Penile Stretching as a Treatment for Peyronie’s Disease: A Review

Research Advances in Stem Cell Therapy for Erectile Dysfunction

Erectile dysfunction (ED) is a common clinical condition that mainly affects men aged over 40 years. Various causes contribute to the progression of ED, including pelvic nerve injury, diabetes, metabolic syndrome, age, Peyronie's disease, smoking, and psychological disorders. Current treatments for ED are limited to symptom relief and do not address the root cause. Stem cells, with their powerful ability to proliferate and differentiate, are a promising approach for the treatment of male ED and are gradually gaining widespread attention. Current uses for treating ED have been studied primarily in experimental animals, with most studies observing improvements in erectile quality as well as improvements in erectile tissue. However, research on stem cell therapy for human ED is still limited. This article summarizes the recent literature on basic stem cell research on ED, including cavernous nerve injury, aging, diabetes, and sclerosing penile disease, and describes mechanisms of action and therapeutic effects of various stem cell therapies in experimental animals. Stem cells are also believed to interact with host tissue in a paracrine manner, and improved function can be supported through both implantation and paracrine factors. To date, stem cells have shown some preliminary promising results in animal and human models of ED.

Assessment of Conservative Combination Therapies for Active and Stable Peyronie's Disease: A Systematic Review and Meta-analysis

CONTEXT

In patients with Peyronie's disease (PD), oral, injected, or topical agents provide limited efficacy. In this setting, combination of two or more conservative treatments may improve symptoms further.

OBJECTIVE

To explore the effects of available conservative combination therapies for active and stable PD through a systematic review and meta-analysis.

EVIDENCE ACQUISITION

We searched multiple databases and sources of gray literature until June 2021. We included randomized or observational comparative studies assessing any conservative combination therapies for PD. We undertook a random-effect meta-analysis when at least two studies employed the same treatment modality (PROSPERO: CRD42021224517).

EVIDENCE SYNTHESIS

Overall, 13 studies on active PD and ten on stable PD (1962 participants) were included. Most included studies raised methodological concerns. In patients with active or stable PD, the available evidence is inconclusive to support the use of any combination treatment modality, such as intralesional verapamil injections, antioxidants, and other oral, injected, or topical agents. Based on data availability, we performed a meta-analysis to compare the effect of collagenase Clostridium histolyticum (CCH) plus adjunctive mechanical therapies (penile traction or vacuum pump) versus CCH monotherapy on penile curvature and length in patients with stable PD. CCH and adjunctive mechanical therapies resulted in an additional decrease of 0.3° in penile curvature (95% confidence interval [CI]: -3.97 to 4.49, I² = 0%) and in an increase of 0.5 cm in penile length (95% CI: -0.32 to 1.4, I² = 70%) compared with CCH monotherapy.

CONCLUSIONS

The available combination treatment modalities, including the addition of adjunctive mechanical therapies to CCH, do not improve symptoms further compared with monotherapy and should not be implemented in patients with active or stable PD. Further high-quality randomized trials combining only recommended treatments are mandatory.

PATIENT SUMMARY

Despite the interest in and optimism for combination treatment modalities, the road to an effective conservative therapy for Peyronie's disease still seems long.

Intratunical injection of rat-derived bone marrow mesenchymal stem cells prevents fibrosis and is associated with increased Smad7 expression in a rat model of Peyronie's disease

Objective

Peyronie’s disease (PD) is a fibrotic disorder of the penis, but effective treatments are lacking. Here, we observed the effects of rat-derived bone marrow mesenchymal stem cells (BMSCs) injection in the active phase and chronic phase in a rat model of PD, and the possible mechanism was analysed with fibroblasts derived from rat penile tunica albuginea (TA).

Methods

Thirty-two male Sprague-Dawley rats were divided into four groups. In sham group, the rats were injected with 50 µL of vehicle. In the PD group, the rats were injected with 50 µg TGF-β1. In the PD + BMSCs early treatment group, the rats were injected with 50 µg TGF-β1 and injected with 1 × 10⁶ BMSCs after 1 day. In the PD + BMSCs late treatment group, the rats were injected with 50 µg TGF-β1 and injected with 1 × 10⁶ BMSCs after 28 days. Twenty-seven days after the last injection, the erectile function of the rats was measured, and then, penile fibrosis was analysed by histology and western blot. In vitro, fibroblasts derived from rat penile TA were used to identify a possible antifibrotic mechanism of BMSCs, and a Smad7 expression vector was used as a positive control. Fibroblasts were pretreated with the Smad7 expression vector or BMSCs for 48 h and then activated with 10 ng/mL TGF-β1 for 24 h. Cells viability was assessed, and Smad7, collagen 3, elastase-2B and osteopontin expression levels were analysed by immunofluorescence and western blot. Furthermore, fibroblasts were transfected with Smad7 siRNA or scramble control to observe whether the effects of BMSCs could be offset.

Results

Erectile function obviously improved, and fibrosis of penile TA was prevented after BMSCs treatment compared with that in the rats with PD. Furthermore, the effects of BMSCs treatment in the active phase were better than those in the chronic phase. After cocultured with BMSCs, cell viability was not affected, Smad7 expression was upregulated, and collagen 3, elastase-2B and osteopontin levels were decreased in the TGF-β1-treated fibroblasts. After transfection with Smad7 siRNA, the antifibrotic effects of BMSCs were offset.

Conclusions

The antifibrotic effects of BMSCs treatment in the active phase of the PD rat model were better than those in the chronic phase. A possible mechanism of BMSCs treatment was related to increased Smad7 expression, suggesting a possible effective and safe procedure for the treatment of PD.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13287-022-03090-w.

Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease

INTRODUCTION

Across many cultures, penis size has been associated with virility, and concerns about penile length are commonplace. Peyronie's disease (PD) is a known acquired cause of penile shortening.

OBJECTIVES

This paper describes the psychosocial impacts of penile length on men and their partners, both generally and in men with PD, and evaluates the effect of PD treatments (eg, collagenase clostridium histolyticum , surgery, mechanical therapy) on this outcome measure.

METHODS

A PubMed database search was performed for English language articles through July 2021. Main outcome measures were association of penile length with emotional well-being, selfesteem, and relationship satisfaction in men with PD, and change from baseline penile length after treatment.

RESULTS

Shortened penile length caused by PD can negatively impact patient and partner quality of life, including effects on body image, emotional well-being, sexual function, and interpersonal relationships. In men with PD, studies have demonstrated an association between loss of penile length and emotional problems, reduced satisfaction with sexual performance, poor self-esteem, depression, and relationship difficulties. Loss of penile length can frequently occur after surgery for PD (including plication, plaque incision/excision with grafting, and penile implant). Advanced surgical techniques may preserve/increase penile length, but the increased risks associated with these complex procedures must be carefully considered. Treatment with collagenase clostridium histolyticum does not appear to negatively impact penile length, and 5-year follow-up data suggest potential longterm posttreatment improvements in this outcome measure. Penile traction therapy, either alone or as adjunctive therapy, may increase penile length in men with PD, but nonadherence may limit improvement.

CONCLUSION

Changes in penile length are important to many men, particularly those with PD, and should be considered during PD treatment selection. Penile length should be measured objectively before and after treatment for PD and should be included as an outcome measure in future studies on treatment effectiveness. Goldstein I, Gelbard MK, Lipshultz LI. Clinical Significance of Shortened Penile Length and Alterations in Penile Length Following Treatment for Peyronie's Disease. Sex Med Rev 2022;10:409-420.

Indications and characteristics of penile traction and vacuum erection devices

A variety of devices are available for the management of patients with erectile dysfunction, Peyronie's disease, penile dysmorphophobia, for support before and after penile prosthesis insertion, and after radical prostatectomy. Traction devices include, but are not limited to, Penimaster PRO (MSP Concept, Berlin, Germany), Andropenis and Andropeyronie (Andromedical, Madrid, Spain), and the Restorex (PathRight Medical, Plymouth, USA). The other type of devices are vacuum devices such the Osbon ErecAid (Timm Medical, MN, USA). Different devices are optimal for different clinical applications, and robust and contemporary clinical data show a variety of strengths and weaknesses for each device. Research currently favours the use of traction devices for improvement of penile curvature and erectile function in patients with Peyronie's disease compared with vacuum devices; Penimaster Pro and Restorex have been shown to be associated with the best outcomes in this indication. Vacuum devices are favoured for treatment of erectile dysfunction and penile length loss after radical prostatectomy; the Osbon ErecAid is the most well-studied device for this indication. Research into other uses of vacuum and traction devices, such as for penile dysmorphophobia or before and after penile prosthesis, is very limited. Compliance, cost and availability remain substantial challenges, and further high-quality evidence is required to clarify the role of traction devices in urology and sexual medicine.

Multiple plaque incisions with or without grafting for Peyronie's disease

Objectives

To assess novel surgical techniques in management of Peyronie's disease.

Subjects

Forty-three men underwent corrective surgery using either partial plaque incision and nongraft (PPING) or multiple plaque incisions and graft (MPIG). The technique used was determined intra-operatively. Patients were assessed at baseline and follow-up based on Peyronie's disease questionnaire patient-reported outcome measure (PDQ-PROM) and erectile function.

Results

The two groups were well matched in age and erectile function. At baseline MPIG group had greater deformity and poorer patient-reported outcome. Penile curvature improved from 67.9° to 10.5° in the PPING group and 77.9° to 7.1° with MPIG. PDQ-PROM improved from 29 to 13 in those who underwent PPING and 38.5 to 17.6 in those undergoing MPIG. Erectile function was preserved in both groups.

Conclusions

These novel surgeries are effective in restoring penile shape and length while preserving erectile function. This is reflected in improved patient-reported outcomes. These findings should be verified by multi-institutional study.

Update on the Penuma® an FDA-cleared penile implant for aesthetic enhancement of the flaccid penis

The Penuma® implant is a medical-grade silicone implant surgically inserted subcutaneously to provide cosmetic improvement of the penile aesthetic. The principal author was invited to provide an update on the usage of the Penuma® implant for penile aesthetics. He collected as yet unpublished data, which is undergoing synchronous submission to Urologic meetings and peer-reviewed publications by a variety of authors for this communication. The objective of this article is to provide updated information regarding the Penuma® aesthetic penile implant. A new scrotal method of implantation named "concealed" is emerging. Through physician comparison of various factors prior to and after the scrotal method intervention, early findings suggest this approach seems to have less visible scar, is quicker and is followed by less seroma formation. As the device is now surgically implanted by surgeons other than its inventor, new developments have appeared authenticating the original published paper in 2018. Patients were contacted via phone and were asked five questions regarding satisfaction with the responses recorded. This new multicenter study shows findings of high patient and partner satisfaction coupled with acceptable adverse outcomes similar to the single-surgeon study. A new penile rehabilitation program has been developed with the aim for the penis appearance to be restored to its pre-operative state if the Penuma® is removed. 12 patients who underwent penile implant removal were followed for 6 months while participating in the penile rehabilitation program. The discipline worked in patients who desired removal for dissatisfaction and is currently under evaluation in patients who require device removal for medical reasons, e.g., infection or suture-related issues. Through new developments, the acceptance of Penuma® in the prosthetic community seems to be further solidified.

Peyronie's disease: pharmacological treatments and limitations

Introduction: Peyronie's disease (PD) is a disorder of the tunica albuginea from disordered and excessive deposition of collagen resulting in a palpable scar, pain, erect penile deformity and erectile dysfunction that significantly impacts patients both physically and emotionally.Areas Covered: Several treatment options have been described for PD, including shockwave therapy, traction therapy, both oral and intralesional pharmacological options, and surgery. This review seeks to examine the data for different types of non-surgical treatments for PD. We review how various treatment modalities impact several relevant clinical endpoints for Peyronie's disease, including effects on pain, penile curvature, plaque formation, and erectile function. We performed a literature search using PubMed and SCOPUS while referencing AUA, EAU, and CUA guidelines for management of Peyronie's Disease for studies published 1980-2020.Expert opinion: Intralesional collagenase injections have the strongest evidence and are the only FDA approved intralesional treatment for PD. Penile traction therapy (PTT) is low risk and may be beneficial in patients willing to invest significant time using the devices. Furthermore, oral combination therapy with other modalities may provide some benefit. Further investigation is required to better understand pathophysiology of PD and clarify the therapeutic utility of existing treatments, potentially with a multimodal strategy.

Conservative Therapy for Peyronie's Disease: a Contemporary Review of the Literature

PURPOSE OF REVIEW

To analyze the literature on current conservative treatment options for Peyronie's disease (PD).

RECENT FINDINGS

Conservative therapy with intralesional collagenase clostridium histolyticum (CCH) is safe and efficacious in either the acute or chronic phases of PD. Combination treatment with penile traction therapy (PTT) can produce even better results. While most PTT devices require extended periods of therapy up to 8 h per day, the RestoreX® device can be effective at 30-90 min per day. A variety of conservative therapies are available for treatment of PD. The available literature does not reveal any treatment benefit of oral therapies. Intralesional therapy is the mainstay conservative treatment of PD. Intralesional CCH therapy is the first Food and Drug Administration-approved intralesional therapy and represents the authors' preference for medical therapy. The most effective conservative management of PD likely requires a combination of therapies.

Intralesional injection of the calcium channel blocker Verapamil in Peyronie's disease: A critical review

OBJECTIVE

To assess the effectiveness of an intralesional injection of verapamil in men with Peyronie's disease (PD).

MATERIALS AND METHODS

The data provided in the current review are based on a thorough review of the available original articles on PD retrieved with a systematic literature search using PubMed- Medline, and the Cochrane Central Register of Controlled Trials, up to December 2019, to identify studies dealing with Peyronie's disease and its treatment. Included were only original articles, that we thoroughly evaluated. We searched for the primary and secondary terms of: "Peyronie's disease," "Penile curvature," "Erectile dysfunction," "Verapamil and Peyronie's disease," "Calcium channel blocker," and "Intralesional injection."

RESULTS

The initial search of the databases yielded a total of 1240 studies (PubMed: 1058; Cochrane: 182), as of December 2019. Seventy studies were removed due to duplication. Further 986 studies were removed due to not being in English (except for one study by Arena F. for which we got a translation form Italian), being about animal experimentations, not being full-text, and not being clinical trials. Likewise, studies not referring at all to verapamil were excluded (148). From the remaining 36 full-text articles we focused on 13 studies which met the inclusion criteria, mainly being deemed relevant to the context of this study.

CONCLUSIONS

Calcium channel blockers have been shown in both in vitro and in vivo studies to inhibit the synthesis and secretion of extracellular matrix molecules, as well as to increase collagenase activity. Patients with localised plaque are the best candidates for intralesional injections of verapamil. The beneficial effects of intralesional verapamil are apparent within the first three months. For patients who respond to treatment, the injections should be continued for six months. Patients who fail to respond to intralesional verapamil or whose angulation is greater than 30° at presentation should be considered candidates for surgery. Injection of verapamil is clinically safe for patients with Peyronie's disease, and it appears to induce a rapid, beneficial effect in patients for the reduction of plaque size. Intralesional verapamil injection for Peyronie's disease could reduce pain, decrease penile curvature, and improve sexual function.

Peyronie's Disease Intervention Studies: An Exploration of Modern-Era Challenges in Study Design and Evaluating Treatment Outcomes

INTRODUCTION

Peyronie's disease (PD) is characterized by pain, deformity, sexual dysfunction, and psychological bother. Several treatments are available with varying levels of efficacy, and significant limitations exist with the currently available literature.

AIM

To explore modern-era methodological challenges inherent to PD research as they pertain to intervention studies.

METHODS

We performed a critical review of the PD intervention literature to identify common methodological challenges with emphasis on aspects of patient assessment and treatment outcomes, study design, and statistical analysis. The key objective was to provide an impetus on which to build future research protocols, rather than focus on weaknesses with any individual studies.

MAIN OUTCOME MEASURE

Expert opinion was used to summarize limitations with commonly reported objective outcomes such as penile curvature, girth, and length along with imaging modalities and objective questionnaires. Appropriate study design and statistical analysis were also reviewed to discuss common pitfalls in the PD literature.

RESULTS

There are multiple shortcomings inherent to studying objective PD outcomes such as penile curvature, girth, and length. These include lack of standardized protocols for preintervention and postintervention assessment, interobserver and intraobserver variability, and lack of consistent definitions for what defines an objective outcome as clinically "meaningful" for patients. Similarly, imaging studies including penile ultrasound are subject to marked variation, thereby limiting their utility to measure predefined primary or secondary study outcomes including cavernosal artery hemodynamics and penile plaque size. Objective and validated questionnaires such as the Peyronie's Disease Questionnaire and International Index of Erectile Function require that patients have recently engaged in sexual activity, which is challenging for many patients as a result of penile deformity with PD. Finally, careful study design and statistical analysis (including appropriate study power) are imperative to ensure reliable results. Current shortcomings in the majority of studies contribute to the low level of evidence available for most PD interventions.

CLINICAL IMPLICATIONS

Future PD intervention studies should focus on optimizing study design and statistical analysis. Furthermore, authors must incorporate standardized protocols for assessing preintervention and postintervention outcomes.

STRENGTH & LIMITATIONS

The current analysis and recommendations for future study are based on the expertise and opinion of the manuscript authors.

CONCLUSION

Multiple areas of weakness in study design, statistical analysis, and patient outcomes assessment limit the reliability of data derived from PD intervention studies in the modern era. The global themes identified herein should serve as a basis upon which to build future research protocols. Ziegelmann MJ, Trost LW, Russo GI, et al. Peyronie's Disease Intervention Studies: An Exploration of Modern-Era Challenges in Study Design and Evaluating Treatment Outcomes. J Sex Med 2020;17:364-377.