Vascular abnormalities in Peyronie's disease: the role of color Doppler sonography

Epidemiology regarding penile prosthetic surgery

With the onset of a metabolic syndrome epidemic and the increasing life expectancy, erectile dysfunction (ED) has become a more common condition. As incidence and prevalence increase, the medical field is focused on providing more appropriate therapies. It is common knowledge that ED is a chronic condition that is also associated with a myriad of other disorders. Conditions such as aging, diabetes mellitus, hypertension, obesity, prostatic hypertrophy, and prostate cancer, among others, have a direct implication on the onset and progression of ED. Characterization and recognition of risk factors may help clinicians recognize and properly treat patients suffering from ED. One of the most reliable treatments for ED is penile prosthetic surgery. Since the introduction of the penile prosthesis (PP) in the early seventies, this surgical procedure has improved the lives of thousands of men, with reliable and satisfactory results. The aim of this review article is to characterize the epidemiology of men undergoing penile prosthetic surgery, with a discussion about the most common conditions involved in the development of ED, and that ultimately drive patients into electing to undergo PP placement.

The influence of promoter -202 A/C polymorphism (rs2854744) of the IGFBP-3 gene on erectile dysfunction risk and serum levels of IGF-I and IGFBP-3

PURPOSE

We studied whether the IGFBP-3 gene polymorphism rs2854744 is associated with erectile dysfunction.

MATERIALS AND METHODS

We investigated the association of this polymorphism with erectile dysfunction in 176 cases and 352 controls. We genotyped rs2854744 using polymerase chain reaction-restriction fragment length polymorphism. Circulating concentrations of IGF-I and IGFBP-3 were also measured.

RESULTS

Allelic frequencies were 0.474 (A allele) and 0.526 (C allele) in men with erectile dysfunction, and 0.457 (A allele) and 0.543 (C allele) in normal controls (adjusted OR 1.74, 95% CI 0.82-2.43, p = 0.08). The frequency of the IGFBP-3 A-202C polymorphism genotype was 0.273 (CC), 0.506 (AC) and 0.221 (AA) in the case group, and 0.296 (CC), 0.494 (AC) and 0.210 (AA) in the control group (chi-square test p = 0.08). Neither the IGFBP-3 A-202C polymorphism nor serum IGF-I and IGFBP-3 levels were significantly associated with the risk of erectile dysfunction. Carriers of the AA genotype had the highest age adjusted serum IGFBP-3. This demonstrated a stepwise decrease in the presence of 1 or 2 copies of the C allele (mean ± SD 4,541 ± 796.2, 3,552 ± 642.4 and 3,314 ± 669.3 ng/ml, respectively). There was a positive correlation between serum IGFBP-3 and serum IGF-I concentrations (Spearman correlation coefficient r = 0.34, p for trend = 0.001).

CONCLUSIONS

The IGFBP-3 gene A-202C polymorphism does not modulate the risk of erectile dysfunction.

Standard operating procedures for Peyronie's disease

INTRODUCTION

Peyronie's disease (PD) refers to a penile deformity that is associated with sexual dysfunction.

AIM

To provide recommendations and Standard Operating Procedures (SOPs) based on best evidence for diagnosis and treatment of PD.

METHODS

Medical literature was reviewed and combined with expert opinion of the authors.

MAIN OUTCOME MEASURES

Recommendations and SOPs based on grading of evidence-based medical literature.

RESULTS

PD is a fibrotic wound-healing disorder involving the tunica albuginea of the corpora cavernosa. The resulting scar is responsible for a variety of deformities, including curvature, shortening, narrowing with hinge effect, and is frequently associated in the early phase with pain. Patients frequently experience diminished quality erections. All of these conditions can compromise sexual function for the affected male. The etiopathophysiology of PD has yet to be clarified and as a result, effective, reliable, mechanistic directed non-surgical therapy is lacking.

CONCLUSIONS

The management of PD consists of proper diagnosis and treatment, ranging from non-surgical to surgical interventions. The main state of treatment for PD rests at this time on surgical correction that should be based on clear indications, involve surgical consent, and follow a surgical algorithm that includes tunica plication, plaque incision/partial excision and grafting, and penile prosthesis implantation.

Surgery for Peyronie's disease

Peyronie's disease (PD) is most simply referred to as a fibrotic wound-healing disorder of the tunica albuginea. It is both a physically and psychologically devastating disorder that causes penile deformity, curvature, hinging, narrowing and shortening, which may compromise sexual function. Although a variety of non-surgical treatments have been suggested, none to date offer a reliable and effective correction of the penile deformity. As a result, surgery remains the gold standard treatment option, offering the most rapid and reliable treatment which will be the focus of this article. We review the preoperative evaluation, surgical algorithm, graft materials and postoperative management of PD. Outcomes for tunical shortening, tunical lengthening and penile prosthesis placement for penile straightening are reviewed. Tunica albuginea plication is the preferred method of straightening for men with adequate rigidity and less severe disease defined as curvature less than 70° without narrowing/hinging. Men who have more severe, complex deformity, but maintain strong preoperative erectile function should be considered candidates for straightening with plaque incision or partial excision and grafting. Finally, for those men who have inadequate rigidity and PD, penile prosthesis placement with straightening is the best approach to address both problems.

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.

US Imaging in Peyronie's Disease

The aim of this study is to assess the role of ultrasound (US) in Peyronie's Disease (PD). PD is a psychologically and physically devastating disorder that manifests in middle-aged men. Fibrous inelastic plaques in the tunica albuginea, result in palpable penile scar in the flaccid condition and cause painful erections and penile deformity, including penile curvature, hinging, narrowing, and shortening of penis. Penile deformity is the most common (52%) first symptom of PD and is present in 94% of affected men. US is the primary imaging modality of choice due to its easy availability, low risk, and ability to image and quantify both calcified and soft tissue elements of PD. US provides identification of smaller and non-palpable lesions and shows the extent of fibrosis. Detection of calcifications within the plaque suggests stabilization of the disease and provides information useful to select patients for appropriate treatment.

Inflatable penile prosthesis placement in men with Peyronie's disease and drug-resistant erectile dysfunction: A single-center study

INTRODUCTION

Erectile dysfunction (ED) frequently accompanies Peyronie's disease (PD) and changes the therapeutic approach.

AIM

To evaluate a single-center experience with inflatable penile prostheses (IPP) in men with medication refractory ED and PD.

METHODS

Ninety men underwent placement of an IPP with straightening maneuvers as necessary to address their deformity and ED.

MAIN OUTCOME MEASURES

Preoperative assessment included International Index of Erectile Function-erectile function domain (IIEF-EF) and duplex ultrasound to confirm ED and measure erect deformity. Postoperative assessment included a modified Erectile Dysfunction Index of Treatment Satisfaction (EDITS) questionnaire, as well as office visits at 1, 6, and every 12 months thereafter.

RESULTS

Complete chart review was performed with mean follow-up of 49 months. Mean preoperative IIEF-EF score was 11. Full rigidity was not obtained in any patient during duplex ultrasound. Mean curvature at maximum erection was 53°. There were seven mechanical failures requiring device replacement, two revision surgeries for pump or reservoir malposition, one infected device, and two corporoplasties for distal tunica erosion. Postoperative office assessment revealed a functionally straight (i.e., <20°) erect penis and a properly positioned as well as operational device in all patients. The modified EDITS questionnaire was returned by 56 (62%). Overall, 84% of patients were satisfied with their outcome, yet only 73% were satisfied with their straightness. Patient perceived postoperative curvature correction stabilized quickly and was complete by 3 months in 84% of patients. Satisfaction with ease of inflation, deflation, and concealability was 84%, 71%, and 91%, respectively. Coital activity was reported by 91% of men in this group.

CONCLUSION

In men with PD and ED, IPP placement allowed reliable and satisfactory coitus for the great majority of men. Mechanical failure was 7%. Men with PD undergoing IPP placement should be counseled regarding potential penile length loss and residual curvature, neither of which appeared to interfere with coitus but may reduce satisfaction.

Preoperative clinical and diagnostic characteristics of patients who require delayed IPP after primary Peyronies repair

INTRODUCTION

Penile vascular abnormalities occur in a high proportion of patients with Peyronie's disease (PD). Penile duplex ultrasonography (PDU) and dynamic infusion cavernosometry and cavernosography (DICC) are tools that can be used to help tailor individualized treatment for patients undergoing surgical intervention for their PD. However, precisely which parameters can be used to predict those patients with PD at risk for developing erectile dysfunction (ED) after intervention without inflatable penile prosthesis (IPP) has not been previously elucidated.

AIM

To evaluate preoperative vascular parameters that predispose PD patients for developing ED after intervention without IPP.

METHODS

Twenty-six patients receiving surgical intervention for their PD at a single center were retrospectively identified. Of these, 11 (42.3%) opted for primary repair without placement of an IPP. Three (27.2%) of these 11 patients went on to develop ED postoperatively.

MAIN OUTCOME MEASURES

We compared various demographic, PDU, and DICC parameters between patients who did and did not fail primary repair of their PD.

RESULTS

Mean age and follow-up of patients who went on to develop ED after repair of PD without IPP were not significantly different (P < 0.05). Resistive index (RI) and end diastolic volume were significantly different between these two groups (P < 0.05), while peak systolic volume, flow to maintain, and pressure decay were not significantly different. An RI cutoff of <0.80 was found to identify all patients who would later develop ED and fail primary repair without IPP.

CONCLUSIONS

Penile vascular assessment can aid in counseling patients about their risk of developing delayed ED after primary repair of PD. In our cohort of patients, PDU provided preoperative risk stratification for postoperative erectile dysfunction in men undergoing Peyronie's repair without IPP. We propose the prospective study of an RI cutoff to identify patients at risk of failing primary PD repair without IPP.

DOES THE TYPE OF THE PEYRONIE'S CURVATURE EFFECT PENILE VASCULAR PARAMETERS IN NORMOPOTENT MEN?

The aim of this study is to assess whether the type of penile curvature in normopotent men with Peyronie's disease affects the penile vascular doppler ultrasound parameters. Fifty-three normopotent patients within the stabilization phase of Peyronie's disease were evaluated retrospectively by means of color doppler ultrasonography. Bilateral cavernosal artery diameters before and after intracavernous papaverine injections, peak systolic and end diastolic velocities and the amount of leakage in the deep dorsal penile vein were compared in dorsal and ventral curvature groups of Peyronie's disease. 61% of the patients in dorsal and 59% in ventral Peyronie's curvature group have normal ultrasonographic penile vascular system. 35% and 3.3% in dorsal curvature group and 36.4% and 4.5% in ventral curvature group have venoocclusive dysfunction and mixed vascular pathologies, respectively, having no statistical correlation between them (p > 0.05). No arterial pathology was observed in any group. There was no correlation between the type of Peyronie's curvature and the penile doppler ultrasonographic findings in normopotent patients.

RETRACTED: Efficacy and safety of omega-3 for treatment of early-stage Peyronie's disease: A prospective, randomized, double-blind placebo-controlled study

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief. Following the retraction of Dr. Safarinejad's work by other journals, The Journal of Sexual Medicine has undertaken an extensive re-review of all papers Dr. Safarinejad published with the journal. Following an intensive re-evaluation and close scrutiny of the manuscripts, our expert reviewers raised multiple concerning questions about the methodology, results, and statistical interpretation as presented in this article. Dr. Safarinejad was contacted to provide his original data and offer explanations to address the concerns expressed by the reviewers. Dr Safarinejad chose not to respond. Consequently, we can no longer verify the results or methods as presented and therefore retract the article.

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.

Diabetes mellitus is associated with severe Peyronie's disease

OBJECTIVES

To evaluate the severity of penile deformity and penile blood flow variables in men with Peyronie's disease (PD) and diabetes mellitus (DM), and those with no risk factors.

PATIENTS AND METHODS

Men with PD and DM (59 men, group 1) and those with no risk factors (109, group 2) were compared for penile blood flow variables, severity of penile deformity, patient's age, duration of PD, the presence of pain on erection, and the degree of erectile dysfunction (ED). The men were evaluated with penile duplex Doppler ultrasonography and were categorized into specific vascular groups, using established criteria. Penile curvature was objectively measured and stratified according to the Kelâmi classification. Results were compared using Student's t-test.

RESULTS

Men with PD and DM (group 1) were significantly older than those in group 2. The duration of disease was significantly longer in group 1 than in group 2 (median 24 vs 12 months). The mean degree of penile deformity in group 1 was significantly higher than in group 2 (45.2 degrees vs 30.2 degrees). The rate of severe penile curvature (>60 degrees ) was more frequent in group 1 (27.1% vs 5.5%). Pain on erection was significantly higher in group 2 (39.7% vs 25.5%), whereas the rate of ED was more common in group 1 (81% vs 47%). Group 1 had poorer peak-systolic velocity values and significantly higher rates of arterial insufficiency and mixed vascular disease. Nonvascular causes were twice as common in group 2 than in group 1.

CONCLUSIONS

This comparative clinical study suggests that the presence of DM as the only risk factor significantly increases the severity of PD. Furthermore, DM as a risk factor is associated with significantly worse vascular status, as shown by penile duplex Doppler ultrasonography, in men with PD.

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.

Prevalence of Peyronie's disease among patients with erectile dysfunction

PURPOSE

To assess the prevalence of Peyronie's disease (PD) among patients with erectile dysfunction (ED).

MATERIALS AND METHODS

A total of 1,440 male patients with ED were enrolled in this study. Patients were interviewed for ED using the International Index of Erectile Function (IIEF). All patients were also screened for socio-demographic data and risk factors for ED that included age, smoking, diabetes, hypertension, dyslipidemia, Ischemic Heart Disease (IHD), and psychological disorders. The diagnosis of PD was based on a palpable penile plaque or acquired penile curvature. Patients underwent routine laboratory investigation in addition to testosterone and prolactin assessment.

RESULTS

Mean ages +/-SD were 54.1 +/- 6.9 (range 42-71) and 52.5 +/- 11.9 (range 20-84) years for patients with and without PD respectively. Of the patients, 11.8% had mild, 38.3% had moderate and 49.9% had severe ED. 7.9% of the patients had PD. Significant associations between PD and both the longer duration and the increased severity of ED were detected. There were also significant associations between PD and the following socio-demographic risk factors of ED: age, obesity, smoking, duration and number of cigarettes smoked per day. Concomitant diseases and medical comorbidities such as diabetes, dyslipidemia, psychological disorders and the presence of at least one risk factor were significantly associated with PD in patients with ED.

CONCLUSIONS

Peyronie's disease was not rare among the study population. There were significant associations between ED risk factors and PD. Further studies are needed to investigate how much ED and PD influence each other.

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.

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.

The management of Peyronie's disease

Peyronie's disease has no known cause; recent understanding of the molecular mechanisms involved and the development of an animal model will aid the medical management of early disease. The medical management of chronic disease is futile as the delicate tunical architecture cannot regenerate. Surgical correction of the penile deformity is required in a minority of patients, and a choice lies between a Nesbit operation and a plaque incision and venous patch in patients who are concerned with penile shortening.

Erectile dysfunction: symptom or disease?

Erectile dysfunction (ED) has been defined by the National Institute of Health (NIH) as the inability to achieve and/or to maintain an erection for a sufficiently long period of time so as to permit satisfactory sexual intercourse. ED affects millions of men throughout the world and could have a negative influence on the individual's well-being as well as on the quality of life of affected subjects. Discordant data have been reported on ED epidemiology with prevalence ranging from 12% to 52%, probably depending on the different criteria utilized in the different studies for patient selection. ED is a symptom, sometimes the first, of different pathological conditions. In 15.7% of 45-yr-old patients with vascular ED a dynamic ergometric test has shown electrocardiographic alterations in the absence of any cardiac symptom. In 15% of the patients with ED, high fasting glucose plasma levels are discovered for the first time and in patients with ED and normal fasting glucose plasma levels the prevalence of undiagnosed diabetes mellitus is 12.1% after an oral glucose tolerance test (OGTT). The different risk factors are often additive in the possible development of systemic vasculopathy, neuropathy and ED. ED, underestimated in clinical practice due to archaic prejudice which hinders the patient in spontaneously revealing the problem and the physicians in investigating it, can mark the point where evaluation and prevention of important diseases (such as diabetes, arterial hypertension, atherosclerosis) hitherto unknown by the patients, can begin. The physicians' cultural baggage must include the ability to identify the pathology that can determine ED and the ability to program a specific diagnostic workup. In this paper the different specialists involved in ED diagnosis agreed that a clinical approach which allows the identification of systemic pathologies contributing to the development of ED constitutes an improvement in disease prognosis and may either induce a spontaneous reduction of ED or facilitate its specific treatment.

Biomechanical aspects of Peyronie's disease in development stages and following reconstructive surgeries

Peyronie's disease is a disorder of the penile connective tissues that leads to development of dense fibrous or ossified plaques in the tunica albuginea, causing penile deformity and painful erection. A biomechanical model of the penis was utilized for analyzing the mechanical stresses that develop within its soft tissues during erection in the presence of Peyronie's plaques. The model's simulations demonstrated stress concentrations around nerve roots and blood vessels due to the plaques. These stresses may irritate nerve endings or compress the vascular bed, and thus cause penile deformity and/or painful erection. The model was further used to elaborate the effects of different biological or artificial materials for reconstruction of the penis following plaque removal. Clinical applications of the present model can range from analysis of the etiology of the disease to assisting in the determination of optimal timing for therapeutic interventions and in the selection of patch material for penile reconstructions.

Peyronie's disease

Peyronie's disease remains one of the most perplexing diseases in urology. With continued basic research in wound healing and scarring, the understanding and management of this frustrating disease will improve. Initial treatment of Peyronie's disease should be conservative, with expectant therapy and medical management. Once the penile curvature and plaque have stabilized, patients with severe deformity can be offered surgery depending on their symptoms and complaints. Patient selection is the key to proper treatment. Less experienced surgeons should limit themselves to medical management or simple surgical management of the disease, including plication or Nesbit procedures. Penile-lengthening procedures or the placement of complicated penile prosthesis should be reserved for surgeons with familiarity and expertise in this type of reconstruction. Education on the pathogenesis and natural history of the disease will allow the patient and his partner to make an informed decision in regards to treatment options and expected outcomes.

Computational tools in rehabilitation of erectile dysfunction

Erectile dysfunction (ED) is defined as the inability to achieve and maintain an erection adequate for satisfactory intercourse. It is a common problem among approximately 50% of men between the ages of 40 and 70. Erectile dysfunction is not only stressful to both the affected individual and his partner, but it can also negatively affect self-esteem. Biomechanical models have recently been developed to study both the structural and hemodynamic factors involved in normal and pathological erectile conditions. These computational models, which are reviewed in the present paper, allow for better understanding of the mechanisms acting in ED and provide a suitable basis for development of state-of-the-art interdisciplinary treatment approaches aimed to improve the quality of life for these men.

Corporal plication for penile curvature caused by Peyronie's disease: the patients' perspective

OBJECTIVE

To determine the acceptability by patients of corporal plication for Peyronie's disease.

PATIENTS AND METHODS

A postal questionnaire was sent to 69 patients who had undergone corporal plication for Peyronie's disease between 1992 and 1999, to ascertain the subjective outcome and acceptance by the patients and their sexual partners of the results of the procedure. Of the 65 patients who were still alive, 44 (68%) returned the questionnaire.

RESULTS

The mean (range) follow-up was 4.1 (0.5-7.25) years and the mean age of the patients 54.6 (32-80) years. Of the 44 patients responding, 24 (55%) were sexually active; after surgery, 16 (36%) had significant impairment of erections, seven (16%) continued to have significant penile discomfort and 15 (34%) could feel nodules at the suture site. Twenty-five (57%) patients reported a mild and six (14%) a severe persistent penile deformity; 40 (90%) reported having a shorter penis, of whom 22 (55%) thought it significant. Overall, 14 (32%) reported 'numbness' of the glans penis. Only 23 (52%) of the patients would recommend the surgery, with 25 (57%) reporting a deterioration in their overall quality of life. Of the partners of the evaluable patients, 38 (86%) responded, and a significant deterioration in sexual performance was reported by 19 (35%).

CONCLUSIONS

Overall, the long-term results of corporal plication appear to be disappointing. These poor results could be related to a current lack of understanding of the natural history and progression of the disease, to case selection, or to the surgery. We intend to use these results to counsel our patients before such surgery and inform them of the possible outcome in the long term.

A biomechanical model of Peyronie's disease

Peyronie's disease is a pathological condition of the penis which is characterized by localized ossification of the tunica albuginea. A common symptom of the chronic stage is penile deformity during erection, which is frequently associated with pain and erectile dysfunction. A two-dimensional biomechanical model of the penis was applied to study the development of Peyronie's disease by simulating the mechanical stress distribution which would result from the interaction of the ossified tunical tissue with other penile soft tissues. The model was solved by using commercial finite element software for a characteristic erectile pressure. The results demonstrate that Peyronie's plaques may induce intensified stresses around the penile nerves and blood vessels, up to double those in the normal penis. These elevated stresses may cause a painful sensation of neural origin or ischemia in regions of compressed vascular tissue. Severe penile deformities have been shown to develop if Peyronie's plaques develop only around one of the corpora cavernosa due to the non-homogeneous resistance of the tunica to expansion during erection. The present model can be clinically applied as an aid in the planning process of reconstructive surgery or insertion of a prosthesis.

Tamoxifen versus placebo in the treatment of Peyronie's disease

PURPOSE

We evaluated the effects of oral tamoxifen and placebo in patients with Peyronie's disease.

MATERIALS AND METHODS

We selected 25 patients with Peyronie's disease who did not have calcified plaque for treatment in the andrology outpatient clinic. A medical history was obtained, and physical examination, penile x-ray, penile ultrasound and pharmacologically induced erection with prostaglandin E1 were performed. Patients were randomly divided into group 1--those who received 20 mg. tamoxifen twice daily for 3 months and group 2--those who received placebo for the same period. The same evaluations were done 4 months later and results were compared. Qualitative (chi-square test) and quantitative (Student's t test) results were analyzed using the Yates correction factor with p <0.05 considered significant.

RESULTS

Pain subsided in 66.6 and 75% of the patients treated with tamoxifen and placebo, respectively (p >0.05). In groups 1 and 2 a reduction in the penile deformity was noticed by 46.1 and 41.7% of the patients (p >0.05), and a decrease in plaque size was noticed by 30.7 and 25%, respectively. On the other hand, objective measurements did not reveal any difference in plaque area or curvature angle.

CONCLUSIONS

This study did not show significant improvement in pain, curvature or plaque size in patients with Peyronie's disease who were treated with tamoxifen compared with those treated with placebo.

Venous patch graft for Peyronie's disease. Part II: outcome analysis

PURPOSE

We evaluate the results of tunical incision and venous patch grafting for correcting penile deformity in Peyronie's disease.

MATERIALS AND METHODS

In 113 [corrected] patients with symptoms of Peyronie's disease for more than a year indications for surgery included penile shortening, persistent pain, severe curvature, penile narrowing or indentation and/or failure of previous surgery. Preoperative evaluation included determination of patient and partner expectation, potency status, circumcision status, measurement of penile length (short and long side) and saphenous vein, and color duplex ultrasonography to evaluate possible accessory vascular communication. Patients underwent plaque incision and venous patch grafting. The configuration, size and number of tunical incisions depended on the size and shape of the lesion. Lower and upper saphenous, and deep dorsal veins served as the graft materials. Postoperative followup was as long as 18 months.

RESULTS

In 96% of patients the penis became straight, while residual curvature was 30 degrees in 3% and 15 degrees in 1%. In 94% of patients narrowing and indentation were absent and in 83% penile length was the same or longer postoperatively. Of the patients who were potent preoperatively 88% experienced the same or better erectile quality after surgery. In 10% of cases a change in sensation occurred lasting longer than 6 months. Overall satisfaction was expressed by 92% of men who believed that surgery improved the psychological state as well as the relationship with the partner.

CONCLUSIONS

The results are satisfactory and this procedure offers a reasonable solution for correction of Peyronie's disease.

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

PURPOSE

We obtained an objective evaluation of erectile function in patients with Peyronie's disease.

MATERIALS AND METHODS

Sexual dysfunction was analyzed in 222 patients with Peyronie's disease without previous local plaque therapy using a standardized protocol.

RESULTS

Of the 222 patients 70 (31.5%) complained of not being able to perform intercourse. In 4 men (1.8%) standardized diagnostic procedure demonstrated only a severe angulation making coitus impossible, and in 3 men (1.4%) intercourse became unsatisfactory due to pain. Seven men (3.1%) reported distal penile flaccidity, including 4 in whom dynamic pharmacocavernosometry and pharmacocavernosography revealed veno-occlusive dysfunction. Of 56 men who complained of a complete loss of erection 51 did not respond to intracavernous pharmacological injection with prostaglandin E1, and 27 (48.2%) had abnormal arterial blood flow as shown by duplex sonography of the cavernous arteries, 47 (83.9%) had evidence of veno-occlusive dysfunction based on cavernosometric criteria and 33 (58.9%) also had cavernosographic evidence of the condition. Plaque associated venous drainage was evident in 15 of the 56 impotent patients (26.8%), equivalent to 45.5% of all cases with abnormal cavernosographic findings.

CONCLUSIONS

Sexual dysfunction was evaluable in 31.5% of patients, and the main cause of impotence and loss of erection was veno-occlusive dysfunction.

Techniques of corporoplasty for penile curvature: review of 18 patients

Penile curvature which can be acquired or combined with some congenital anomalies may cause trouble in sexual function or can affect the psychological status of the individual. Whatever the causes or the results are, this condition has been tried to be corrected for many years by many different techniques. Eighteen patients with penile curvature have been reviewed. Thirteen patients underwent Nesbit procedure, in 3 patients plication of the tunica albuginea was done and in 2 patients longitudinal incision and horizontal closure of the tunica albuginea were performed. In all cases the results were both functionally and cosmetically satisfying. The advantages and disadvantages of these techniques are discussed, with a review of the relevant literature.