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Şahin A, Babayev H, Cirigliano L, Preto M, Falcone M, Altıntas E, Gül M. Unveiling the molecular Hallmarks of Peyronie's disease: a comprehensive narrative review. Int J Impot Res 2024:10.1038/s41443-024-00845-2. [PMID: 38454161 DOI: 10.1038/s41443-024-00845-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 01/26/2024] [Accepted: 02/12/2024] [Indexed: 03/09/2024]
Abstract
Peyronie's disease, a fibroinflammatory disorder, detrimentally impacts the sexual well-being of men and their partners. The manifestation of fibrotic plaques within penile tissue, attributed to dysregulated fibrogenesis, is pathognomonic for this condition. The onset of fibrosis hinges on the perturbation of the equilibrium between matrix metalloproteinases (MMPs), crucial enzymes governing the extracellular matrix, and tissue inhibitors of MMPs (TIMPs). In the context of Peyronie's disease, there is an elevation in TIMP levels coupled with a decline in MMP levels, culminating in fibrogenesis. Despite the scant molecular insights into fibrotic pathologies, particularly in the context of Peyronie's disease, a comprehensive literature search spanning 1995 to 2023, utilizing PubMed Library, was conducted to elucidate these mechanisms. The findings underscore the involvement of growth factors such as FGF and PDGF, and cytokines like IL-1 and IL-6, alongside PAI-1, PTX-3, HIF, and IgG4 in the fibrotic cascade. Given the tissue-specific modulation of fibrosis, comprehending the molecular underpinnings of penile fibrosis becomes imperative for the innovation of novel and efficacious therapies targeting Peyronie's disease. This review stands as a valuable resource for researchers and clinicians engaged in investigating the molecular basis of fibrotic diseases, offering guidance for advancements in understanding Peyronie's disease.
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Affiliation(s)
- Ali Şahin
- Selcuk University School of Medicine, 42250, Konya, Turkey
| | - Huseyn Babayev
- Swiss Institute of Allergy and Asthma Research (SIAF), University of Zurich, 7265, Davos, Switzerland
| | - Lorenzo Cirigliano
- Department of Urology, Molinette Hospital, University of Torino, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Mirko Preto
- Department of Urology, Molinette Hospital, University of Torino, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Marco Falcone
- Department of Urology, Molinette Hospital, University of Torino, AOU Città della Salute e della Scienza di Torino, Turin, Italy
| | - Emre Altıntas
- Department of Urology, Selcuk University School of Medicine, 42250, Konya, Turkey
| | - Murat Gül
- Department of Urology, Molinette Hospital, University of Torino, AOU Città della Salute e della Scienza di Torino, Turin, Italy.
- Department of Urology, Selcuk University School of Medicine, 42250, Konya, Turkey.
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Fernandez Crespo RE, Stroie F, Taylor L, Pignanelli M, Parker J, Carrion R. Penile fibrosis-still scarring urologists today: a narrative review. Transl Androl Urol 2024; 13:127-138. [PMID: 38404545 PMCID: PMC10891380 DOI: 10.21037/tau-23-206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 12/07/2023] [Indexed: 02/27/2024] Open
Abstract
Background and Objective Implantation of penile prosthesis (PP) into scarred and fibrotic corpora can be a difficult challenge. In this review article, we provide a review of penile fibrosis, discuss current medical and surgical management and summarize preventative strategies. Methods In this study, we searched PubMed between the years 2000-2023 for publications with search strategy: "penile fibrosis" OR "scarred corpora" OR "fibrosed corpora". Key Content and Findings This search returned a total of 137 articles. We examine the evidence for preoperative patient evaluation and penile ultrasound (US), oral phosphodiesterase-5 inhibitors, pentoxifylline, and L-arginine, vacuum device therapy and the use of surgical approaches and tools in the context of complex penile fibrosis cases. Severe penile fibrosis is most associated with priapism and infection. Estimating the degree of fibrosis via preoperative US may help set realistic patient expectations. Phosphodiesterase inhibitors and L-arginine reduce fibrosis in animal models however their impact in humans remains unclear despite theoretical advantage for their use. Vacuum device therapy may preserve penile length following priapism and infected PP cases. The use of Coloplast Narrow-Based or AMS-700 CXR implants are used primarily for severe fibrosis. Various surgical excisional/incisional techniques, the Carrion-Rossello, Mooreville Uramix cavernotomes and reverse cutting scissors are all options, and their use varies from case to case. Finally, prevention of penile fibrosis in patients with history of penile implant infection and the safety of early implantation of a penile implant in patients with refractory priapism is encouraged. Conclusions The management of penile fibrosis remains a challenge but there are multiple options to assist clinicians. Complex cases should be managed and studied at high volume centers.
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Affiliation(s)
| | - Florian Stroie
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Laura Taylor
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Michael Pignanelli
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Justin Parker
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
| | - Rafael Carrion
- University of South Florida, Morsani College of Medicine, Tampa, FL, USA
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Shirazi M, Dehghanmanshadi A, Sadr S, Jahanabadi Z. Comparison between combination of tamsulosin and Pentoxifylline versus tamsulosin alone in the treatment of lower urinary tract symptoms due to benign prostate hyperplasia: A preliminary study. Low Urin Tract Symptoms 2024; 16:e12509. [PMID: 38282138 DOI: 10.1111/luts.12509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 10/06/2023] [Accepted: 12/01/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND In older adults, bladder outlet obstruction (BOO) is prevalent, primarily due to benign prostatic hyperplasia (BPH). These patients' lower urinary tract symptoms can be treated surgically and with medical therapy. Compared to standard treatment with tamsulosin, Pentoxifylline, a phosphodiesterase inhibitor, could benefit patients with BOO due to its properties on microcirculatory blood flow and oxygenation of ischemic tissues. Hence, this trial intended to study the efficacy of Pentoxifylline combined with tamsulosin in treating BOO patients. MATERIALS AND METHODS This randomized, double-blind clinical trial recruited 60 patients with BPH from a single center in 2022. Upon consent of patients meeting the eligibility criteria, they were randomly allocated to intervention (Pentoxifylline + tamsulosin) and control (placebo + tamsulosin) groups. The patients were evaluated for international prostate symptom score (IPSS), quality of life (QoL), maximum urinary flow rate (Qmax ) by uroflowmetry, and post-void residual volume (PVR) by abdominal sonography at the onset of the study and after the 12th week. RESULTS Patients who used the combination therapy had significantly better results of prostate symptoms and quality of life improvement (IPSS: -36.6%, QoL: -45.3%) compared to patients who received tamsulosin alone (IPSS: -21.2%, QoL: -27.7%) (p < .001). Also, this study shows that the improvement in maximum urinary flow rate and residual volume by combination therapy is significantly higher (Qmax : +42.5%, PVR: -42.6%) compared to monotherapy (Qmax : +25.1%, PVR: -26.1%) (p < .001). CONCLUSION When combined with tamsulosin, Pentoxifylline could significantly improve the lower urinary symptoms of BPH patients. It is well tolerated, and the treatment outcomes are better in patients who receive the combination of Pentoxifylline and tamsulosin than those who only receive tamsulosin.
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Affiliation(s)
- Mehdi Shirazi
- Department of Urology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
- Histomorphometry and Stereology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Dehghanmanshadi
- Department of Urology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Soroush Sadr
- Department of Urology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zahra Jahanabadi
- Department of Urology, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
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Role of Oxidative Stress in Peyronie's Disease: Biochemical Evidence and Experiences of Treatment with Antioxidants. Int J Mol Sci 2022; 23:ijms232415969. [PMID: 36555611 PMCID: PMC9781573 DOI: 10.3390/ijms232415969] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 11/29/2022] [Accepted: 12/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Peyronie's disease (PD) is a chronic inflammatory condition affecting adult males, involving the tunica albuginea of the corpora cavernosa of the penis. PD is frequently associated with penile pain, erectile dysfunction, and a secondary anxious-depressive state. The etiology of PD has not yet been completely elucidated, but local injury is generally recognized to be a triggering factor. It has also been widely proven that oxidative stress is an essential, decisive component in all inflammatory processes, whether acute or chronic. Current conservative medical treatment comprises oral substances, penile injections, and physical therapy. AIM This article intends to show how antioxidant therapy is able to interfere with the pathogenetic mechanisms of the disease. METHOD This article consists of a synthetic narrative review of the current scientific literature on antioxidant therapy for this disease. RESULTS The good results of the antioxidant treatment described above also prove that the doses used were adequate and the concentrations of the substances employed did not exceed the threshold at which they might have interacted negatively with the mechanisms of the redox regulation of tissue. CONCLUSIONS We believe new, randomized, controlled studies are needed to confirm the efficacy of treatment with antioxidants. However, we consider the experiences of antioxidant treatment which can already be found in the literature useful for the clinical practice of urologists in the treatment of this chronic inflammatory disease.
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Paulis G, De Giorgio G. Patients with Peyronie's disease achieve complete plaque regression after multimodal treatment with antioxidants: a case series. J Med Case Rep 2022; 16:359. [PMID: 36207748 PMCID: PMC9547413 DOI: 10.1186/s13256-022-03614-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/16/2022] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Gianni Paulis
- Peyronie's Care Center, Department of Uro-Andrology, Castelfidardo Medical Team, Castelfidardo Clinical Analysis Center, Rome, Italy.
| | - Giovanni De Giorgio
- Ultrasound Diagnostics Section, Department of Uro-Andrology, Castelfidardo Medical Team, Castelfidardo Clinical Analysis Center, Rome, Italy
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Piraino J, Chaudhary H, Ames K, Okoye F, Sterling M, Clavell-Hernandez J, Levine L, Ziegelmann MJ. A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature. Sex Med Rev 2022; 10:698-713. [PMID: 37051957 DOI: 10.1016/j.sxmr.2022.08.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 07/21/2022] [Accepted: 08/10/2022] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities. OBJECTIVES To review the criteria used to define acute and chronic phase PD in modern PD intervention studies. METHODS We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis. RESULTS We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain. CONCLUSION Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.
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Israeli JM, Lokeshwar SD, Efimenko IV, Masterson TA, Ramasamy R. The potential of platelet-rich plasma injections and stem cell therapy for penile rejuvenation. Int J Impot Res 2022; 34:375-382. [PMID: 34743193 PMCID: PMC9072597 DOI: 10.1038/s41443-021-00482-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 09/28/2021] [Accepted: 10/11/2021] [Indexed: 11/09/2022]
Abstract
Penile concerns include erectile dysfunction (ED) and Peyronie disease (PD). Restorative therapies including Stem Cell Therapy (SCT) and Platelet Rich Plasma (PRP) injections are proposed to treat these concerns. SCT encompasses the harvesting and injection of mesenchymal stem cells or stromal vascular fractions from various tissue sources. PRP is derived autologously from a patient's plasma and is then injected into the penile tissue. These therapies repair damaged penile tissue and promote both new cellular and vascular growth, as demonstrated in basic science studies. Human trials on SCT and PRP for both ED and PD and have yielded promising results with few side effects. While encouraging, small cohort size and lack of blinding or placebo control limit these studies' external validity. Recently, the first double-blinded randomized controlled trial on PRP for ED was published, providing significant evidence of efficacy. With the rapid commercial availability of SCT and PRP for ED and PD, it is imperative to perform more randomized and placebo-controlled trials with standardized procedures and preparations to evaluate efficacy and safety. This narrative review will summarize the available literature on these penile restorative therapies to date.
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Affiliation(s)
- Joseph M Israeli
- Department of Urology, Miller School of Medicine, Miami, FL, USA
| | - Soum D Lokeshwar
- Department of Urology, Yale University School of Medicine, New Haven, CT, USA
| | - Iakov V Efimenko
- Department of Urology, Miller School of Medicine, Miami, FL, USA
| | | | - Ranjith Ramasamy
- Department of Urology, Miller School of Medicine, Miami, FL, USA.
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Chung E, Yafi FA. Pharmacotherapy in Peyronie's disease: a state-of-the-art review on established contemporary and emerging drugs. Expert Opin Pharmacother 2022; 23:1035-1042. [PMID: 35209789 DOI: 10.1080/14656566.2022.2043274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Current clinical guidelines on Peyronie's disease (PD) advocate non-surgical treatment options as the first-line therapy despite inconsistent clinical outcomes when compared to definitive penile reconstructive surgery. AREAS COVERED This article examines the current understanding of established contemporary and emerging pharmacotherapies for PD. Emphasis has been placed on published clinical studies on drugs in the last 10 years. EXPERT OPINION Published studies have shown that combination therapy is likely more effective than monotherapy. Combined treatment modalities involving various oral and/or intralesional pharmacotherapies together with mechanical devices or clinical psychosexual therapy may provide additional or synergistic benefits for PD patients. A multidisciplinary approach coupled with more novel targets for pharmacological intervention could deliver a more effective treatment paradigm to prevent or at least delay the need for definitive penile reconstructive surgery. Drugs targeting the inhibition of TGF-β1 pathway and myofibroblast transformation are of great interest and studies into next-generation genetic sequencing and transcriptional biomarker regulatory pathways in PD will provide useful insights into the pathophysiology of PD, and assist the development of future regenerative technology including cellular-based therapies to target various anti-fibrotic molecular mechanisms and the potential to be integrated into existing treatment armamentarium for PD.
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Affiliation(s)
- Eric Chung
- AndroUrology Centre, Brisbane Qld and Sydney, NSW, Australia.,Department of Urology, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia.,Department of Urology, Macquarie University Hospital, Sydney, NSW, Australia
| | - Faysal A Yafi
- Department of Urology, University of California Irvine, Orange, CA, USA
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Peyronie Disease as a Marker of Inflammation-Is There Hope on the Horizon? Am J Med 2021; 134:1218-1223. [PMID: 34273285 DOI: 10.1016/j.amjmed.2021.06.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/14/2021] [Accepted: 06/18/2021] [Indexed: 12/26/2022]
Abstract
Although the description of Peyronie disease, a connective tissue disorder involving the growth of fibrous plaques in the soft tissue of the penis, is attributed to François de la Peyronie, surgeon to Louis XV of France, there are reports previous to that time. Over the intervening 450 years, a variety of empiric treatments, varying in barbarity, have been proposed. The frequency of this condition and the etiology of the fibrosis are unknown. Quality of life for affected men and their partners is adversely impacted. In this review, the authors summarize the history of the discovery of this condition, review contemporary management approaches, and address the pathophysiology leading to the underlying disordered fibrosis. The potential immunomodulatory role of testosterone as well as inflammatory conditions and environmental stimuli that may provoke fibrosis are also considered. Peyronie disease may be part of a spectrum of fibrotic conditions, including Dupuytren contracture. Treatment strategies to date have focused on reversing fibrosis; work is needed to prevent fibrosis and to accurately document disease prevalence.
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Serag-Eldin YMA, Mahmoud WH, Gamea MM, Hegab DS. Intralesional pentoxifylline, triamcinolone acetonide, and their combination for treatment of keloid scars. J Cosmet Dermatol 2021; 20:3330-3340. [PMID: 34138506 DOI: 10.1111/jocd.14305] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/24/2021] [Accepted: 06/14/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Keloids are common fibroproliferative tumors, and their treatment still represents a dilemma. Intralesional triamcinolone acetonide (TAC) injection is effective, but frequently associated with side effects. Pentoxifyllin (PTX) is a vasodilator, anti-inflammatory, and antifibrotic agent. Its intralesional injection in keloids has not been evaluated yet. AIMS Evaluating the efficacy and safety of intralesional PTX versus intralesional TAC and their combination for treatment of keloids. PATIENTS/METHODS Thirty patients with keloids were divided into three equal groups and treated by intralesional injection of TAC, PTX, or their combination (admixed in 1:1 ratio). Injections were repeated every 3 weeks until lesional flattening or for maximum of 5 sessions. The evaluation was done using the Vancouver Scar Scale and the Verbal Rating Scale for pain and itching. RESULTS A significant improvement in VSS was detected in all groups. Significantly better improvements in keloid height, pliability, pain, and itching were detected in the TAC and combination groups than in the PTX group. There was a significantly higher incidence of side effects (atrophy, hypopigmentation, telangiectasia, and precipitation of TAC) in the TAC group than in the combination group, while no side effects were reported in the PTX group. A statistically significant reduction in the number of treatment sessions (required to achieve best results) was detected in patients in the combination group. CONCLUSIONS Intralesional injection of PTX is a potentially helpful, safe, and well-tolerated therapeutic tool for keloids, but with lower efficacy than intralesional TAC when used solely. Combining PTX and TAC produces significantly better results for keloid treatment and lowers the risk of TAC-induced side effects.
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Affiliation(s)
| | | | - Mohamed Mahmoud Gamea
- Dermatology and Venereology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Doaa Salah Hegab
- Dermatology and Venereology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
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Ferretti L, Madec FX, Akakpo W, Methorst C, Carnicelli D, Terrier JE, Morel Journel N, Beley S, Graziana JP, Marcelli F, Hupertan V, Yiou R, Ben-Naoum K, Savareux L, Huyghe E, Faix A. [French Urological Association (AFU) guidelines for Peyronie's disease assessment and treatment]. Prog Urol 2021; 31:477-494. [PMID: 33941460 DOI: 10.1016/j.purol.2020.11.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/31/2020] [Accepted: 11/09/2020] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Peyronie's disease is a common cause for consultation in urology. Many controversies surround its treatment. No French Guidelines have been published so far. The Committee of Andrology and Sexual Medicine of the French Association of Urology therefore offers a series of evidence-based recommendations. MATERIALS AND METHODS These recommendations are made according to the ADAPTE method, based on European (EAU, ESSM), American (AUA, ISSM) and Canadian (CAU) recommendations, integrating French specificities due to the availability of treatments, and an update of the recent bibliography. RESULTS The assessment of the disease is clinical. Patients with functional impairment or significant psychological repercussions may be offered treatment. The benefits and drawbacks of each treatment should be explained to the patient. Regarding non-surgical treatments, no available treatment has market authorization in France. Vitamin E is not recommended. Analgesic (oral or low-intensity shock waves) or proerectile treatments may be offered as needed, as well as traction therapy. Due to the unavailability of collagenase injections, verapamil injections may be offered. Surgical treatments are to be considered in the stabilized phase of the disease, and consist of performing a plication, an incision-graft or the placement of a penile implant according to the patient's wishes, the curvature and the penis size, as well as erectile function. Combination treatments can be offered. CONCLUSION The management of Peyronie's disease is complex, and the levels of evidence for treatments are generally low. The success of treatment will depend on the quality of the initial assessment, the patient's information and understanding of the expected effects, and the practitioner's experience.
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Affiliation(s)
- L Ferretti
- Service d'urologie, MSP Bordeaux Bagatelle, Talence.
| | - F-X Madec
- Service d'urologie, hôpital Foch, Suresnes
| | - W Akakpo
- Département d'urologie, Hôpital Pitié-Salpétrière, Paris
| | - C Methorst
- Service d'urologie, hôpital des 4 Villes, Saint-Cloud
| | - D Carnicelli
- Service d'urologie, hôpital Privé Jean Mermoz, Lyon
| | - J-E Terrier
- Service d'urologie, Hôpital Lyon Sud, Pierre-Bénite
| | | | | | - J-P Graziana
- Clinique Mutualiste de la Porte de l'Orient, Lorient
| | - F Marcelli
- Service d'urologie, andrologie et transplantation rénale, hôpital Huriez CHU Lille, France
| | | | - R Yiou
- Département d'urologie, CHU Henri Mondor, Créteil
| | | | - L Savareux
- Service d'urologie, Hôpital Privé la Chataigneraie, Beaumont
| | - E Huyghe
- Département d'urologie, CHU Rangueil, Toulouse
| | - A Faix
- Centre d'urologie du Polygone, Montpellier
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Li EV, Esterquest R, Pham MN, Panken EJ, Amarasekera C, Siebert A, Bajic P, Levine LA. Peyronie's disease: pharmacological treatments and limitations. Expert Rev Clin Pharmacol 2021; 14:703-713. [PMID: 33719851 DOI: 10.1080/17512433.2021.1903873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Introduction: Peyronie's disease (PD) is a disorder of the tunica albuginea from disordered and excessive deposition of collagen resulting in a palpable scar, pain, erect penile deformity and erectile dysfunction that significantly impacts patients both physically and emotionally.Areas Covered: Several treatment options have been described for PD, including shockwave therapy, traction therapy, both oral and intralesional pharmacological options, and surgery. This review seeks to examine the data for different types of non-surgical treatments for PD. We review how various treatment modalities impact several relevant clinical endpoints for Peyronie's disease, including effects on pain, penile curvature, plaque formation, and erectile function. We performed a literature search using PubMed and SCOPUS while referencing AUA, EAU, and CUA guidelines for management of Peyronie's Disease for studies published 1980-2020.Expert opinion: Intralesional collagenase injections have the strongest evidence and are the only FDA approved intralesional treatment for PD. Penile traction therapy (PTT) is low risk and may be beneficial in patients willing to invest significant time using the devices. Furthermore, oral combination therapy with other modalities may provide some benefit. Further investigation is required to better understand pathophysiology of PD and clarify the therapeutic utility of existing treatments, potentially with a multimodal strategy.
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Affiliation(s)
- Eric V Li
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Robert Esterquest
- Division of Urology, Rush University Medical Center, Chicago, Illinois, USA
| | - Minh N Pham
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Evan J Panken
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Channa Amarasekera
- Division of Urology, Rush University Medical Center, Chicago, Illinois, USA
| | - Aisha Siebert
- Department of Urology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
| | - Petar Bajic
- Cleveland Clinic, Center for Men's Health, Glickman Urological and Kidney Institute, Cleveland, Ohio, USA
| | - Laurence A Levine
- Division of Urology, Rush University Medical Center, Chicago, Illinois, USA
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Rainer QC, Rodriguez AA, Bajic P, Galor A, Ramasamy R, Masterson TA. Implications of Calcification in Peyronie's Disease, A Review of the Literature. Urology 2021; 152:52-59. [PMID: 33476600 DOI: 10.1016/j.urology.2021.01.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Revised: 12/14/2020] [Accepted: 01/03/2021] [Indexed: 02/06/2023]
Abstract
A common characteristic of Peyronie's Disease (PD) is plaque calcification, which is associated with decreased response to treatments and higher rates of surgical intervention. Despite its prevalence in the PD population, the literature on plaque calcification is limited. While the diagnosis of PD is mostly clinical, imaging modalities such as ultrasound can be used to identify plaque calcification. The proper identification of plaque calcification is crucial for guiding management and setting therapeutic expectations for patients with PD. Herein we discuss what is known about PD plaque calcification, including epidemiology, etiology, diagnosis, and management.
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Affiliation(s)
| | | | | | - Anat Galor
- University of Miami Miller School of Medicine, Miami FL; Bruce W Carter VA Medical Center, Miami FL
| | | | - Thomas A Masterson
- University of Miami Miller School of Medicine, Miami FL; Bruce W Carter VA Medical Center, Miami FL.
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Abstract
Treating men with Peyronie's disease remains a challenging problem facing clinicians working across urology and sexual medicine fields. Patients can often be left disappointed by current treatment paradigms, and an overall lack of suitable molecular targets has limited the options for novel, effective medical therapy. Managing men with Peyronie's disease often involves careful counselling alongside multifaceted and possible combination treatments to help improve symptoms whilst ameliorating potential side effects of therapy. We review the latest medical literature and evidence in the contemporary management of Peyronie's disease.
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Affiliation(s)
- Asrit Babu
- Department of Urology, Leeds Teaching Hospitals, Leeds, UK
| | - Oliver Kayes
- Department of Urology, Leeds Teaching Hospitals, Leeds, UK
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15
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Farrell MR, Ziegelmann MJ, Levine LA. Minimally invasive therapies for Peyronie's disease: the current state of the art. Transl Androl Urol 2020; 9:S269-S283. [PMID: 32257868 PMCID: PMC7108992 DOI: 10.21037/tau.2019.08.06] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 07/25/2019] [Indexed: 01/18/2023] Open
Abstract
Peyronie's disease (PD) is a relatively common condition that can result in significant penile deformity, sexual dysfunction, and psychological bother. Surgical straightening offers the highest probability of success during the stable phase of the disease. However, for men in the acute phase of PD or for those with less severe deformity who elect to avoid surgery, a variety of non-surgical treatment options are available. Oral therapies, including L-citrulline and pentoxifylline, are most useful as part of a combination regimen rather than as monotherapy. Intralesional therapy with IFN-α2b, verapamil, and collagenase clostridium histolyticum (CCH) can cause significant reduction in penile curvature, yet these results may not be clinically significant for men with more severe curvature. Further investigation into the timing of administration and optimal patient characteristics is required. Penile traction therapy offers a clinically significant improvement in penile length and curvature. However, this has traditionally required hours of daily therapy. Overall, a combination of oral, topical, injection and traction therapies may provide the most significant benefit among the non-surgical modalities for PD.
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Affiliation(s)
- M Ryan Farrell
- Division of Urology, Rush University Medical Center, Chicago, IL, USA
| | | | - Laurence A Levine
- Division of Urology, Rush University Medical Center, Chicago, IL, USA
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Outcomes of Surgery in Peyronie’s Disease Following Intralesional Collagenase Clostridium Histolyticum Injections. Curr Urol Rep 2019; 20:42. [DOI: 10.1007/s11934-019-0910-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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17
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Gallo L, Sarnacchiaro P. Ten-year experience with multimodal treatment for acute phase Peyronie's disease: A real life clinical report. Actas Urol Esp 2019; 43:182-189. [PMID: 30704797 DOI: 10.1016/j.acuro.2018.08.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2018] [Revised: 08/04/2018] [Accepted: 08/27/2018] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To present our experience with multimodal therapy for Peyronie's disease. METHODS Retrospective data were collected since 2008 to 2017. The following features were evaluated at baseline and after treatment: age, duration of disease, erectile function, erected penile curvature, and stretched penile length. All patients were offered the same protocol including: 12 intralesional verapamil injections, oral therapy (OT) ?L-arginine 2g once and pentoxifylline 400mg 3 times a day for 6 months?, and penile traction therapy. The adherence to each of the 3 components of multimodal treatment was evaluated. RESULTS One hundred and seventy-seven individuals were considered. Depending on the grade of adherence our survey was divided into 3 groups. Group 1: patients who only completed OT; group 2: men who accomplished OT and intralesional verapamil injections; group 3: patients who completed the entire protocol. Seventy-six, 45 and 56 men were assigned to group 1, 2 and 3 respectively. The mean age at the diagnosis was 59±8.4, 59.1±5.9 and 54.2±4.8 years, while the mean duration of the disease was 6.3±3.4, 4.8±2.9 and 3.9±3.1 months in group 1, 2 and 3. The erected penile curvature before and after treatment was 24.2±9 and 23.7±8.9° in group 1 (P<.36); 25.4±16.8 and 24.1±13.6° in group 2 (P<.34), and 34.3±17.9 and 26.1±17.2° in group 3 (P<.001). CONCLUSIONS OT alone was successful to block the progression of the disease. The add of intralesional verapamil injections to OT brought only mild improvements. The complete protocol significantly reduced erected penile curvature and improved erectile function.
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Affiliation(s)
- L Gallo
- Gallo Uro-Andrology Centre, Nápoles, Italia.
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19
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Elseweidy MM, Mohamed HE, Elrashidy RA, Atteia HH, Elnagar GM, Ali AEM. Potential therapeutic roles of 10-dehydrogingerdione and/or pentoxifylline against calcium deposition in aortic tissues of high dietary cholesterol-fed rabbits. Mol Cell Biochem 2018; 453:131-142. [PMID: 30173373 DOI: 10.1007/s11010-018-3438-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 08/24/2018] [Indexed: 02/08/2023]
Abstract
The present study aimed to investigate the inhibitory effects of 10-dehydrogingerdione (10-DHGD) and pentoxifylline (PTX) either individually or in combined form on calcium deposition in high cholesterol diet (HCD)-fed rabbits as compared to atorvastatin (ATOR), and to clarify the underlying mechanisms. Three-months-old male New Zealand white rabbits received either normal chow or HCD for 12 weeks. The latter group was subdivided into five groups and concurrently treated either with vehicle (dyslipidemic control), ATOR, 10-DHGD, PTX or combined 10-DHGD and PTX. Blood samples and aortic tissue were collected for biochemical and histological analyses. HCD-fed rabbits displayed dyslipidemia, inflammation, atherosclerotic lesions, and calcium deposition in aortas as compared to normal group. This was associated with up-regulation of bone morphogenetic protein-2 (BMP-2), wingless-type MMTV integration site family 3A (Wnt3a) mRNA levels and osteopontin expression in their aortic tissue, along with higher serum alkaline phosphatase and osteocalcin levels. Furthermore, a marked decrease in osteoprotegerin, along with a significant increase in receptor activator of NF-κB(RANK) levels, was found in aortic tissue of dyslipidemic rabbits. 10-DHGD and PTX monotherapy significantly modulated the afore-mentioned calcification markers and attenuated aortic calcification to greater extent than ATOR. Combination of 10-DHGD and PTX exerted more anti-calcifying effect than either individual drug. Our findings suggested therapeutic roles of 10-DHGD and PTX against aortic calcium deposition in dyslipidemic rabbits, likely mediated by HDL-raising effect and attenuation of associated inflammation. Combination of 10-DHGD and PTX may represent a promising therapeutic strategy for aortic calcification associated with atherosclerosis.
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Affiliation(s)
- Mohamed M Elseweidy
- Department of Biochemistry, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt.
| | - Hoda E Mohamed
- Department of Biochemistry, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Rania A Elrashidy
- Department of Biochemistry, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Hebatallah H Atteia
- Department of Biochemistry, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt.,Department of Pharmaceutical Chemistry, Faculty of Pharmacy, University of Tabuk, Tabuk, Kingdom of Saudi Arabia
| | - Gehad M Elnagar
- Department of Biochemistry, Faculty of Pharmacy, Zagazig University, Zagazig, 44519, Egypt
| | - Abd El-Monem Ali
- Department of Pathology, Faculty of Veterinary Medicine, Zagazig University, Zagazig, 44519, Egypt
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20
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21
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Collagenase Clostridium Histolyticum in the Treatment of Urologic Disease: Current and Future Impact. Sex Med Rev 2018; 6:143-156. [DOI: 10.1016/j.sxmr.2017.03.005] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 03/22/2017] [Accepted: 03/24/2017] [Indexed: 01/09/2023]
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22
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Paulis G, Paulis A, Romano G, Barletta D, Fabiani A. Rationale of combination therapy with antioxidants in medical management of Peyronie's disease: results of clinical application. Res Rep Urol 2017; 9:129-139. [PMID: 28791261 PMCID: PMC5530853 DOI: 10.2147/rru.s141748] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Peyronie's disease (PD) is a connective tissue disorder involving the tunica albuginea of the corpora cavernosa of the penis. We have published several studies describing a "combined therapy" for PD patients, but the present study aims to clearly demonstrate how the association between various antioxidants in PD treatment can significantly increase the likelihood of therapeutic success. We used the following substances: silymarin, ginkgo biloba, vitamin E, bilberry, topical diclofenac sodium, and pentoxifylline (PTX). We analyzed the therapeutic impact and possible side effects of one or more antioxidants in patients with early-stage PD. To clearly prove that it is possible to achieve better results when combining more than one agent, we designed this study with five treatment groups, corresponding, respectively, to the administration of a single oral antioxidant; two oral antioxidants; three oral antioxidants; five oral antioxidants + local diclofenac; and five oral antioxidants + local diclofenac + PTX by perilesional injection. One hundred and twenty patients were assigned to five groups of treatment designed according to the abovementioned study aim. Outcomes after 6 months of treatment showed that combined antioxidant therapy is effective in treating PD. Statistical analysis showed significant differences between the treatment groups with regard to: improvement and disappearance of penile pain; percentage of reduction in the volume of penile plaque; reduction in penile curvature; recovery of erectile function in patients with erectile dysfunction; increase in the International Index of Erectile Function score; and reduction of psychosexual impact. Furthermore, we observed that the clinical efficacy of combined therapy is greater when topical use of diclofenac gel and perilesional injection of PTX are added to oral treatment with more than one antioxidant. Although several articles have already been published reporting the effectiveness of combined treatment in PD, this is the first study clearly proving how, as the number of substances used in treatment rises, a proportionally greater therapeutic effect is achieved.
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Affiliation(s)
- Gianni Paulis
- Department of Surgical Sciences, Andrology Center, Regina Apostolorum Hospital, Rome, Italy.,Department of Uro-Andrology, Peyronie's Disease Care Center, Rome, Italy
| | - Andrea Paulis
- Section of Psycho-Sexology, Peyronie's Disease Care Center, Rome, Italy
| | - Gennaro Romano
- Department of Urologic Oncology, Section of Avellino, Italian League against Cancer, Avellino, Italy
| | - Davide Barletta
- Department of Urology, Andrology Center, San Matteo Hospital, Pavia, Italy
| | - Andrea Fabiani
- Department of Surgery, Section of Urology and Andrology, Macerata, Italy
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23
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Recent Pathophysiological Aspects of Peyronie's Disease: Role of Free Radicals, Rationale, and Therapeutic Implications for Antioxidant Treatment-Literature Review. Adv Urol 2017; 2017:4653512. [PMID: 28744308 PMCID: PMC5514334 DOI: 10.1155/2017/4653512] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 05/30/2017] [Indexed: 12/13/2022] Open
Abstract
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.
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Chung E, Ralph D, Kagioglu A, Garaffa G, Shamsodini A, Bivalacqua T, Glina S, Hakim L, Sadeghi-Nejad H, Broderick G. Evidence-Based Management Guidelines on Peyronie's Disease. J Sex Med 2017; 13:905-23. [PMID: 27215686 DOI: 10.1016/j.jsxm.2016.04.062] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Revised: 03/19/2016] [Accepted: 03/27/2016] [Indexed: 12/26/2022]
Abstract
INTRODUCTION Despite recent advances in our knowledge and treatment strategies in Peyronie's Disease (PD), much remained unknown about this disease. AIM To provide a clinical framework and key guideline statements to assist clinicians in an evidence-based management of PD. METHODS A systematic literature search was conducted to identify published literature relevant to PD. The search included all relevant articles published up to June 2015, including preclinical studies and published guidelines. References used in the text were assessed according to their level of evidence, and guideline recommendations were graded based on the Oxford Centre for Evidence-Based Medicine Levels of Evidence. Owing to the paucity of larger series and randomized placebo-controlled trials with regard to surgical intervention, guideline statements are provided as clinical principle or expert opinion. MAIN OUTCOME MEASURES This literature was discussed at a panel meeting, and selected articles with the highest evidence available were used to create consensus guideline statements for the Fourth International Consultation on Sexual Medicine guidelines on PD. RESULTS In addition to existing Third International Consultation on Sexual Medicine guidelines on PD, seven new summary recommendations were created. CONCLUSION A greater understanding of the scientific basis of PD is greatly needed to address our understanding of the pathophysiology, clinical epidemiology, psychosocial, and diagnostic assessment as well as treatment strategies.
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Affiliation(s)
- Eric Chung
- Department of Urology, University of Queensland, Princess Alexandra Hospital, Brisbane, QLD, Australia; AndroUrology Centre, St. Andrew's War Memorial Hospital, Brisbane, QLD, Australia.
| | - David Ralph
- Institute of Urology, University College London Hospital, London, UK
| | - Ates Kagioglu
- Department of Urology, Istanbul Faculty of Medicine, Istanbul, Turkey
| | - Guilio Garaffa
- Institute of Urology, University College London Hospital, London, UK
| | | | - Trinity Bivalacqua
- James Buchanan Brady Urological Institute and Department of Urology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Sidney Glina
- Instituto H. Ellis and Department of Urology, Ipiranga Hospital, Sao Paulo, Brazil
| | - Lawrence Hakim
- Department of Urology, Cleveland Clinic Florida, Weston, FL, USA
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Wen WX, Lee SY, Siang R, Koh RY. Repurposing Pentoxifylline for the Treatment of Fibrosis: An Overview. Adv Ther 2017; 34:1245-1269. [PMID: 28484954 DOI: 10.1007/s12325-017-0547-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2017] [Indexed: 12/20/2022]
Abstract
Fibrosis is a potentially debilitating disease with high morbidity rates. It is estimated that half of all deaths that occur in the USA are attributed to fibrotic disorders. Fibrotic disorders are characterized primarily by disruption in the extracellular matrix deposition and breakdown equilibrium, leading to the accumulation of excessive amounts of extracellular matrix. Given the potentially high prevalence of fibrosis and the paucity of agents currently available for the treatment of this disease, there is an urgent need for the identification of drugs that can be utilized to treat the disease. Pentoxifylline is a methylxanthine derivative that is currently approved for the treatment of vascular diseases, in particular, claudication. Pentoxifylline has three main properties: improving the rheological properties of blood, anti-inflammatory, and antioxidative. Recently, the effectiveness of pentoxifylline in the treatment of fibrosis via attenuating and reversing fibrotic lesions has been demonstrated in several clinical trials and animal studies. As a result of the limited availability of antifibrotic agents in the long-term treatment of fibrosis that can attenuate and even reverse fibrotic lesions effectively, it would be of particular importance to consider the potential clinical utility of pentoxifylline in the treatment of fibrosis. Thus, this paper discusses the evolving roles of pentoxifylline in the treatment of different types of fibrosis.
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Affiliation(s)
- Wei Xiong Wen
- International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia
| | - Siang Yin Lee
- Colloids and Interface Science Centre, Centre of Excellence, RRIM Sungai Buloh Research Station, Malaysian Rubber Board, 47000, Sungai Buloh, Selangor, Malaysia
| | - Rafaella Siang
- International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia
- Acute Medicine, George Eliot Hospital NHS Trust, College St, Nuneaton, UK
| | - Rhun Yian Koh
- International Medical University, No. 126, Jalan Jalil Perkasa 19, Bukit Jalil, 57000, Kuala Lumpur, Malaysia.
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Abstract
Peyronie's disease (PD) is a localized, wound-healing, connective tissue disorder of the penis characterized by scarring of the tunica albuginea. This fibrous inelastic scar leads to penile pain, penile deformity and erectile dysfunction (ED), and a difficulty performing coitus. Over the past several decades, a myriad of oral agents for the treatment of PD have been studied and suggested. While the gold standard of care remains surgical therapy, many physicians continue to prescribe oral and intralesional injections for treatment during the acute phase of the disease. This article seeks to summarize the different oral therapy agents for PD and the research associated with each medication. While the American Urological Association has not recommended most of the mentioned medications for the treatment of PD, two newer therapies have shown success and have the potential of becoming baseline treatments for the acute phase of PD.
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Affiliation(s)
| | - Run Wang
- University of Texas Medical School at Houston, Houston, TX, USA
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27
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Ostrowski KA, Gannon JR, Walsh TJ. A review of the epidemiology and treatment of Peyronie's disease. Res Rep Urol 2016; 8:61-70. [PMID: 27200305 PMCID: PMC4857830 DOI: 10.2147/rru.s65620] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Introduction Peyronie’s disease (PD) has significant effect on patients and their partners. We provide a current review of the epidemiology as well as the nonsurgical and surgical treatment of PD. Materials and methods Review of literature pertaining to PD with focus on epidemiology and treatment options. Conclusion PD is common and likely underreported. The availability of new and highly effective treatment options will catalyze patient awareness and subsequently the prevalence of disease.
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Affiliation(s)
| | - John R Gannon
- Department of Urology, University of Washington, Seattle, WA, USA
| | - Thomas J Walsh
- Department of Urology, University of Washington, Seattle, WA, USA
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28
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Paulis G, Barletta D, Turchi P, Vitarelli A, Dachille G, Fabiani A, Gennaro R. Efficacy and safety evaluation of pentoxifylline associated with other antioxidants in medical treatment of Peyronie's disease: a case-control study. Res Rep Urol 2015; 8:1-10. [PMID: 26770906 PMCID: PMC4706125 DOI: 10.2147/rru.s97194] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Peyronie's disease (PD) is a chronic disorder involving the tunica albuginea surrounding the corpora cavernosa of the penis. A conservative treatment is indicated in the first stage of disease. The aim of this study was to assess the therapeutic impact and possible side effects of treatment with pentoxifylline (PTX) in combination with other antioxidants in 307 patients with early-stage PD. Patients were subdivided into three groups: A, B, and C. Both groups, A and B, comprising of 206 patients, underwent treatment, whereas Group C was the control group (n=101). Treatment lasted 6 months and included the following: Group A: PTX 400 mg twice a day + propolis 600 mg/d + blueberry 160 mg/d + vitamin E 600 mg/d + diclofenac 4% gel twice/a day + PTX 100 mg via perilesional penile injection/every other week (12 injections in all); Group B: the same treatment as Group A except for the penile PTX injections. After the 6-month treatment course, we obtained the following results: actual mean decrease in plaque volume -46.9% and -24.8% in Group A and B, respectively (P<0.0001); mean curvature reduction -10.1° and -4.8°, respectively (P,0.0001); resolution of pain in 67.6% and 67.2% of cases, respectively (P=0.961); recovery of normal penile rigidity in 56.09% and 23.5% of cases, respectively (P=0.005). After 6 months, progression of disease was observed in all patients belonging to Group C: plaque volume +123.3%; curvature +15.7°; no recovery of penile rigidity. The statistically significant results of our study show that multimodal treatment with PTX in association with other antioxidants and topical diclofenac is efficacious in treating early-stage PD. Furthermore, treatment proved to be more effective when PTX was administered both orally and by penile injection. No serious adverse effects occurred.
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Affiliation(s)
- Gianni Paulis
- Regina Apostolorum Hospital, Andrology Center, Albano L, Italy
- Castelfidardo Medical Team, Peyronie’s Disease Care Center, Rome, Italy
| | - Davide Barletta
- Department of Urology, Andrology Center, San Matteo Hospital, Pavia, Italy
| | - Paolo Turchi
- Azienda ASL 4 Prato – Andrology Service, Prato, Italy
| | | | | | - Andrea Fabiani
- Department of Surgery, Section of Urology and Andrology, Macerata, Italy
| | - Romano Gennaro
- Department of Urologic Oncology, Section of Avellino, Italian League Against Cancer, Avellino, Italy
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Hussein AA, Alwaal A, Lue TF. All about Peyronie's disease. Asian J Urol 2015; 2:70-78. [PMID: 29264123 PMCID: PMC5730743 DOI: 10.1016/j.ajur.2015.04.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2014] [Revised: 01/31/2015] [Accepted: 02/10/2015] [Indexed: 12/27/2022] Open
Abstract
Peyronie's disease (PD) is an acquired connective tissue disorder of the tunica albuginea of the corpus cavernosum, characterized by excessive fibrosis and plaque formation. PD can result in significant physical and psychological morbidity; as it may prevent intercourse and cause adverse impacts on partner relationships. The exact etiology and pathophysiology remain unclear, and many misconceptions about the disease associations, course and treatment exist. The disease has two distinct stages. The acute stage is characterized by pain, and disease may progress during this stage. Non-surgical managements at this stage aim to alleviate pain and stabilize the disease. Results for non-surgical treatment are often conflicting. The chronic stage occurs 6–12 months later, where pain disappears and the deformity stabilizes. Surgical treatment is reserved for significant deformity or with inability to penetrative intercourse. The choice of the surgical technique depends on the length of the penis, degree of deformity, erectile function, patients' expectations and surgeon's preference.
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Affiliation(s)
- Ahmed A Hussein
- Department of Urology, University of California, San Francisco, CA, USA.,Department of Urology, Cairo University, Egypt
| | - Amjad Alwaal
- Department of Urology, University of California, San Francisco, CA, USA.,Department of Urology, King Abdul Aziz University, Saudi Arabia
| | - Tom F Lue
- Department of Urology, University of California, San Francisco, CA, USA
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Hussein AA, Alwaal A, Lue TF. WITHDRAWN: All about Peyronie’s disease. Asian J Urol 2015. [DOI: 10.1016/j.ajur.2015.02.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Pentoxifylline is a methyl-xanthine derivative with many anti inflammatory effects. Pentoxifylline has been found to be effective for many dermatological as well as non-dermatological conditions. It has been used both as primary drug as well as adjuvant and is a safe and relatively cost-effective alternative drug. In this article, we review the literature and highlight various important aspects of pentoxifylline.
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Affiliation(s)
- Iffat Hassan
- Department of Dermatology, STD and Leprosy, Government Medical College Srinagar, University of Kashmir, Jammu and Kashmir, India
| | - Konchok Dorjay
- Department of Dermatology, STD and Leprosy, Government Medical College Srinagar, University of Kashmir, Jammu and Kashmir, India
| | - Parvaiz Anwar
- Department of Dermatology, STD and Leprosy, Government Medical College Srinagar, University of Kashmir, Jammu and Kashmir, India
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32
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Medical Management of Peyronie’s Disease: a 2014 Update. CURRENT SEXUAL HEALTH REPORTS 2014. [DOI: 10.1007/s11930-014-0021-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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33
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The effect of pentoxifylline on penile cavernosal tissues in ischemic priapism-induced rat model. Int Urol Nephrol 2014; 46:1961-7. [PMID: 25027804 DOI: 10.1007/s11255-014-0769-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 06/11/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION Priapism is defined as persisting (>4 h), painful and abnormal tumescence that can occur without sexual stimulation. Three subtypes priapisms are seen-the non-ischemic priapism, intermittent and the ischemic priapism. In ischemic priapism, there is an abnormality in the veno-occlusive mechanism, resulting in venous stasis and accumulation of deoxygenated blood within the penile cavernosal tissue. Cavernosal tissue necrosis develops after extended period of ischemia and is eventually replaced by fibrotic tissue. It may results in erectile dysfunction if not treated promptly. Although, standard treatment of the ischemic priapism is penile aspiration and intracavernosal alpha-adrenergic agents, new oral agents have been investigated to reduce the cavernosal damage. In this study, the effect of different doses of pentoxifylline on cavernosal tissues was evaluated. MATERIALS AND METHODS Thirty-six male Wistar albino rats, age 5.5-6 months and weighing 250-300 g, were used in this study. The rats were randomly divided into five groups. In Group 1 (n = 7), the control group, only penectomy was performed. In Group 2 (n = 8), after 1 h of ischemic priapism, penectomy was performed. Group 3 (n = 7) received daily a 10 mg oral pentoxifylline for 4 weeks after 1 h of ischemic priapism, group 4 (n = 7) received a daily 30 mg oral pentoxifylline for 4 weeks after 1 h of ischemic priapism, and group 5 (n = 7) received a daily 100 mg oral pentoxifylline for 4 weeks after 1 h of ischemic priapism. At the completion of a 4-week period, penile tissues were obtained. Before penile tissues were obtained, intracavernosal pressures measured with electrical field stimulation and smooth muscle collagen ratio were evaluated pathologically. RESULTS Electrical field stimulation-induced intracavernosal relaxation decreased in group 2 compared with group 1 (p < 0.05). Electrical field stimulation-induced relaxation enhanced in the group 3, 4 and 5 compared to group 2 (p < 0.05). In group 2, the collagen density was significantly higher than group 1. Administration of pentoxifylline reduced the collagen density caused by ischemic priapism in groups 3, 4 and 5 compared with group 2. CONCLUSION The results of the present study showed that ischemic priapism caused damage in the penile tissues of rats, and treatment with pentoxifylline reduced the harmful effects of ischemic priapism.
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Tan RBW, Sangkum P, Mitchell GC, Hellstrom WJG. Update on Medical Management of Peyronie’s Disease. Curr Urol Rep 2014; 15:415. [DOI: 10.1007/s11934-014-0415-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Abstract
OBJECTIVE Peyronie's disease (PD) is a progressive fibrotic disorder of the penis that is characterized by formation of collagen plaques on the tunica albuginea of the penis that may result in penile deformity, pain (typically early in the disease course), and often occurs in conjunction with erectile dysfunction. This review's purpose is to raise awareness of PD among primary care physicians, who are likely to provide the initial diagnosis and information to patients. METHODS PubMed was searched for articles related to epidemiology, diagnosis, and management of PD. Reference lists of relevant articles were also examined for further pertinent research. Following the goals of this review, references were selected based on their appropriateness for a primary care audience. RESULTS The symptoms of PD may physically limit intercourse and impose a severe physical and psychological burden. The course of PD includes an early 'inflammatory' phase that may last 1-18 months and a subsequent 'stable' phase. In the early phase, patients may experience penile pain as the tunical plaque develops. During the stable phase, the plaque becomes more organized, penile curvature stabilizes, and the pain usually subsides. Currently, there are no US Food and Drug Administration approved therapies that have shown significant efficacy for PD. Nonsurgical treatment options are often used to manage PD with variable success. Most studies of nonsurgical management of PD are small, poorly controlled, and include patients in variable disease stages. Surgical treatment of PD is reserved for stable patients with erectile dysfunction and penile deformity that impairs sexual function. CONCLUSION PD is frequently undiagnosed. Even when PD is correctly identified, choice of treatment is problematic, based on the limited currently available clinical data demonstrating clinical benefits associated with treatment. Newer medications in clinical testing seem to offer some potential benefit for men with PD, though further research is necessary.
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Affiliation(s)
- Martin M Miner
- Miriam Hospital Men's Health Center, Warren Alpert School of Medicine, Brown University , Providence, RI , USA
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Shaw EJ, Mitchell GC, Tan RB, Sangkum P, Hellstrom WJG. The non-surgical treatment of peyronie disease: 2013 update. World J Mens Health 2013; 31:183-92. [PMID: 24459651 PMCID: PMC3888887 DOI: 10.5534/wjmh.2013.31.3.183] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 10/12/2013] [Accepted: 10/28/2013] [Indexed: 01/17/2023] Open
Abstract
Peyronie disease is a common cause of penile deformity and sexual dysfunction. Although surgery is regarded as the definitive management for this condition, there are many medical and minimally invasive therapies available, with widely varying efficacy reported in the literature. The purpose of this review is to describe the current state-of-the-art for each of the most commonly used as well as several developing non-surgical treatments. Further, we hope to offer perspectives that will aid practitioners in deciding among these treatments that are either already in use or have the potential to be used as alternatives to surgery in the management of this frustrating disease.
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Affiliation(s)
- Eric James Shaw
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | | | - Ronny B Tan
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
| | - Premsant Sangkum
- Department of Urology, Tulane University School of Medicine, New Orleans, LA, USA
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Guillot-Tantay C, Phé V, Chartier-Kastler E, Mozer P, Bitker MO, Rouprêt M. [Medical and surgical treatments of congenital and acquired penile curvatures: a review]. Prog Urol 2013; 24:203-11. [PMID: 24560211 DOI: 10.1016/j.purol.2013.08.328] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2013] [Revised: 08/05/2013] [Accepted: 08/30/2013] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The aim of the current study was to provide an overview about the surgical and medical management of acquired and congenital penile's curvature. MATERIALS AND METHODS [corrected] A systematic review of the literature was done from the PubMed database by searching the following keywords alone or in combination: Congenital penile curvature; Congenital penile deviation; Acquired penile curvature; Acquired penile deviation; Peyronie's disease. RESULTS The treatment of congenital curvature is only surgical. The most common technique is the Nesbit's technique which consists in making elliptical excisions of the tunica albuginea. There are also incison or plication procedures which are efficient as well. Acquired curvature is most of the time represented by the Peyronie's disease or is post-traumatic. Among oral treatments available, the Potaba is the only drug which has proved a significant reduction in penile plaque size. Injections of interferon and nicardipine have also shown their efficacy. Ionotophoresis and extracorporeal shock-wave therapy may be beneficial for penile pain. Other therapies (vacuum, traction devices, topical Verapamil) can be interesting but other studies are necessary to recommend them. Surgical treatment is recommended during the fibrotic phase. The most common technique is also the Nesbit's technique. In case of severe curvature (curve superior to 60°), small penis, major deformations, graft techniques can be used. Moreover, if there is a sexual dysfunction, penile prosthesis is recommended. CONCLUSION Other studies are necessary to prove the efficacy of most of the drugs already available in the treatment of the penile curvature. It seems to be interesting to combine the different treatments to improve the results of those therapies.
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Affiliation(s)
- C Guillot-Tantay
- Service d'urologie, faculté de médecine Pierre-et-Marie-Curie, université Paris VI, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France
| | - V Phé
- Service d'urologie, faculté de médecine Pierre-et-Marie-Curie, université Paris VI, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France.
| | - E Chartier-Kastler
- Service d'urologie, faculté de médecine Pierre-et-Marie-Curie, université Paris VI, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France
| | - P Mozer
- Service d'urologie, faculté de médecine Pierre-et-Marie-Curie, université Paris VI, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France
| | - M-O Bitker
- Service d'urologie, faculté de médecine Pierre-et-Marie-Curie, université Paris VI, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France
| | - M Rouprêt
- Service d'urologie, faculté de médecine Pierre-et-Marie-Curie, université Paris VI, CHU Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47-83, boulevard de l'hôpital, 75651 Paris cedex 13, France
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Sicard KG, Aliperti LA, Usta MF, Hellstrom WJG. State of the art: medical treatment of Peyronie's disease. Expert Opin Orphan Drugs 2013. [DOI: 10.1517/21678707.2013.851026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ferretti L, Faix A, Droupy S. La maladie de Lapeyronie. Prog Urol 2013; 23:674-84. [DOI: 10.1016/j.purol.2013.02.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2013] [Accepted: 02/06/2013] [Indexed: 01/21/2023]
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Gokce A, Wang JC, Powers MK, Hellstrom WJ. Current and emerging treatment options for Peyronie's disease. Res Rep Urol 2013; 5:17-27. [PMID: 24400231 PMCID: PMC3826933 DOI: 10.2147/rru.s24609] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Peyronie’s disease (PD) is a condition of the penis, characterized by the presence of localized fibrotic plaque in the tunica albuginea. PD is not an uncommon disorder, with recent epidemiologic studies documenting a prevalence of 3–9% of adult men affected. The actual prevalence of PD may be even higher. It is often associated with penile pain, anatomical deformities in the erect penis, and difficulty with intromission. As the definitive pathophysiology of PD has not been completely elucidated, further basic research is required to make progress in the understanding of this enigmatic condition. Similarly, research on effective therapies is limited. Currently, nonsurgical treatments are used for those men who are in the acute stage of PD, whereas surgical options are reserved for men with established PD who cannot successfully penetrate. Intralesional treatments are growing in clinical popularity as a minimally invasive approach in the initial treatment of PD. A surgical approach should be considered when men with PD do not respond to conservative, medical, or minimally invasive therapies for approximately 1 year and cannot have satisfactory sexual intercourse. As scientific breakthroughs in the understanding of the mechanisms of this disease process evolve, novel treatments for the many men suffering with PD are anticipated.
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Affiliation(s)
- Ahmet Gokce
- Department of Urology, Tulane University - School of Medicine, New Orleans, LA, USA
| | - Julie C Wang
- Department of Urology, Tulane University - School of Medicine, New Orleans, LA, USA
| | - Mary K Powers
- Department of Urology, Tulane University - School of Medicine, New Orleans, LA, USA
| | - Wayne Jg Hellstrom
- Department of Urology, Tulane University - School of Medicine, New Orleans, LA, USA
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Affiliation(s)
- Alex K Wu
- Department of Urology, University of California, San Francisco, USA
| | - Tom F Lue
- Department of Urology, University of California, San Francisco, USA
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Akman T, Tefekli A, Armagan A, Kiliçaslan I, Özerman B, Tepeler A, Kadioğlu A. Decorin as a new treatment alternative in Peyronie's disease: preliminary results in the rat model. Andrologia 2012; 45:101-6. [PMID: 22670875 DOI: 10.1111/j.1439-0272.2012.01318.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2012] [Indexed: 12/28/2022] Open
Abstract
The purpose of this study is to investigate the effect of decorin, a naturally occurring proteoglycan with anti-transforming growth factor beta (TGF-β) activity, on the rat model of Peyronie's disease (PD). Twenty-five adult male Sprague-Dawley rats were divided in three groups: I) TGF-β (0.5 μg) injected (n: 8); II) TGF-β injected and decorin treated (n: 8); and III) controls (n: 9). Decorin (0.5 μg per day) was given with intracavernous injection on the second, third, fourth and fifth day following TGF-β injection. All rats underwent electrical stimulation of the cavernous nerve after 6 weeks. Intracavernosal and arterial blood pressures were measured during this procedure. Cross-sections of the rat penises were examined using Mason trichrome and H&E stains. Statistical analyses were carried out using one-way anova. Histopathological examinations confirmed the Peyronie's-like condition in TGF-β-injected rats, which exhibited a thickening of the tunica albuginea (TA), when compared to controls. Disorganisation of collagen on the TA was also prominent in TGF-β-injected rats, but not in decorin-treated and control rats. Decorin-treated rats showed significantly higher maximal intracavernosal pressure (MIP) responses to cavernous nerve stimulation, when compared to group 1 (P < 0.05). Our results indicate that decorin antagonises the effects of TGF-β in the rat model of PD and prevents diminished erectile response to cavernous nerve stimulation.
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Affiliation(s)
- T Akman
- Department of Urology, Faculty of Medicine, Bezmialem Vakif University, Istanbul, Turkey.
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Abstract
Peyronie's disease (PD) is the occurrence of a fibrous inelastic scar of the tunica albuginea of the penis. It is a relatively common disorder among men, with a reported prevalence of 3% to 8%. It is often associated with penile pain, anatomical deformities in the erect state, and difficulty with intromission. Because the exact pathophysiology of PD remains unknown and standards for evaluating or reporting treatment outcomes are unclear, research on effective therapies has been limited. The benefits of nonsurgical treatment options are conflicting and further controlled studies are required before any therapy can be fully recommended. The success of surgery has been well documented; however, surgery is invasive and costly and carries potential side effects. Patients who report stable disease that has been present for longer than 12 months and who experience penile deformity preventing satisfactory sexual intercourse are best suited for surgery. Additionally, failed conservative management and a patient's preference for definitive correction are important additional indications for surgical treatment.
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