Sexual dysfunction in Peyronie's disease: an analysis of 222 patients without previous local plaque therapy

Use of thermographic imaging for the evaluation of erectile dysfunction and Peyronie's disease

Thermographic imaging is a technique to measure infrared radiation to report temperature and has been used in prior research to assess sexual arousal by measuring genital temperature. We hypothesized this can be used quantitatively to assess erectile function. We conducted an observational clinical trial of this technique by performing thermographic imaging in the flaccid and erect state and compared these values with hemodynamic measurements performed by penile Doppler/duplex ultrasound (PDDU). We also hypothesized that in men with Peyronie's disease (PD), the plaque would be visible on thermographic imaging and took thermographic measurements in this area for patients with PD. Any man scheduled to undergo PDDU in our urology clinic was approached for recruitment. PDDU was performed by one of two experienced urologists. We recruited 30 men for this study. Seven of these men had PD. The change in measured temperature between flaccid and erect states correlated significantly with the peak systolic velocity r = 0.46 (p = 0.025). In the seven men with PD the mean change in temperature of the plaque was +0.9 °C versus +2.1 °C in the normal penis (p = 0.28). Thermographic imaging shows a significant correlation with objective hemodynamic measurements on PDDU.

Clinical Anatomy of the Superficial Preprostatic Vein and Accessory Pudendal Artery in Robot-Assisted Radical Prostatectomy

Purpose: We herein describe the superficial preprostatic vein (SPV) anatomy and determine its relationship with the accessory pudendal artery (APA). Materials and Methods: We reviewed 500 patients with localized prostate cancer who underwent conventional robot-assisted radical prostatectomy between April 2019 and March 2023 at our institution. SPV was defined as "any vein coming from the space between the puboprostatic ligaments and running within the retropubic adipose tissue anterior to the prostate toward the vesical venous plexus or pelvic side wall." While APA was defined as "any artery located in the periprostatic region running parallel to the dorsal vascular complex and extending caudal toward the anterior perineum." The intraoperative anatomy of each SPV and APA was described. Results: SPVs had a prevalence rate of 88%. They were preserved in 252 men (58%) and classified as I-, reversed-Y (rY)-, Y-, or H-shaped (64%, 22%, 12%, and 2%, respectively) based on their intraoperative appearance. Overall, 214 APAs were found in 142 of the 252 men with preserved SPV (56%; 165 lateral and 50 apical APAs in 111 and 41 men, respectively). SPVs were pulsatile in 39% men perhaps due to an accompanying tiny artery functioning as a median APA. Pulsations seemed to be initially absent in most SPVs but become apparent late during surgery possibly due to increased arterial and venous blood flow after prostate removal. Pulsations were common in men with ≥1 APA. Conclusions: This study, which described the anatomical variations in arteries and veins around the prostrate and their preservation techniques, revealed that preserving this vasculature may help preserve postprostatectomy erection. ClinicalTrials: The Clinical Research Registration Number is 230523D.

Clinical Presentation of Peyronie's Disease: A Retrospective Study of 564 Cases

Peyronie's disease (PD) affects the penile albuginea, resulting in penile deformity, pain, erectile dysfunction (ED), and an anxious-depressive state. PD diagnosis involves a thorough medical history, penile palpation, documentation of the penile deformation, a dynamic penile echo color Doppler ultrasound (PCDU), and the completion of questionnaires for the evaluation of pain, ED, and psychometric tests. The aim of this study was to evaluate the symptoms of PD and their prevalence in PD patients in the active phase who had access to our andrology clinic. Inclusion criteria: availability of data on patients diagnosed with PD, including detailed medical history, blood tests, penile palpation, photographic documentation of penile deformity, and penile PCDU. Exclusion criteria: PD patients in the stable phase or those without the specified tests and data mentioned above. Our study found a higher prevalence of PD in younger patients (24.2%), a higher coexistence of PD with chronic prostatitis (35.6%), a higher percentage of cases of association between penile deformity and penile curvature (84.4%), a higher prevalence of "significant anxiety" (88.4%), a higher presence of plaque calcification (35.6%), and the detection of a longer duration of the first phase of PD (>18 months). The most frequently observed type of penile curvature was dorsal, followed by left lateral, right lateral, and, less commonly, ventral. We observed a significant statistical correlation between patient age and IIEF score, indicating that patients over the age of 40 years are at a higher risk of experiencing ED. We found a strong statistical relationship between VAS score and age. As age increases, the VAS score decreases, suggesting that younger patients reported more penile pain compared to those who were older than 40 years. Furthermore, we found that penile pain has a significant impact on the psychological state of PD patients. We also found that 38.8% of PD patients suffered from severe anxiety. In relation to this, psychotherapy should be integrated into PD treatment to improve the quality of life and treatment adherence.

Daily low-dose tadalafil may reduce the penile curvature progression rate in patients with acute Peyronie's disease: a retrospective comparative analysis

The aim of this study was to evaluate the clinical outcomes of patients in acute phase of Peyronie's disease (PD) treated with daily low-dose of Tadalafil. An observational retrospective study involving patients in acute phase of PD with erectile dysfunction (ED) was designed. All subjects were offered Tadalafil 5 mg one tablet a day. Men who accepted treatment were compared to patients who refused Tadalafil. Penile curvature progression was chosen as the primary outcome. PD Questionnaire (PDQ) and IIEF-5 scores were selected as secondary outcomes. A total of 191 patients were included in the study (108 intervention vs. 83 control). Penile curvature progression rate was significantly lower in subjects taking Tadalafil at 12 weeks (25.9% vs. 39.7%, p = 0.042). Mean IIEF-5 score improved in the intervention group, becoming significantly higher compared to the observation group at 12 weeks (19.3 vs. 11.2 points, p < 0.001). Mean PDQ-Overall and PDQ-Penile Pain scores only improved in the intervention group and the statistically significant differences at baseline between groups became not statistically significant at 12 weeks (p = 0.001 vs. p = 0.232 and p < 0.001 vs. p = 0.078, respectively). Daily low-dose Tadalafil in patients with acute phase of PD seems to significantly reduce the penile curvature progression rate compared to observation, especially when it is administrated early. It also appears to improve erectile function and PD-related symptoms.

Measurement of Oxidative Stress Index (OSI) in Penile Corpora Cavernosa and Peripheral Blood of Peyronie's Disease Patients: A Report of 49 Cases

Peyronie's disease (PD) is a chronic inflammatory disease affecting the penile albuginea. Oxidative stress (OS) is important for the development of the disease; therefore, it seemed interesting to us to directly measure OS at both the site of the disease and in peripheral blood. For a precise OS study, it is necessary to evaluate not only the single results of the total oxidant status (TOS) and total antioxidant status (TAS) but also their ratio: OS index (OSI) (arbitrary unit) = TOS/TAS × 100. This study included 49 PD patients examined and diagnosed in our Peyronie's care center and a control group of 50 cases. We collected blood samples from both the penis and a vein in the upper extremity; we used d-ROMs and PAT-test (FRAS kit) for OS measurement. Pearson's study found a statistical correlation between penile OSI values and PD plaque volumes: p-value = 0.002. No correlation was found between systemic OSI values and PD plaque volumes: p-value = 0.27. Penile OSI values were significantly reduced after the elimination of the PD plaque (p < 0.00001). The mean value of the penile OSI indices in the PD patients after plaque elimination corresponded to 0.090 ± 0.016 (p = 0.004). The comparison between the penile OSI values of the PD patients (with plaque elimination) and the control group revealed no statistically significant differences (p = 0.130). The absence of a correlation between Peyronie's plaque volume and systemic OSI values indicates that it is preferable to carry out the OS study by taking a sample directly from the site of the disease. By carrying out a penile OSI study, it would be possible to obtain a precise plaque-volume-dependent oxidative marker. Even if the study did not demonstrate any correlation between OSI indices and anxious-depressive state, we detected a high prevalence of anxiety (81.6%) and depression (59.1%) in PD patients.

Congenital penile curvature as a possible risk factor for the onset of Peyronie's disease, and psychological consequences of penile curvature

OBJECTIVE

To investigate a possible relationship between a history of congenital penile curvature (CPC) and Peyronie's disease (PD), and to characterize the psychological profile of patients suffering from PD, with or without concomitant CPC.

METHODS

We included 519 patients with Peyronie's disease (PD), of which 73 were found to have underlaying CPC. As a comparator population, we selected 2166 patients without PD, referring to our tertiary care clinic. In this population we detected 15 subjects with CPC. All patients completed the GAD-7 (Generalized-Anxiety-Disorder - 7 questions) and the PHQ-9 (Patient-Health-Questionnaire - 9 questions) questionnaires.

RESULTS

The overall prevalence of CPC in PD-patients was 14.07%, compared to a prevalence of 0.69% in the non-PD control population (p < 0.00001). Moderate-to-severe anxiety was found to be present in 89.4% of all PD-patients. Significantly higher proportions of patients with CPC associated with PD showed severe anxiety, compared to patients with PD alone (57.5% vs. 36.7%, respectively, p = 0.0008). Moderate- severe depression was found to be present in 57.8% of all PD- patients. Significantly higher proportions of PD patients with a history of CPC showed severe depression, compared to patients with PD alone (13.6% vs. 3.36%, respectively, p < 0.0002). GAD-7 median scores were significantly higher in patients with more severe penile curvatures (> 45°; p = 0.029). We did not detect a statistically significant difference between PHQ-9 medi- an scores based on the severity of PD (p = 0.53). Analysis of PHQ-9 and GAD-7 median scores showed significantly worse depressive and anxious symptoms in younger patients (p < 0.001 and p = 0.0013, respectively).

CONCLUSIONS

The presence of congenital-penile-curvature may represent a risk factor for the subsequent onset of Peyronie's disease. Moderate/severe anxiety and moderate/severe depression were reported in a high fraction of cases. Anxiety was significantly higher in patients with more severe penile-curvatures, and depression was present independently of the degree of penile curvature. Depression and anxiety were found to be more severe in younger subjects.

Disappearance of Plaque Following Treatment with Antioxidants in Peyronie's Disease Patients-A Report of 3 Cases

Peyronie's disease (PD) is a fibrotic disorder of the penile tunica albuginea. To date, only a few cases of recovery from PD following medical treatment have been reported in the literature. In this article, we describe three new cases of PD where patients achieved complete resorption of plaque following multimodal antioxidant treatment. In all three cases, treatment included the following antioxidants: bilberry, propolis, ginkgo biloba, silymarin, and vitamin E. Only in case nos. 1 and 2 did we also use the following antioxidant substances: L-carnitine, coenzyme Q10, and Boswellia. In all three cases, we also used a local therapy with diclofenac gel. Only in case no. 2 did we also use periodic perilesional injections with pentoxifylline. Although the sample of cases presented here was small, these patients incontrovertibly experienced complete plaque disappearance and recovery (in one case, only after a short course of treatment). Therefore, it is our conviction that urologists may find our experiences of considerable interest in their clinical practices.

Patients with Peyronie's disease achieve complete plaque regression after multimodal treatment with antioxidants: a case series

BACKGROUND

Peyronie's disease is a chronic inflammatory condition of the corpora cavernosa characterized by the formation of plaque in the tunica albuginea, which results in penile deformity. Conservative medical approaches encompass oral, topical, and physical treatment. Only two cases of patients with Peyronie's disease with complete plaque regression after treatment have been described in literature.

CASE PRESENTATION

Case 1: A 50-year-old Caucasian man with penile pain and double penile curvature of 5° (left ventrolateral), palpable nodule, and normal penile rigidity. The patient underwent multimodal therapy (oral antioxidants + topical diclofenac gel). At follow-up after over 4 years of treatment, the patient no longer complained of any penile deformity or pain. Ultrasound examination did not show any plaque. Case 2: A 26-year-old Caucasian man with lateral-right penile curvature of 30° (previous congenital curvature of 15°), palpable nodule, and normal penile rigidity. The patient underwent multimodal therapy (oral antioxidants + topical diclofenac gel + penile injections/pentoxifylline). After 28 months of treatment, the patient presented a lateral right curve of 15° at follow-up, similar to the original congenital penile curvature. Ultrasound examination no longer showed any plaque. Case 3: A 36-year-old Caucasian man with penile pain and a complex penile curvature of 15° and 20° (left dorsolateral), palpable nodule, and normal penile rigidity. The patient underwent multimodal therapy (oral antioxidants + topical diclofenac gel + penile injections/pentoxifylline). At follow-up after 28 months of treatment, the patient presented a dorsal curve (10°) similar to the original congenital curvature. Penile palpation did not detect any nodules, and ultrasound no longer showed any plaque.

CONCLUSIONS

This study demonstrates that our multimodal therapy is able to completely regress plaque, as demonstrated in our previously published article. Peyronie's disease has the potential to be treated conservatively with good results. However, this method of treatment needs to be combined with accurate ultrasound assessment, performed using a sufficiently advanced machine by an experienced operator.

Full Regression of Peyronie’s Disease Plaque Following Combined Antioxidant Treatment: A Three-Case Report

Peyronie’s disease (PD) is a fibrotic disorder of the tunica albuginea of the penis. Conservative medical therapy includes oral and/or injective active substances. Until now, only two PD patients who recovered after medical treatment are described in the literature. This article describes three new cases of PD patients who achieved complete resorption of plaque following antioxidant treatment. Case Presentations: Case 1. The patient was a 34-year-old man, a smoker, with lateral-left penile curvature (40 degrees), penile pain, and good penile rigidity. The patient was treated with combined therapy (oral antioxidants + Propolis creme). At follow-up, after about 29 months of treatment, we observed the disappearance of the acquired penile deformity. The ultrasound examination no longer showed any plaque. Case 2. The patient was a 32-year-old man with chronic prostatitis, penile lichen sclerosus, lateral-left penile curvature (10 degrees), a palpable lump, and good penile rigidity. The patient was treated with combined therapy (oral antioxidants + Propolis creme + penile injections of pentoxifylline). After 33 months of treatment, at follow-up, we observed the disappearance of the penile deformity. Ultrasound examinations no longer showed any plaque. Case 3. The patient was a 33-year-old man with penile pain, dorsal penile curvature (30 degrees), and good penile rigidity. The patient was treated with combined therapy (oral antioxidants + Propolis creme + penile injections of pentoxifylline). At follow-up, after 41 months of treatment, the penile pain was no longer present, and the ultrasound study no longer showed any plaque. Conclusions: Although our study presents a limited number of cases, it is a matter of fact that these patients obtained full regression in the affected area. We believe our experience may be very useful for urological clinical practice.

Urologists' knowledge base and practice patterns in Peyronie's disease. A national survey of members of the italian andrology society

Peyronie's disease is a chronic inflammatory disease involving the formation of plaque in the tunica albuginea of the corpora cavernosa, resulting in penis deformity. It is often associated with penile pain, especially in younger patients, but it is not rare for pain to be absent; the disease is also associated with erectile dysfunction and a depressive state in a large percentage of cases.

OBJECTIVE

Aim of our study was to explore the basic knowledge base and diagnostic and therapeutic practice patterns in Peyronie's disease (PD) of a large number of physicians belonging to the Italian Andrology Society (SIA).

METHODS

Our survey is based on two questionnaires which were e-mailed to the members of the SIA. The first questionnaire explored diagnostic and therapeutic practice patterns of SIA physicians, while the second questionnaire focused on their knowledge of the disease, as well as their training and level of experience in the specific field. We then planned to compare our outcomes with similar PD surveys from other countries.

RESULTS

The first questionnaire was answered by 142 SIA physicians. The second questionnaire was answered by 83 SIA physicians. Most respondents (74.6%) chose penile ultrasonography as first-line diagnostic approach and 47.1% prefer to perform a color Doppler ultrasound after pharmaco-induced erection. Concerning the therapeutic practice patterns in active stage of the disease, most respondents (99.29%) prefer conservative medical therapy. Additionally, most respondents (64.78%), when failure of conservative treatment had been established, considered surgical treatment necessary, specifically corporoplasty, which may be associated with other techniques.

CONCLUSIONS

The results of our survey show that, in comparison to their foreign counterparts, Italian SIA uro-andrologists have a more proactive diagnostic approach right from when patients first present. When PD is still in its active stage, SIA uro-andrologists mostly opt for medical therapy. In advanced disease or if conservative treatment fails, our survey indicates a greater preference for surgical treatment. Answers to the theoretical knowledge questions showed that SIA physicians have a good understanding of the disease's etiology, epidemiology, and clinical picture, and of the appropriate indications for treatment.

Sonography of the penis/erectile dysfunction

Erectile dysfunction (ED) is defined as the persistent inability to achieve and/or maintain an erection for a satisfactory sexual activity. It is secondary to several organic, psychogenic, and combined causes, and represents a serious health dilemma affecting both men and their partners. The diagnostic approach to erectile dysfunction has significantly changed in the last years with the advent of phosphodiesterase-5 (PDE5) inhibitors, and with the recognition that surgical treatment of both arterial insufficiency and penile venous leak have poor long-term clinical outcomes. Although imaging modalities have diminished in importance, differentiating among causes of erectile dysfunction remains mandatory in good medical practice, and ultrasound (US) still remains the cornerstone of the diagnostic workup. US provides an objective, minimally invasive evaluation of penile hemodynamics. Moreover, it provides an excellent depiction of the penile anatomy and of its changes in pathological conditions such as in patients with Peyronie's disease, priapism, and posttraumatic erectile dysfunction.

The role of inflammatory parameters (neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio, and monocyte-to-eosinophil ratio) in patients with Peyronie's disease

OBJECTIVES

The aim of the study was to investigate the ability of the systemic inflammatory parameters to predict the discrimination of the phases of Peyronie's disease (PD).

MATERIALS AND METHODS

Demographic, clinical, and laboratory data from 156 patients with PD were analyzed. A complete blood count (CBC) was obtained for every patient, and the neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), and monocyte-to-eosinophil ratio (MER) were calculated for every men. Subsequently, patients were divided into two groups based upon the phase of the disease.

RESULTS

The mean age was 51.9 ± 9.6 in all study population. The mean duration between symptom onset and patient evaluation was 4.2 ± 3.2 months in acute phase group, while it was 32.7 ± 31.7 months in chronic phase group (p < 0.001). There were no significant differences between the groups according to comorbidities such as diabetes, hypertension, lipid abnormalities, ischemic heart disease, smoking, and alcohol consumption. There was a statistically significant difference in NLR and PLR between two groups (p = 0.008, p = 0.008, respectively). NLR and PLR were significantly correlated with discrimination status in univariate analysis (p = 0.003, p = 0.005, respectively). Multivariate regression analysis revealed that NLR was the only independent risk factor for discrimination of the phases of PD (p < 0.001). The ROC analysis revealed a cutoff value of 1.8 (AUC 0.712, p < 0.001; sensitivity 61.1%; specificity 75.0%) for the NLR.

CONCLUSION

Our study demonstrated that NLR could be helpful to differentiate the chronic phase from the acute phase in patients with PD. Therefore, NLR could be used as an objective biomarker to the management of the disease and choosing the appropriate treatment.

Ultrasound on Erect Penis Improves Plaque Identification in Patients With Peyronie's Disease

OBJECTIVES

To compare the sensitivity of identification of penile plaques in the erect and flaccid penises by ultrasound in patients with Peyronie's disease (PD).

MATERIALS AND METHODS

A total of 75 PD patients were screened by palpation and ultrasonography for penile lesions in both flaccid and erect penises induced by prostaglandin E1 (PG-1) injection.

RESULTS

A total of 138 lesions were identified by ultrasound in the erect penises induced by injection of PG-1. However, only 74.6% of the lesions (103) were detectable by the palpation of the flaccid penises, and 84.1% (116) by ultrasound of the flaccid penises. The ultrasound confirmed 99 of the palpated lesions in the flaccid penises. The detection rate of lesions in drug-induced erect penises by ultrasound was significantly higher than those in the flaccid penises by the ultrasound (P < 0.01) or palpation (P < 0.0005) The type of penile lesions identified by ultrasonography included tunical thickening, calcifications, septal fibrosis, and intracavernosal fibrosis. The ratios of these lesions confirmed by ultrasound were 52.6, 33.6, 6.0, and 7.8%, respectively, in the flaccid penises, and 55.8, 28.3, 8.7, and 7.2%, respectively, in the erect penises.

CONCLUSION

Drug-induced erection can be used in suspicious PD patients when penile lesion is not identified by palpation or ultrasound in the flaccid penis.

Recent Pathophysiological Aspects of Peyronie's Disease: Role of Free Radicals, Rationale, and Therapeutic Implications for Antioxidant Treatment-Literature Review

Peyronie's disease (PD) is a chronic inflammation of tunica albuginea of the corpora cavernosa that causes an inelastic plaque resulting in penis deformation. Although its etiology is not completely known, there is general consensus that PD is genetically transmitted and secondary to penile trauma. In recent years, numerous studies demonstrated the role played by oxidative stress in PD pathogenesis, and other studies have described successful use of antioxidants in PD treatment. Oxidative stress is an integral part of this disease, influencing its progression. In the early stages of PD, the inflammatory infiltrate cells produce high quantities of free radicals and proinflammatory and profibrotic cytokines, with consequent activation of transcription factor NF-κB. While conservative therapies commonly used in the early stages of PD include oral substances (Potaba, tamoxifen, colchicine, and vitamin E), intralesional treatment (verapamil, interferon, steroids, and more recently collagenase clostridium histolyticum-Xiaflex), and local physical treatment (iontophoresis, extracorporeal shock wave therapy, and penile extender), the significant results obtained by emerging treatments with the antioxidants cited in this article suggest these therapeutic agents interfere at several levels with the disease's pathogenetic mechanisms. Antioxidants therapy outcomes are interesting for good clinical practice and also confirm the fundamental role played by oxidative stress in PD.

Prevalence, psychological impact, and risk factors of erectile dysfunction in patients with Peyronie's disease: a retrospective analysis of 309 cases

Peyronie's disease (PD) is a chronic inflammatory disease involving the tunica albuginea of the penis. Erectile dysfunction (ED) is a possible invalidating symptom of PD. The aim of this study was to evaluate the prevalence, psychological impact, and risk factors of ED in patients with PD. The study was conducted by carrying out a retrospective analysis of the clinical records of 309 patients with PD who visited our andrology clinic. All patients underwent the following tests: body mass index, common blood tests and hormone assays, questionnaire for erectile function assessment, dynamic penile color Doppler ultrasonography, imaging of the penis at maximum erection with photographic poses according to Kelâmi, psychosexual impact evaluation with PD Questionnaire (symptom bother score), evaluation of depression symptoms with the Patient Health Questionnaire-9, and evaluation of the intensity of penile pain with the pain intensity numeric rating scale. ED was observed in 37.5% of the cases. We divided the cases into two groups: group A (PD + ED), 116 cases, and group B (PD without ED), 193 cases. After multivariate analysis, we concluded that the following comorbidities are independent risk factors for ED: dyslipidemia, obesity, chronic prostatitis, benign prostatic hyperplasia, and autoimmune diseases. A depressive disorder was observed in 62.4%, and it was more frequent in patients with PD + ED (91.37% versus 45.07% group B). Sexual bother was greater in group A compared with group B (9.7 versus 7.6). Intensities of depressive symptoms and sexual bother were significantly higher compared with cases with no curvature when the bend angle was ≥30°. Our study confirms that an integrated psychological support with medical treatment is needed in patients with PD.

Peyronie's disease: a literature review on epidemiology, genetics, pathophysiology, diagnosis and work-up

Peyronie's disease (PD), a fibromatous disorder of the tunica albuginea of the penile corpus cavernosum, named after the French physician Francois de la Peyronie, is characterized by pain, plaque formation, penile curvature, and plaque calcification. The epidemiological data on PD is inconsistent, with recent reports stating a prevalence of up to 9%, and the condition affecting men of all ages, from teenagers to septuagenarians. We are just beginning to elucidate the role of genetics as a causative factor for PD. Chromosomal abnormalities and single-nucleotide polymorphisms have been shown to be associated with fibrotic diatheses. Tunical mechanical stress and microvascular trauma are major contributory factors to the pathophysiology of PD. The diagnosis of PD can be made using a combination of clinical history, physical examination and, sometimes, imaging modalities. A better understanding of the molecular pathophysiology of this condition remains paramount for the development of newer and more effective disease-targeted interventions.

The Efficacy of Medical Treatment of Peyronie's Disease: Potassium Para-Aminobenzoate Monotherapy vs. Combination Therapy with Tamoxifen, L-Carnitine, and Phosphodiesterase Type 5 Inhibitor

PURPOSE

This study was designed to evaluate the efficacy of medical treatment of Peyronie's disease.

MATERIALS AND METHODS

A total of 109 patients with Peyronie's disease who had been treated from January 2011 to December 2014 were retrospectively reviewed in this study. Forty-four patients (Group 1) were treated with 12 mg of potassium para-aminobenzoate daily. Sixty-five patients (Group 2) were treated with combination therapy: tamoxifen (20 mg) and acetyl-L-carnitine (300 mg) twice daily in addition to a phosphodiesterase type 5 inhibitor. Ability to perform sexual intercourse, pain during erection, size of plaque, and penile curvature angle were assessed.

RESULTS

In Group 1, 30 of 44 patients (68.2%) discontinued treatment within 12 weeks, while 5 patients (7.7%) in Group 2 discontinued treatment. Pain during erection and plaque size were improved in both groups but showed no statistical difference due to the high dropout rate in Group 1. In both groups, penile curvature was improved, but demonstrated no statistical difference between the treatment groups. However, combination therapy demonstrated a better response rate in patients whose penile curvature angle was less than 30° (44.4% vs. 79.1%, p=0.048). The rate of successful sexual intercourse was significantly higher in Group 2 (42.8% vs. 78.3%, p=0.034). The number of patients who underwent surgical correction despite medical treatment was significantly higher in Group 1 (35.7% vs. 13.3%, p=0.048).

CONCLUSIONS

Early medical combination therapy in Peyronie's disease may present better results in patients whose curvature angle is less than 30°.

Investigation of erectile dysfunction

Erectile dysfunction (ED) represents a common and debilitating condition with a wide range of organic and non-organic causes. Physical aetiologies can be divided into disorders affecting arterial inflow, the venous occlusion mechanism or the penile structure itself. Various imaging modalities can be utilised to investigate the physical causes of ED, but penile Doppler sonography (PDS) is the most informative technique, indicated in those patients with ED who do not respond to oral pharmacological agents (e.g. phosphodiesterase type 5 inhibitors). This review will examine the anatomical and physiological basis of penile erection, the method for performing PDS and features of specific causes of ED, and will also consider the alternative imaging modalities available.

Safety and Tolerability of Local Treatment with Iloprost in Patients with Peyronie's Disease. A Phase 1 Pilot Study and Proposal of a new Symptom Questionnaire

Purpose

Intralesional therapy is a less invasive method for the treatment of Peyronie's disease. The objective of this study was to evaluate safety and tolerability of intralesional injections of lloprost (I2 Prostacyclin analogue) for its property to suppress in fibroblasts CTFG (Connective tissue growth factor) production, which acts in concert with TGF-β to stimulate the fibrotic process.

Methods

Nineteen patients with Peyronie's disease were preliminarily evaluated by considering the degree of penile curvature, plaque size and local and systemic symptoms. Each patient then received weekly intralesional injections of 200ng of lloprost in 1 ml of normal saline for 4–5 weeks. If tolerated, the single dose increased weekly to the maximum of 400 ng (2 mL).

Results

The treatment has shown that all patients seem to well tolerate a 200 ng lloprost dose; 7 of them reached a 300 ng dose and 6 tolerate a 400 ng dose without showing side effects. There was no placebo control group in this study. To evaluate the efficacy of the treatment, the absence of objective parameters (except for the auto-photograph of penis in erection) led us to develop a subjective questionnaire that was given to all patients to assess sexual function, pain reduction, ecc.

Conclusions

Due to the relatively small size of the sample, the efficacy evaluation has been restricted to check the questionnaire reliability. Iloprost is well tolerated to a dose of 400ng in the local treatment of Peyronie's disease.

Stereological and biochemical analysis of muscular and connective tissue components in the penile corpus cavernosum adjacent to the fibrous plaque of Peyronie's disease

OBJECTIVE

To investigate the structural organization of the connective tissue in the corpus cavernosum (CC) adjacent to the fibrous plaque in Peyronie's disease (PD) using stereological and biochemical techniques, as most studies on PD have focused on the analysis of the fibrous plaque that forms in the tunica albuginea (TA). Because this fibrotic reaction is mediated by various inflammatory soluble factors, adjacent connective tissues might also be affected and this secondary effect might explain, for example, the erectile dysfunction that occurs in PD.

PATIENTS AND METHODS

During surgery biopsies were taken from the CC adjacent to the fibrous plaque and from the plaque itself in seven patients with PD (mean age 48.3 years). All the patients had normal erections. Control samples were similarly located samples from 'normal' penises obtained during autopsy of five men (mean age 52.3 years). Tissue samples were stained with Weigert's stain (elastic fibres), Van Gieson's stain (connective tissue), and Sirius red (collagen). Stereological analysis was done using a 42-point grid to determine volumetric densities (Vv). Total collagen content was estimated as micrograms of hydroxyproline per milligram dry CC.

RESULTS

The Vv of elastic fibres was significantly reduced in PD by 17.3% compared with controls, at a mean (sd) of 19.49 (3.27)% vs 23.56 (1.87)% (P < 0.05). While in PD the Vv of smooth muscle at 34.46 (2.06)% and connective tissue at 35.39 (6.15)% were not significantly different from those of controls at 38.38 (3.17)% and 38.02 (5.03)%, respectively. The Vv of elastic fibres in the fibrous plaque was decreased by 38.3% compared with the normal TA, at 20.25 (5.49)% vs 32.81 (4.75)% (P < 0.02). The mean (sd) collagen concentration in the CC from controls was 77.94 (24.26) microg/mg and in the patients with PD was 66.57 (19.39) microg/mg, which did not differ significantly. Sirius red-stained sections under polarized light showed that, in the normal CC, collagen-associated colours were homogeneously distributed. However, in the PD samples, stained collagen had a disrupted orientation and had a more heterogeneous birefringence, implying looser collagen bundles.

CONCLUSIONS

The quantitative analyses indicated that collagen in the CC close to the fibrous plaque was not affected, although its organization was noticeably altered. The CC elastic fibres were reduced though, and there was a similar change in the fibrous plaque of the TA. These results suggest that, although occurring primarily in the TA, the PD fibrous plaque may induce changes in the adjacent CC.

Open Preliminary Randomized Prospective Clinical Trial of Efficacy and Safety of Three Different Verapamil Dilutions for Intraplaque Therapy of Peyronie’s Disease

OBJECTIVES

To investigate the efficacy and safety of three different dilutions of verapamil used in intraplaque injections in an attempt to reduce Peyronie's disease symptoms.

METHODS

A total of 77 patients (age 48 +/- 9 years) with chronic Peyronie's disease were randomized into three groups, each receiving 12 intraplaque injections (1 injection every 2 weeks) of 10 mg verapamil in different dilutions. Group 1 (27 patients) received verapamil 10 mg/4 mL, group 2 (24 patients) received verapamil 10 mg/10 mL, and group 3 (26 patients) received verapamil 10 mg/20 mL. The variables, assessed before and 8 months after therapy, were erectile function (assessed by semistructured interview), plaque size, peak systolic velocity, end-diastolic velocity, left and right cavernosal arteries (assessed with dynamic Duplex ultrasonography), pain (assessed with a pain scale), penile curvature (measured using a photograph of a pharmacologically induced full erection), and side effects. Analysis of variance and the chi-square test were used to analyze the differences among the groups.

RESULTS

No significant differences were found in the baseline values among the groups. The peak systolic velocity of the left and right cavernosal arteries was never significantly modified. The plaque area, penile curvature, erectile function, end-diastolic velocity of the left and right cavernosal arteries, and pain improved more significantly in group 3 than in groups 1 and 2. The side effects were ecchymosis, with no significant differences among the groups.

CONCLUSIONS

The dilution of verapamil significantly improved its efficacy in improving Peyronie's disease symptoms.

Measurement of Penile Curvature in Peyronie’s Disease Patients: Comparison of Three Methods

AIM

Peyronie's disease (PD) may be treated in a medical or surgical fashion. Factors involved in the decision of which treatment to choose include duration of disease and magnitude of penile deformity. Curvature can be measured using at-home photography (AHP), vacuum erection device (VED), or intracavernosal injection (ICI). This study was undertaken to determine the concordance between the three methods of deformity assessment. Patients were also questioned regarding the presence of erectile dysfunction (ED) based on self-report and the International Index of Erectile Function.

MATERIALS AND METHODS

A total of 68 men presented to their urologist after taking penile photographs from three angles during maximal erectile rigidity. In the office, a VED was used to induce erection, and a goniometer was utilized to measure degree of curvature. ICI with trimix was then used to induce artificial erection, which was measured with a goniometer as well.

RESULTS

There was a statistically significant difference in self-report curvature magnitude compared with measured ICI-assisted curvature. Curvature profiles included dorsal plaques in 50 patients (73.5%), ventral plaques in 10 (15%), and lateral in eight (11%). Using ICI, the mean curvature measured was 42 degrees. Mean degree of curvature using VED was 33 degrees, while that of photography was 34 degrees. Photographic measurements differed most from ICI in men with concurrent ED (P < 0.01), while vacuum device measurements were most inaccurate in men with curvatures of >60 degrees.

CONCLUSIONS

Our results show that the degree of curvature measured using vacuum-assisted device and AHP is underestimated as compared with the gold standard ICI. We therefore recommend that ICI be used to most accurately determine degree of deformity. If ICI is not available, it is imperative that the same manner of measurement be used between all patients in a study group, as well as during serial evaluation in a trial.

Single-blind, multicenter, placebo controlled, parallel study to assess the safety and efficacy of intralesional interferon alpha-2B for minimally invasive treatment for Peyronie's disease

PURPOSE

We investigated the efficacy and safety of intralesional interferon alpha-2b for the treatment of Peyronie's disease.

MATERIALS AND METHODS

A total of 117 consecutive patients with a mean age of 55.1 years who had Peyronie's disease were enrolled in a single-blind, multicenter, placebo controlled, parallel study to determine the efficacy and safety of intralesional interferon alpha-2b therapy (Schering, Kenilworth, New Jersey), including 62 who received placebo and 55 who received interferon alpha-2b. Saline (10 ml) in controls and interferon alpha-2b (5 x 10(6) U) were administered biweekly for 12 weeks. Each patient was evaluated for penile curvature, plaque size and density, penile pain, erectile function and penile hemodynamics before and after study completion. Improvement in these parameters was statistically compared between the groups.

RESULTS

A total of 53 patients in the control arm and 50 in the interferon alpha-2b arm completed the study. Improvement in penile curvature, plaque size and density, and pain resolution was significantly greater in patients treated with interferon alpha-2b vs placebo. The increase in mean International Index of Erectile Function scores was not significantly different between the groups. Penile blood flow improvement was observed in interferon alpha-2b treated patients but not in those who received placebo. The decrease in the number of penile vascular pathologies was significantly higher in interferon alpha-2b cases. Side effects, mostly flu-like symptoms, which were frequently noted in patients on interferon alpha-2b, were mild to moderate in degree and of short duration.

CONCLUSIONS

This single-blind, multicenter, placebo controlled, parallel study demonstrates that intralesional interferon alpha-2b at a dose of 5 x 10(6) units biweekly for 12 weeks is effective and safe as minimally invasive therapy for Peyronie's disease.

Erectile Function Profiles in Men With Peyronie’s Disease

PURPOSE

In this study we investigated the erectile function status of men presenting with Peyronie's disease.

MATERIALS AND METHODS

Demographics of patients regarding age, duration of PD, nature of deformity and comorbidities were compared between the patients with PD, with and without erectile dysfunction. Patients with erectile dysfunction underwent dynamic infusion cavernosometry/cavernosography. The hemodynamic profile of patients presenting with combined PD and ED were analyzed and compared between those with onset of ED before and after diagnosis of PD.

RESULTS

Of the 222 patients 78 had ED (35%) by self-report at presentation. The mean age of patients with PD and ED was 52 +/- 22 years old. Hypertension (71.5%), hyperlipidemia (60.4%) and smoking (49.2%) were the leading comorbidities in the entire group. Statistically significant differences were found between the groups with and without ED for hypertension (p = 0.02) and cigarette smoking (p = 0.009). Of 222 patients 45 (20%) had ED that predated PD onset (group 1) and 33 (15%) had ED that postdated the onset of PD (group 2). DICC showed normal hemodynamics in 14 of 78 patients (18%), arteriogenic insufficiency in 50 (64%) and corporoveno-occlusive dysfunction in 16 (20%). CVOD was evenly distributed between groups 1 and 2, whereas arteriogenic ED was significantly higher in group 1 (82%). Site specific leak was seen in 4 of 33 (12%), all group 2 patients.

CONCLUSIONS

Patients in whom ED postdates the onset of PD are more likely to have normal erectile hemodynamics. Site specific leak is an uncommon contributor to PD and is seen only in the patients with PD in whom ED postdated PD onset. The leading vascular etiology of ED in PD is arteriogenic in older patients and those with greater associated comorbidities.

Early echographical assessment of minimal lesions of cavernosum corpora and tunica albuginea in subjects with erectile dysfunction, suggestive of La Peyronie's disease

The aim of the study is to evaluate the incidence and the echographic characteristics of minimal lesions of cavernosum corpora and tunica albuginea (TA) in subjects reporting erectile dysfunction (ED), which could suggest the suspicious of La Peyronie's disease (LPD). In total, 185 patients (pts) underwent dynamic penile Ultrasound Color Doppler (USCD) for ED. None of the pts presented any clinical symptoms or any clinical findings for LPD. In this study we evaluated, using USCD, thickness, echogenicity, regularity of the surface profile of the dorsal TA, the intercavernous and the intercaverno-spongeous septa, and the extension of the eventual pathologic lesions. In all, 16 pts (8.7%) presented minimal lesions at the ultrasound examinations. In nine of these pts (56%) the lesion was localized at the dorsal position, in six (38%) on the intercavernous septum and in one patient (6%) in both positions. The dorsal lesions were represented in nodular form in four pts (4%), and in diffuse form in five pts (55%). The nodular form was present in all the intercavernous septal lesions observed. As reported in the literature, USCD represents the investigative technique of choice in the study of LPD and in ED. Furthermore, the results of this study suggest that this technique could allow the localization of minimal lesions attributable to LPD during a preclinical phase of this disease. The localization of these lesions could permit to start a therapeutic approach during an early phase of the disease.

Conservative management options for peyronie’s disease

Peyronie's disease is an acquired condition that presents clinically with a palpable induration, a distinct plaque, or a curvature of the erect penis. At times, the erections are painful. Erectile dysfunction (ED) often is associated with Peyronie's disease. The current era of phosphodiesterase therapy for the treatment of ED seems to have increased the number of patients presenting for treatment of Peyronie's disease. During the past decade, significant advances have been made in understanding the pathophysiology of the disease, resulting in numerous nonsurgical therapies proposed for the treatment of Peyronie's disease. These medical treatments can be administered systemically, locally, or intralesionally. Unfortunately, there are few randomized, placebo-controlled trials to evaluate most of these proposed therapies. In evaluating therapies for Peyronie's disease, it must be remembered that the natural disease history includes spontaneous resolution of pain and even a small improvement in penile curvature in some men. This article reviews the natural history, scientific understanding, and nonsurgical treatment options for the mild to moderate Peyronie's deformities. Surgical therapy remains the mainstay of treatment for severe and refractory cases of Peyronie's disease that result in a physical or psychologic dysfunction.

Einschätzung der verschiedenen konservativen Therapieverfahren der Induratio penis plastica unter deutschen Urologen

BACKGROUND

The aim of this study was to evaluate the frequency and the assessment of the different conservative modalities of treatment in Peyronie's disease. A representative survey among 3187 German urologists was performed using a standardized questionnaire comprising currently used concepts of therapy, their efficacy, and their tolerability.

MATERIAL AND METHODS

A total of 636 urologists participated in the study. Altogether they had treated 6019 patients with Peyronie's disease in 2003. The majority of urologists treated between 3 and 15 patients per year. The most frequent treatment modality was the administration of potassium paraaminobenzoate, followed by vitamin E and extracorporeal shock wave therapy. Other oral drugs and intralesional drug administrations were used considerably less frequently.

RESULTS

The most commonly used treatment modalities were assessed for the best results in terms of efficacy and tolerability. However, this outcome is contradictory to the few controlled studies regarding the efficacy of the different drugs.

CONCLUSIONS

The large number of patients treated demonstrates the importance of conservative therapy for Peyronie's disease. Therefore, it is unfortunate that no conservative treatment modality is currently available that cures the symptoms of this disorder in all patients affected.

The Impact of Intralesional Interferon α‐2b Injection Therapy on Penile Hemodynamics in Men with Peyronie's Disease

INTRODUCTION

Penile duplex Doppler ultrasound (PDDU) is currently the preferred method for the functional evaluation of penile hemodynamics. PDDU may be used to monitor objectively changes in penile vascular parameters in men who undergo treatment for Peyronie's disease (PD), including intralesional interferon alpha-2b (IFN alpha-2b).

AIM

To investigate the impact of intralesional IFN alpha-2b therapy for PD on penile hemodynamics by using PDDU and to assess the objective role of PDDU in monitoring treatment outcomes.

MATERIALS AND METHODS

Thirty-nine patients (20 in the placebo and 19 in the IFN alpha-2b treatment arm) were enrolled in this prospective, placebo-controlled, parallel study. Patients received either 10 mL saline or 5 x 10(6) units of IFN alpha-2b intralesional injections every other week for a total of six injections. Patients in each group were evaluated at baseline and after completion of treatment regarding changes in penile hemodynamic parameters, penile curvature, plaque size and density, pain on erection, and erectile function. Specific published criteria were used for PDDU measurements. Outcomes were statistically compared between each group by using Mann-Whitney U and chi-square tests.

RESULTS

The mean age of the patients and the duration of PD were similar in both groups. The improvement in penile blood flow was significantly greater in IFN alpha-2b-treated patients than those in the placebo group. The number with the nonvascular classification increased significantly in the IFN alpha-2b arm from 31.5% to 57.8%. Additionally, improvements in penile curvature, plaque size and density, and pain on erection were better in the IFN alpha-2b group compared with the control. No significant improvement was observed in the erectile function domain in either group.

CONCLUSION

This study reveals that intralesional IFN alpha-2b injections have a significant benefit on penile hemodynamic parameters. Moreover, intralesional IFN alpha-2b is an effective, minimally invasive treatment for PD, and PDDU is a useful adjunct to monitor objectively changes in penile vascular parameters. interferon alpha-2b injection therapy on penile hemodynamics in men with Peyronie's disease.

THE RELATIONSHIP BETWEEN THE TYPE OF PENILE ABNORMALITY AND PENILE VASCULAR STATUS IN PATIENTS WITH PEYRONIE'S DISEASE

PURPOSE

We evaluated penile vascular status using penile duplex Doppler ultrasound (PDDU) according to the type of abnormality in men with Peyronie's disease (PD).

MATERIALS AND METHODS

A total of 523 patients with PD were evaluated retrospectively. Each patient underwent PDDU following injections of 10 to 15 mug prostaglandin E1 intracavernously with accompanying visual sexual stimulation to evaluate penile blood flow. Abnormalities were divided into 7 groups. Objective evaluation of penile curvature was done with a protractor during maximum erection. Specific criteria were used to categorize patients into varying definitions of vascular status. The results were compared statistically among groups.

RESULTS

Mean patient age +/- SEM was 54.2 +/- 1.5 years. The most frequently noted type of curvature was dorsal (43.5% of cases), followed by lateral (24.8%). Mean peak systolic velocity in the ventrolateral group was the highest, while the lowest peak systolic velocity was noted in the hourglass abnormality group. The hourglass group had the highest rate of pure arterial insufficiency, while veno-occlusive dysfunction was seen most commonly in the ventral curvature group. The ventrolateral group showed the most normal vascular status parameters.

CONCLUSIONS

This study demonstrates there is a relationship between the type of curvature and penile hemodynamics. Although patients with PD in the hourglass abnormality group were the youngest, this abnormality was associated with the poorest penile vascular status. Patients with ventrolateral curvature had the best penile hemodynamics in our series. PDDU findings may direct the treating physician to different treatment options.

Potassium paraaminobenzoate (POTABA) in the treatment of Peyronie's disease: a prospective, placebo-controlled, randomized study

PURPOSE

The aim of this study was to investigate the effect of potassium paraaminobenzoate (Potaba) in Peyronie's disease in a prospective, randomized, double-blind, placebo-controlled, multicentre study during a 12-months period of treatment.

PATIENTS AND METHODS

103 patients with Peyronie's disease and a history <12 months, non-calcified plaques and without pre-treatment were included. 51 were randomized to potassium paraaminobenzoate, 52 to placebo receiving 4 x 3g/day for 12 months. Follow-up was performed during the treatment period. Response has been defined as regression in plaque-size and/or reduction in penile curvature of at least 30%. Data analysis was focussed on 75 patients who completed the study [valid-cases (VC)].

RESULTS

No severe adverse events occurred. Response rates were 74.3% on potassium paraaminobenzoate and 50.0% on placebo (p=0.016). Mean plaque-size decreased from 259 mm(2) to 142 mm(2) in the treatment arm. In the placebo group, plaque-size aggravated from 259 mm(2) to 303 mm(2) after 6 months but improved slightly to 233 mm(2) after 12 months. Differences between the groups were significant (p=0.042). Pre-existing curvature did not improve under the drug (p=0.066) but comparing the development of new curvature or deterioration of pre-existing curvature under potassium paraaminobenzoate penile deviation remained stable. However, under placebo penile curvature deteriorated significantly in 32.5% of the cases (p<0.001). No significant differences concerning decrease of pain could be observed between the two groups (82.6% vs. 77.3%).

CONCLUSIONS

The results of this study indicate a significant plaque-related effect of potassium paraaminobenzoate. There was no relevant difference with regard to improvement of pre-existing penile deviation. However, under potassium paraaminobenzoate a significant protective effect on deterioration of penile curvature could be demonstrated. Potassium paraaminobenzoate appears to be useful to stabilize the disorder and prevent progression of penile curvature.

Penile Prosthetic Surgery for Peyronie's Disease: Defining the Need for Intraoperative Adjuvant Maneuvers

INTRODUCTION

There are a number of accepted approaches to the patient with Peyronie's disease and erectile dysfunction (ED), including penile prosthesis surgery. During prosthesis surgery for Peyronie's disease some men are left with residual curvature upon maximum device inflation. This analysis was undertaken to define how often and in which patients, intra-operative adjuvant maneuvers are required.

METHODS

Men undergoing penile prosthesis surgery for combined Peyronie's disease/ED constituted the study population. Residual curvature >10 degrees was deemed to warrant the use of a secondary maneuver to correct curvature. In this analysis, plaque release incisions were utilized and grafting was performed only if there was overt exposure of the prosthesis.

RESULTS

36 men were included in the analysis. All patients with preoperative curvatures <or=30 degrees had complete resolution of the penile curvature with full inflation of the prosthesis alone. Of patients who had >45 degrees curvature preoperatively, 86% needed plaque incision to achieve adequate penile straightening. Grafting was required in only 5.5% patients and both of these patients had preoperative curvature >60 degrees .

CONCLUSIONS

In 61% of patients with combined Peyronie's disease/ED in this study, the placement of a three-piece inflatable penile prosthesis alone corrected the penile curvature. 86% of patients requiring plaque incision had preoperative curvatures >45 degrees . This information should enable surgeons to plan such operations more effectively and to counsel patients more comprehensively prior to operative intervention.

Alpha-1-Antitrypsin Levels and Genetic Variation of the Alpha-1-Antitrypsin Gene in Peyronie’s Disease

OBJECTIVES

Alpha-1-antitrypsin (alpha1-antitrypsin) is a major protease inhibitor controlling tissue degradation. Reduced alpha1-antitrypsin levels could result in a change of collagen metabolism. Previous studies have described decreased alpha1-antitrypsin levels in patients with Peyronie's disease. However, only a small number of patients were analyzed, and the reason for the decreased alpha1-antitrypsin levels remained unclear. This study investigated prospectively the levels of alpha1-antitrypsin in patients with Peyronie's disease, as well as genetic variation in the coding region of the alpha1-antitrypsin gene.

METHODS

Alpha1-antitrypsin levels were determined prospectively in 94 patients with Peyronie's disease and compared to healthy controls. Analysis of the alpha1-antitrypsin gene (S, Z variants; single nucleotid polymorphisms [SNPs]: T-395A, M2, M3, G6118A) was done in 141 Peyronie's patients including 43 patients with investigated alpha1-antitrypsin serum levels and compared to healthy controls.

RESULTS

In patients with Peyronie's disease, the alpha1-antitrypsin levels seemed to be decreased significantly compared to healthy controls. However, in the age matched approach no significant differences occurred. Moreover, a significant (p < 0.002) decrease of the alpha1-antitrypsin level with increasing age was observed, explaining the initial differences between the two groups. In confirmation with these findings, no significant association of the alpha1-antitrypsin gene variants with Peyronie's disease was detectable.

CONCLUSIONS

The results of this study do not indicate a significant association between Peyronie's disease and decreased alpha1-antitrypsin levels. Low alpha1-antitrypsin levels in Peyronie's patients are, rather, an age-related phenomenon, as revealed by the comparison with aged matched healthy controls. The decrease of the alpha1-antitrypsin serum level with increasing age has not been described before.

Ultrasound in patients affected with Peyronie?s disease

Peyronie's disease (PD, induratio penis plastica) is uncommon. Its etiology is unknown and the incidence is stated to be 1%, although more recent data suggest that it is higher. The symptoms are penile deviation and painful erection in association with penile plaques. The diagnosis is performed by palpation of the penis. X-ray diagnostics are only used to visualize the calcified plaques in soft tissue imaging, and the survey of plaque size and consistence is done by sonography with high reproduction. This enables the exact evaluation of treatment effects. By application of high frequency scanners (7-12 MHz) the extent and depth of the plaques can be estimated non-invasively in high resolution images. Furthermore, color coded duplex sonography and recording of Doppler spectra are used to assess hemo-perfusion in the penile vessels and the analysis of erectile dysfunction, often seen in combination with PD. Sonographic diagnosis appears as a valuable supplement and requirement for a successful therapy of PD.

STRATIFICATION OF PENILE VASCULAR PATHOLOGIES IN PATIENTS WITH PEYRONIE’S DISEASE AND IN MEN WITH ERECTILE DYSFUNCTION ACCORDING TO AGE: A COMPARATIVE STUDY

PURPOSE

Erectile dysfunction (ED) occurs in 20% to 54% of men with Peyronie's disease (PD). We investigated the role of vascular status in the pathophysiology of ED in patients with PD.

MATERIALS AND METHODS

A total of 509 consecutive men with PD (group 1--impotent 259, 1a, and potent 250, 1b, mean age +/- SD 54.6 +/- 4.4 years) and 507 consecutive men with ED only (group 2--mean age 49.4 +/- 12.4 years) underwent penile duplex ultrasonography (PDU). Detailed sexual and medical history, and focused physical examination were performed in all patients. Patients in the 2, groups were stratified according to age (18 to 80 years) and classified according to PDU results (normal vascular status, arterial insufficiency, veno-occlusive dysfunction [VOD] and mixed vascular pathology).

RESULTS

VOD was observed in 23.1% and 42.8% of patients in groups 1 and 2, respectively (p <0.05). Although VOD was significantly more common in group 2 (ED alone) than in group 1a (PD plus ED) in the third decade (p <0.05), overall PDU results showed no statistical difference for VOD between these 2 groups (p >0.05). Of note, mixed vascular pathologies were significantly higher in group 1a than in group 2 in the third through fifth decades (p <0.05), while arterial insufficiency was more common in the seventh decade (p <0.05).

CONCLUSIONS

While many groups have investigated the vascular causes of ED, the exact etiology of ED in men with PD remains controversial. A possible relationship between ED and VOD in patients with PD has been previously reported. The current PDU study demonstrates that for all ages except 30 to 39 years the prevalence of VOD in patients with PD plus ED is similar to that of patients with ED alone.

Incidentally diagnosed Peyronie's disease in men presenting with erectile dysfuntion

The aim of this study was to analyze characteristics of patients with Peyronie's disease (PD) diagnosed during a standard evaluation for erectile dysfunction (ED) and compare them with patients presenting with the classical complaints of PD. During a 10-y period, a total of 448 patients were evaluated at our two outpatient clinics, directed by the same author (AK). They were divided into two groups: group I consisted of patients, who presented with only ED and were unaware of their penile deformity, and group II consisted of patients with the classical features of the disease. The clinical characteristics, penile deformities, erectile status and the presence of comorbidities were determined in the two groups. Of 448 Peyronie's patients, 16% (n=71) were detected during diagnostic work-up for ED. In this group of patients, ED was the presenting symptom for a mean period of 31.3+/-9.7 months. The mean age of men was 57.54+/-8.75 and 52.21+/-10.27 y in groups I and II, respectively (P=0.0001). The mean degree of deformity was 31.5+/-12.66 degrees in group I and 41.16+/-19.14 degrees in group II (P=0.0001). In group I (n=71), 69% (n=49) of the patients had a poor erectile response to the combined injection and stimulation (CIS) test. Also, in this group, the mean degrees of deformity in CIS-positive and -negative patients were 27.05+/-12.50 and 33.80+/-12.03 degrees , respectively (P=0.033). Diabetes mellitus (40%) was the leading comorbidity in group I, while at least one comorbidity was observed in 73% of the cases (P=0.001). A remarkable percent of Peyronie's patients (16%) were detected during a standard evaluation for ED. This study analyzed, for the first time, the frequency and the characteristics of incidentally diagnosed Peyronie's patients who presented with only ED. Our data indicate that one should always consider the possibility of PD in older patients with diabetes, presenting with only ED.

Peyronie's disease fibroblasts demonstrate tumorigenicity in the severe combined immunodeficient (SCID) mouse model

Peyronie's disease is a localized connective tissue disorder, caused by trauma to the erect penis, which results in cellular proliferation and excess extracellular matrix production within the tunica albuginea of the penis. We have previously demonstrated that cells derived from Peyronie's disease plaque tissue demonstrate increased cell growth, increased S-phase on flow cytometry, stabilization and inactivation of p53, and consistent morphologic transformation, all suggesting that these cells are biologically transformed. Severe combined immunodeficient (SCID) mice have been used extensively to study the pathobiology of malignant and benign tissue and cells. This study was undertaken to determine if Peyronie's derived fibroblasts had the potential to demonstrate tumorigenicity in the SCID mouse model, thus confirming their biologically transformed nature. Cultured fibroblasts were derived from three sources, namely, plaque tissue excised from men with Peyronie's disease, tunical tissue excised from young men with congenital penile curvature and neonatal foreskins. BALB/C SCID mice were divided into three groups and each group was inoculated with cultured fibroblasts from each of the three different sources. All animals were evaluated regularly and maintained in isolation for a period of 3 months following inoculation. All SCID mice inoculated with cells derived from Peyronie's disease plaque tissue (n=10) developed subcutaneous nodules at a mean time period of 2.5+/-0.5 months following injection. The mean maximum dimension and weight of the nodules at the time of killing the animal was 1.1+/-0.2 cms and 0.6+/-0.2 g, respectively. Histologically, the nodules were composed of large pleomorphic epithelioid cells with a high mitotic activity, which were negative for cytokeratin but positive for vimentin. None of the SCID mice inoculated with cells cultured from either normal tunica (n=5) or foreskin (n=5) developed subcutaneous nodules. In conclusion, the tumorigenic nature of Peyronie's disease plaque-derived fibroblasts sheds further light on the pathobiologic characteristics of these cells. Specifically, these data confirm that cells cultured from Peyronie's disease plaque are biologically transformed. Future refinement and study of this animal model may permit a more complete understanding of the pathophysiology of Peyronie's disease and fibromatoses in general. Furthermore, such an animal model may, in the future, allow a more ready evaluation of the therapeutic interventions for Peyronie's disease.

Human Cadaveric Pericardial Graft for the Surgical Correction of Peyronie’s Disease

PURPOSE

In patients with stable penile deformity secondary to Peyronie's disease (PD) penile straightening can be achieved with plaque incision or partial excision and grafting. We present our experience with human cadaveric pericardium for tunica albuginea grafting for men undergoing penile reconstruction for Peyronie's disease.

MATERIALS AND METHODS

We retrospectively reviewed our experience with 40 men with PD who underwent penile straightening with partial plaque excision and grafting using human cadaveric pericardium from January 1999 to January 2003.

RESULTS

All 40 men were evaluable for preoperative, operative and postoperative characteristics. Mean postoperative followup was 22.0 months. Mean preoperative penile curvature was 69.1 degrees. Subjectively 36 of the 40 patients (90%) graded preoperative erection as sufficiently rigid for coitus and 100% had sufficiently rigid erection for coitus following intracorporeal papaverine injection. Mean pericardial graft size was 4.9 x 4.8 cm. Postoperatively 39 of the 40 patients (98%) had successful penile straightening, 38 (95%) achieved coitus, 28 (70%) achieved full, unaided erection and 12 (30%) had some degree of erectile dysfunction (ED) requiring pharmacological assistance for intercourse. There were no significant differences in ED risk factors, plaque location, graft size or complications in men who did and did not have ED postoperatively (p >0.05). There were no major complications or graft related adverse events.

CONCLUSIONS

Human cadaveric pericardium is a safe, readily available and pliable tissue for tunica albuginea grafting following PD plaque incision or partial excision. Careful patient selection must be emphasized and particular attention must be given to deformity stability and preoperative erectile function to maximize surgical outcome.

Validation of the German version of the International Index of Erectile Function (IIEF) in patients with erectile dysfunction, Peyronie's disease and controls

The objective of this study was to validate the German translation of the International Index of Erectile Function (IIEF). The IIEF was administered to 59 patients with erectile dysfunction (ED), to 38 patients with Peyronie's disease and to 33 controls. All patients were investigated by standardized German versions of international questionnaires of anxiety, depression, social desirability, quality of partnership, physical complaints and life-satisfaction. The five subscales of the English version, however, could not be replicated. Internal consistency for the complete questionnaire of 15 items was high (Cronbach's alpha=0.95). Based on the total scale and two subscales, we were able to discriminate sexual function between the ED group and the comparison groups. There was no significant correlation between the IIEF scores and anxiety, depression, somatic complaints and life-satisfaction. The German version of the IIEF has found good comprehension, and acceptance by the majority of patients. Its use is somewhat limited by its focus on sexual activity in partnership. In contrast to the English version, it mainly addresses a single factor of sexual function.