy about the best management. The pathogenesis of PD has been explored in animal models, cell cultures and clinical trials, but the results have led to further questions. New research on the aetiology and pathogenesis of PD is needed, and which will hopefully improve the understanding and management for patients with this frustrating disease.

Understanding the course of Peyronie's disease

AIMS

To correct common misconceptions about Peyronie's disease (PD) that present obstacles to early recognition and treatment.

METHODS

The prevalence, natural disease course, psychosocial effects and treatment considerations for patients with PD were reviewed.

RESULTS

Studies over the past decade have shown that the prevalence of PD may be higher (up to 20%) than previously thought. PD can lead to emotional and relationship distress. Nearly 10% of men who present with PD are younger than 40. Both younger age and comorbid vascular disease have been associated with more severe and progressive PD. In the majority of patients, symptoms will either deteriorate or remain stable. PD is often associated with erectile dysfunction (ED). Effective, minimally invasive treatments used early in the disease course include unapproved and/or investigational intralesional injection therapy with verapamil, interferon (IFN) α-2b, or collagenase clostridium histolyticum (CCH). Surgical intervention is considered in patients with ED and/or penile deformity that impairs sexual functioning; however, preoperative discussion of appropriate expectations is important.

DISCUSSION

The availability of effective minimally invasive and surgical therapies for PD suggests that active management should be considered over a 'wait-and-see' approach.

CONCLUSION

Providing early intervention and improved education/awareness of PD as a chronic and progressive disorder may result in improved physical and psychosocial outcomes for PD patients. As general practitioners are often the first contact for men with PD, they are well positioned to recognise symptoms early and promptly refer patients for further evaluation and treatment.

A novel PI3K inhibitor alleviates fibrotic responses in fibroblasts derived from Peyronie's plaques

Peyronie's disease (PD) is fibrosis localized in the tunica albuginea that is characterized by penile deformity and curvature. The pathogenesis of this disease remains unclear even though transforming growth factor-β (TGF-β)/smad signalling has been reported to be associated with PD. Recent studies have shown that phosphoinositide 3-kinase (PI3K)/Akt signalling regulates fibrotic responses including collagen synthesis and cell proliferation. Thus, we synthesized HS-173, a novel PI3K inhibitor, and determined whether this compound has anti-fibrotic effects on PD-derived primary fibroblasts. In this study, we found that HS-173 inhibited the growth of fibroblasts in a dose-dependent manner and induced apoptosis. In addition, HS-173 reduced the expression of α-smooth muscle actin (α-SMA), vimentin, PAI-1, fibronectin, collagen type I, collagen IV and TGF-β-activated smad2/3 in PD-derived primary fibroblasts. HS-173 blocked the PI3K/Akt signalling pathway by decreasing the activation of Akt, mTOR and P70S6K. Our results showed that HS-173 suppressed fibrotic responses such as cell proliferation and collagen synthesis by blocking PI3K/Akt signalling in PD-derived primary fibroblasts. Our findings provide molecular insights into the potential therapeutic action of HS-173 through targeting the PI3K/Akt pathway in PD-derived fibroblasts and demonstrated that HS-173 could be used as a pharmacological agent for treating other fibrotic diseases.

Penile traction therapy and Peyronie's disease: a state of art review of the current literature

In recent years, penile traction therapy (PTT) has gained considerable interest as a novel nonsurgical treatment option for men with Peyronie's disease (PD) and short penises. The current published literature suggests that selected cases of PD may benefit from a conservative approach with PTT, resulting in increased penile length and reduction of penile deformity. It appears to be safe and well tolerated but requires a great deal of patient compliance and determination. This article reviews the current literature pertaining to the use of PTT in men with PD, short penises and in the setting of pre- and postprosthesis corporal fibrosis.

EAU guidelines on penile curvature

CONTEXT

Penile curvature can be congenital or acquired. Acquired curvature is secondary due to La Peyronie (Peyronie's) disease.

OBJECTIVE

To provide clinical guidelines on the diagnosis and treatment of penile curvature.

EVIDENCE ACQUISITION

A systematic literature search on the epidemiology, diagnosis, and treatment of penile curvature was performed. Articles with the highest evidence available were selected and formed the basis for assigning levels of evidence and grades of recommendations.

EVIDENCE SYNTHESIS

The pathogenesis of congenital penile curvature is unknown. Peyronie's disease is a poorly understood connective tissue disorder most commonly attributed to repetitive microvascular injury or trauma during intercourse. Diagnosis is based on medical and sexual histories, which are sufficient to establish the diagnosis. Physical examination includes assessment of palpable nodules and penile length. Curvature is best documented by a self-photograph or pharmacologically induced erection. The only treatment option for congenital penile curvature is surgery based on plication techniques. Conservative treatment for Peyronie's disease is associated with poor outcomes. Pharmacotherapy includes oral potassium para-aminobenzoate, intralesional treatment with verapamil, clostridial collagenase or interferon, topical verapamil gel, and iontophoresis with verapamil and dexamethasone. They can be efficacious in some patients, but none of these options carry a grade A recommendation. Steroids, vitamin E, and tamoxifen cannot be recommended. Extracorporeal shock wave treatment and penile traction devices may only be used to treat penile pain and reduce penile deformity, respectively. Surgery is indicated when Peyronie's disease is stable for at least 3 mo. Tunical shortening procedures, especially plication techniques, are the first treatment options. Tunical lengthening procedures are preferred in more severe curvatures or in complex deformities. Penile prosthesis implantation is recommended in patients with erectile dysfunction not responding to pharmacotherapy.

CONCLUSIONS

These European Association of Urology (EAU) guidelines summarise the present information on penile curvature. The extended version of the guidelines is available on the EAU Web site (www.uroweb.org/guidelines/).

Penile Doppler sonographic and clinical characteristics in Peyronie's disease and/or erectile dysfunction: an analysis of 1500 men with male sexual dysfunction

What's known on the subject? and What does the study add? Penile colour Doppler ultrasonography (CDU) can be an invaluable investigative tool to characterize penile abnormalities to complement clinical history and physical examination in the evaluation of men with Peyronie's disease (PD) and/or erectile dysfunction (ED). Although CDU findings between men with PD and those with ED were not markedly different, subtle differences were observed. The classic penile CDU findings in men with PD comprise tunical thickening, intracavernosal fibrosis, septal fibrosis and intracavernosal calcification, while, in men with ED, low peak systolic velocity and high end-diastolic velocity are found on penile haemodynamics. Previously published studies have focused predominantly on either ED or PD exclusively, or examine the risk of progression to ED in the PD population. To our knowledge, this is the largest and most comprehensive analysis of penile CDU and clinical findings in men with PD and/or ED. The large sample size and multivariable analysis allow meaningful interpretation of the results. This study has found some substantial differences in the penile CDU findings of men with PD and/or ED that have not previously been reported. Although the risk factors of ED may be greater than those for PD, there is crossover in age, cardiovascular risk factors, trauma and penile CDU findings in men with PD and/or ED.

OBJECTIVE

To explore the differences in penile colour Doppler ultrasonography (CDU) findings between men with Peyronie's disease (PD) and those with erectile dysfunction (ED).

MATERIALS AND METHODS

Patients presenting with PD and/or ED who underwent penile CDU were recruited to the study. Patient demographics, comorbidities, International Index of Erectile Function-5 scores, previous therapies and physical findings were documented. Penile curvature, presence of tunical thickening, septal fibrosis, intracavernosal fibrosis and calcification, and cavernosal vascular status were recorded.

RESULTS

A total of 1500 men underwent penile CDU during the 10-year period. Of these men, 891 men presented with PD and 609 men had ED only. Men with ED had higher rates of diabetes and coronary artery disease (P < 0.05). Isolated tunical thickening was more common in older men and in the PD cohort. The presence of intracavernosal fibrosis correlated strongly with difficulty maintaining erection (P < 0.05). Impaired cavernosal arterial flow was observed in men with decrease penile rigidity and penile pain, while higher end-diastolic velocities were found in men with difficulty maintaining erection and tunical thickening on penile CDU.

CONCLUSIONS

Men with PD and ED had many similarities and differences on penile CDU. Penile CDU continues to be an invaluable clinical tool in the management of men with male sexual dysfunction.

Drugs of the future for Peyronie's disease

With the increasing awareness of Peyronie's disease (PD), the interest in new concept medications to treat the disorder is escalating. Profibrogenic factors such as transforming growth factor (TGF)-beta1, endothelin (ET-1), connective tissue growth factor (CTGF), angiotensin (Ang) II and platelet derived growth factor (PDGF), all appear to be involved in the pathogenesis of PD. β-Thymosins, pirfenidone, nitric oxide (NO) donors, phosphodiesterase (PDE)-5 inhibitors, matrix metalloproteinases (MMPs)/anti-tissue inhibitor of metalloproteinases (TIMP)-1 reduce collagen synthesis, while decorin, follistatin, and Smad 7 exert antifibrotic effects; all have been proposed for the treatment of PD. Alternative and/or novel approaches for the treatment of PD are needed in part because of the recognized multifactorial etiology of this complex disorder. A comprehensive approach for translating available experimental information into clinically effective drug trials for the treatment of PD is needed. We propose a multi-faceted approach for drug development to generate novel drug products for the treatment of PD.