Peyronie's disease: an anatomically-based hypothesis and beyond

Research advances in Peyronie's disease: a comprehensive review on genomics, pathways, phenotypic manifestation, and therapeutic targets

INTRODUCTION

Penile induration disease, commonly known as Peyronie's disease (PD), is a connective tissue disorder that affects the penis, leading to the development of fibrous plaques, penile curvature, and erectile dysfunction. PD is a common male reproductive system disease with a complex etiology involving multiple genes, signaling pathways, and different phenotypes.

OBJECTIVES

The etiology and pathogenesis of PD remain poorly understood, hindering the development of effective treatment strategies. By understanding the underlying mechanisms of PD, we can pave the way for targeted therapies and improved patient outcomes.

METHODS

We reviewed the epidemiology and pathophysiology of PD. We performed database searches on Google Scholar, PubMed, Medline, and Web of Science from inception to September 2023. The literature reviewed included priapism guidelines, review articles, current trial studies, and various literature related to PD.

RESULTS

This article provides a comprehensive overview of the current research progress on the disease, focusing on its genetic factors, signaling pathways, cellular mechanisms, phenotypic manifestations, and therapeutic targets. It can help identify individuals at higher risk, aid in early detection and intervention, and provide insights into fibrosis and tissue remodeling. It can also reveal potential therapeutic targets, guide accurate diagnoses and treatment strategies, and address the impact of the disease on patients' quality of life.

CONCLUSION

By integrating insights from genomics, molecular pathways, clinical phenotypes, and therapeutic potentials, our research aims to achieve a deeper and more comprehensive understanding of PD, propelling the field toward innovative strategies that enhance the lives of those affected by PD. The complex manifestations and pathogenesis of PD necessitate the use of multiple treatment methods for personalized care.

Extratunical grafting for minimally invasive management of complex Peyronie's disease deformities

BACKGROUND

Penile deformities due to Peyronie's Disease (PD) often significantly impair men's sexual health and quality of life.

AIM

In this article we discuss the extratunical graft (ETG) procedure as a management strategy for PD patients with hourglass or indent penile deformities.

METHODS

We compiled descriptions of surgical techniques and performed a review of the literature regarding ETG for PD.

OUTCOMES

The ETG procedure appears to have promising results in the management of indent/hourglass deformity of PD.

RESULTS

The findings of this review of the literature demonstrate that ETG is a safe and effective reconstructive technique for penile deformity with minimal side effects.

CLINICAL IMPLICATIONS

We recommend utilizing ETG with or without plication for PD patients with indent or hourglass deformities.

STRENGTHS AND LIMITATIONS

Strengths of ETG are the improvement in patients with tunical indents and hourglass deformities secondary to PD. Additionally, patients who underwent ETG maintained sexual function given no significant change in penile length and intact erectile function. Limitations, however, are that the procedure is relatively new, and data are limited to small cohorts.

CONCLUSION

The ETG procedure is a safe and effective for management of complex PD in the short- and intermediate-term follow-up cohort.

Use of Himplant® for correction of residual deformity following prior treatment of peyronie's disease: a case series

Over the years, numerous non-surgical and surgical treatment options have been explored for Peyronie's disease. Current options may result in incomplete correction of the deformity, which can be bothersome to the patient. This is a two-center case series of three patients who had previously undergone treatment for Peyronie's disease. Patient 1 underwent plication with extratunical grafting. Patient 2 underwent a series of Xiaflex® injections and then subsequent surgical plication for residual curvature. Patient 3 underwent a series of Xiaflex® injections. The Himplant® subcutaneous silicone penile prosthesis was placed in a standardized manner through a scrotal incision in all cases to mask residual penile deformities and enhance penile girth after Peyronie's disease treatment. Patients were contacted and asked 18 questions regarding satisfaction and erectile function with the responses recorded. This pilot study presents findings of high patient satisfaction, increases in flaccid penile length and girth, and an acceptable profile of adverse events following Himplant® placement. Based on our limited experience, we would consider offering Himplant® implantation when residual curvature is <40° and the penile indentation does not cause instability/buckling during penetrative sexual activity. Further research and larger studies are warranted to validate these findings and assess long-term outcomes and patient-reported satisfaction.

Statins synergize with phosphodiesterase type 5 inhibitors but not with selective estrogen receptor modulators to prevent myofibroblast transformation in an in vitro model of Peyronie's disease

BACKGROUND

Peyronie's disease (PD) is a fibrotic disorder characterized by plaque formation in the tunica albuginea (TA) of the penis, and we have previously shown that inhibition of transformation of TA-derived fibroblasts to myofibroblasts using a combination phosphodiesterase type 5 (PDE5) inhibitors and selective estrogen receptor modulators (SERMs) is effective in slowing the progression of early PD.

AIM

The study sought to investigate whether combinations of statins with PDE5 inhibitors or SERMs would affect myofibroblast transformation in vitro.

METHODS

Primary fibroblasts were isolated from TA of patients with PD and stimulated with transforming growth factor β1 in the absence and presence of a range of concentrations of statins, PDE5 inhibitors, SERMs, and their combinations for 72 hours before quantifying α-smooth muscle actin using in-cell enzyme-linked immunosorbent assay.

OUTCOMES

The prevention of transforming growth factor β1-induced transformation of TA-derived fibroblasts to myofibroblasts was measured in vitro.

RESULTS

Statins (simvastatin, lovastatin) inhibited myofibroblast transformation in a concentration-dependent manner with half maximal inhibitory concentration values of 0.77 ± 0.07 μM and 0.8 ± 0.13 μM, respectively. Simvastatin inhibited myofibroblast transformation in a synergistic fashion when combined with vardenafil (a PDE5 inhibitor; log alpha >0). Combination of tamoxifen (a SERM) and simvastatin did not show synergy (log alpha <0). When 3 drugs (simvastatin, vardenafil, and tamoxifen) were combined, the effect was not synergistic, but rather was additive.

CLINICAL IMPLICATIONS

A combination of a statin with a PDE5 inhibitor might be useful in the clinic to slow the progression of the disease in patients with early PD; however, caution should be taken with such a combination because of the reported myopathy as a side effect.

STRENGTHS AND LIMITATIONS

The use of primary human cells from patients with PD is a strength of this study. The mechanisms by which these drug classes exert synergy when used in combination was not investigated.

CONCLUSION

This is the first demonstration of an antifibrotic synergy between statins and PDE5 inhibitors.

Peyronie's Disease: An Outcomes-Based Guide to Non-Surgical and Novel Treatment Modalities

The clinical landscape of Peyronie's disease is everchanging. There has been growing interest in non-invasive therapeutic options that could assist patients with achieving a meaningful reduction in penile curvature without surgical intervention. These therapies are wide-ranging in terms of their mechanisms of action, efficacies, and short- and long-term safety profiles. Recently, an abundance of outcomes literature on longstanding and novel non-surgical treatment modalities has been published. For sexual medicine providers hoping to offer patients the most up-to-date and evidence-based treatments for the management of Peyronie's disease, it can be challenging to gain a thorough understanding of this body of literature. In this clinical management review, the workup and current theories on the pathophysiology of Peyronie's disease are reviewed, and the most recent outcomes data on the currently available non-surgical treatment modalities are presented. With an accurate understanding of the current landscape of Peyronie's disease treatment, sexual health providers will be able to better evaluate and engage in evidence-based shared decision-making with their patients.

Laser Therapy for Peyronie's Disease: A Randomized Control Double-Blind Pilot Study

Introduction: The management of Peyronie's disease (PD) has remained a therapeutic dilemma for physicians and there is no gold standard treatment. In this paper, we decided to investigate the beneficial effect of the intralesional administration of verapamil compared with the intralesional administration of verapamil plus a low-intensity laser (LIL). Methods: Research was activated from May 2016 to May 2018 and a total of 38 men aged 18 years and older completed the investigation. The subjects were randomly divided into 2 groups. Group 1 was composed of 22 patients that were treated only by verapamil (5 mg) plus a sham laser weekly for 6 weeks, and group 2 consisted of 22 patients that received a laser, using the BTL-6000 HIGH-INTENSITY LASER 12 W machine and the same protocol of intralesional verapamil injection. The visual analogue scale (VAS) was used to evaluate pain during an erection, penile ultrasonography was used to measure plaque size, the penile curvature angle degree was measured using the photographs taken during an erection, and the International Index of Erectile Function questionnaire was used to assess erectile function. The follow-up treatment lasted for nine months, with visits performed in the 3rd and 9th months. Results: All study parameters decreased significantly after treatment in both arms, but the reduction in pain and penile curvature improvements in combination therapy revealed more significant changes in 3 months (p = .035, p=.032). Nevertheless, these improvements were not seen in the follow-up session after 9 months. Conclusion: A laser appears to be safe treatment modality in carefully-selected patients with PD. It has moderate efficacy in the short term.

A review of inflammation and fibrosis: implications for the pathogenesis of Peyronie's disease

Peyronie's disease (PD) is a superficial fibrosing disorder that causes penile deformity and can interfere with sexual intercourse and reproduction, as well as diminish quality of life. While the exact mechanism of PD is still being investigated, there is likely a genetic component to the predisposition to penile plaque formation. Ultimately, however, perturbations in normal wound healing and aberrant deposition of extracellular matrix components lead to fibrotic tissue deposition. Fibrosis in PD is regulated by a complex pathway of inflammatory and fibrotic mediators. Currently there are no treatments for PD that address an underlying cause or disease progression. In this review, we provide an overview of the known inflammatory and fibrotic mediators of PD and explore the pathophysiology of other human superficial fibrosing disorders to develop further insights into PD.

Sonographic patterns of Peyronie's disease in patients with absence of palpable plaques

PURPOSE

Non-palpable isolated septal plaques of the penis are likely present in a significant number of patients affected by erectile dysfunction (ED) and penile pain without deformity or curvature. The aim of this study was to evaluate the ultrasound (US) patterns observed in patients investigated for ED or penile pain without curvature.

MATERIALS AND METHODS

We reviewed the medical records of 386 patients who underwent an initial colour-Doppler ultrasonography (CDU) of the penis for DE and/or penile pain without curvature. After satisfying inclusion criteria, 41 patients were individualized. All patients had a non-palpable plaque with involvement of the penile septum. Three US patterns were identified: focal hyperecoic thickening of the intercavernosum septum (IS) with acoustic shadow (pattern 1), non-calcified thickening (isoechoic or slightly hyperechoic (pattern 2), and microcalcifications in the IS without associated acoustic shadow (pattern 3).

RESULTS

Patients' mean age was 51.3±16.7. ED was the predominant disorder in 73.2% of patients, followed by penile pain and length loss in 19.5% and 7.3% of patients, respectively. 32(78.1%) patients showed the pattern 1, 6 (14.6%) pattern 2, and 3 (7.3%) pattern 3. Plaques size varied from 3 to 13 mm. The penile hemodynamic response to CDU reported abnormal findings distally to the septal plaques in 20 patients (<25cm/sec). Median left and right cavernosum artery flows measured a peak systolic velocity of 31cm/sec and 33 cm/sec, respectively.

CONCLUSIONS

We believe that an US study with CDU provides a way to characterize, localize, and deliver treatment choice in patients with Peyronie's Disease.

The extra-tunical grafting procedure for Peyronie's disease hourglass and indent deformities

Background

To describe a novel, tunica-sparing surgical technique—extra-tunical grafting (ETG)—for the treatment of penile indent and hourglass (HG) deformities and to describe patient-reported outcomes after the ETG procedure.

Methods

An IRB-approved, retrospective chart review of ETG patients was performed to collect data including pre-operative deformity, operation performed, and post-operative patient-reported perception of deformity, erectile function, penile sensation, and overall satisfaction with the ETG operation. The indications for surgery were difficulty with sexual intercourse due to deformity and/or poor cosmesis of the penis. Pre-operatively all patients had erections adequate for intercourse with or without medications. The ETG procedure is performed through a ventral longitudinal penile skin incision. The dissection is continued to the level between Dartos and Bucks fascia, circumferentially for HG deformity and focally for indent deformity. The neurovascular bundle (NVB) is left undisturbed. A cadaveric fascia graft is applied, singly or in multiple layers, to fill the exposed tunical depressions. Our preferred graft material is Tutoplast Suspend^® (Coloplast, Minneapolis, MN, USA). The graft is sutured into position with multiple interrupted, long-lasting absorbable sutures to achieve the desired penile shaft contour. The urethra is excluded from the graft.

Results

From October 2013 to June 2017, 36 patients had the ETG procedure for HG and/or indent with or without penile curvature. Results with a minimum of 6 months of follow-up could be extracted for 18 of the patients. One was excluded as he required concurrent excision of a large calcified tunical plaque, which necessitated incision into the tunica albuginea (TA). Follow-up was between 6 and 44 months (average 21 months). All patients reported satisfactory resolution of the HG or indent. No patient reported worsened erectile function. Two patients (11.8%) reported slight penile hypoesthesia, with one of these having had multiple previous penile degloving surgeries for trauma. Ten of the patients reported being “very satisfied” and six reported being “satisfied” with the procedure. One was neutral. All reported that they would recommend the ETG procedure to a friend, and all would repeat the same surgery again.

Conclusions

The ETG procedure is a straightforward approach to HG and indent deformities to correct the penile deformity and to provide structural support to prevent penile buckling during intercourse. The procedure does not violate the TA and does not require dissection of the NVB. Thus, ETG carries a very low risk of de novo impotence or hypoesthesia as highlighted by this patient series. With such low risk and high patient-reported satisfaction rates, the ETG procedure is a valuable surgical technique for the treatment of complex penile deformities.

Stem cell therapy for the treatment of Peyronie's disease

INTRODUCTION

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

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

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

Nonsurgical treatment options in Peyronie's Disease: 2016 update

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

Advances in stem cell research for the treatment of male sexual dysfunctions

PURPOSE OF REVIEW

To summarize recent literature on basic stem cell research in erectile dysfunction in cavernous nerve injury, aging, diabetes, and Peyronie's disease and to provide a perspective on clinical translation of these cellular therapies.

RECENT FINDINGS

Stem cell research has been concentrated on mesenchymal stem (stromal) cells from bone marrow and adipose tissue. Application of both cell types has produced positive effects on erectile function in various animal models of erectile dysfunction. In acute animal models, such as cavernous nerve injury-induced erectile dysfunction and chemically induced Peyronie's disease, engraftment and differentiation have not been observed, and stem cells are believed to interact with the host tissue in a paracrine fashion, whereas in chronic disease models some evidence suggests both engraftment and paracrine factors may support improved function. Clinical trials are now investigating therapeutic efficacy of cellular therapy, whereas the first safety studies in humans have recently been published.

SUMMARY

Evidence from preclinical studies has established stem cells as a potential curative treatment for erectile dysfunction and early phase clinical trials are currently performed.

Association Between Infertility and Sexual Dysfunction in Men and Women

INTRODUCTION

The relation between infertility and sexual dysfunction can be reciprocal. Causes of sexual dysfunction that affect fertility include erectile dysfunction, Peyronie's disease (abnormal penile curvature), low libido, ejaculatory disorders in men, and genito-pelvic pain/penetration disorder (GPPPD) and low sexual desire in women.

AIM

To review the association between infertility and sexual dysfunction and discuss current management strategies to address sexual disorders in couples with infertility.

METHODS

Peer-reviewed publications from PubMed published from 1980 through February 2016 were identified that related to sexual dysfunction and infertility in men and women.

MAIN OUTCOME MEASURES

Pathophysiology and management approach of erectile dysfunction, Peyronie's disease, low libido, ejaculatory disorders in men, and GPPPD and low sexual desire in women and how each etiology contributes to sexual dysfunction and infertility in the couple.

RESULTS

Treating the infertile couple with sexual dysfunction involves addressing underlying conditions such as psychogenic erectile dysfunction, low testosterone, Peyronie's disease in men, and GPPPD and low sexual desire in women. Psychogenic erectile dysfunction can be successfully treated with phosphodiesterase inhibitors. Low testosterone is often identified in men with infertility, but testosterone therapy is contraindicated in men attempting conception. Men with Peyronie's disease have a new treatment option to address their penile curvature-collagenase Clostridium histolyticum injection directly into the penile plaque. GPPPD is a broad disorder that includes vulvodynia and vaginismus and can be treated with topical lubricants and moisturizers. We must address psychosocial factors in women with low sexual desire. Flibanserin and transdermal testosterone (off-label) are novel therapies for women with low sexual desire.

CONCLUSION

Sexual dysfunction in a couple with infertility is a complex issue. Management of infertility and sexual dysfunction should involve appropriate medical therapy and addressing the psychosocial concerns of the couple.

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

INTRODUCTION

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

AIM

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Structured Self-Rated Response to Iontophoresis with Verapamil and Dexamethasone in Peyronie's Disease

Introduction. New therapies evolve for the treatment of Peyronie's disease (PD) including the application of dexamethasone and verapamil using Electro Motive Drug Administration (EMDA). Patients and Methods. Patients with PD were routinely offered Potaba, Vitamin E, tamoxifen or colchicine for 6 to 18 months and for those with no improvement, 18 applications of dexamethasone and verapamil using EMDA occurred over a 6 week period. All 30 patients receiving EMDA therapy completed a questionnaire before and after treatment. The data was collected from December 2004 to November 2009 and analysed to evaluate the effectiveness of the treatment. Results. Median age of patients was 59 (range 39-71). Curvature was the most common presenting complaint (73.3%) followed by pain (23.3%), erectile dysfunction (13.3%), and lump (13.3%). 24/30 (80%) reported an improvement in symptoms after EMDA. 16 of the responders (66.7%) had a stable plaque for at least 6 months. The patients who complained of shortening of the penis (P = 0.003) or lowered sexual desire (P = 0.024) expressed subsequently significant response to treatment. There was statistically significant (P = 0.019) improvement of penile deviation reported by responding men. Conclusion. A significant proportion of patients who received EMDA reported decreased curvature following iontophoresis. No serious adverse reactions developed.

The pathophysiology of Peyronie's disease

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Is There a Role for Proteomics in Peyronie's Disease?

INTRODUCTION

Peyronie's disease (PD) continues to be a major source of sexual dysfunction among the 3-9% of affected men. The challenge in treating PD is determining the natural history and clinical course for the individual patient. Currently, there exists no reliable means to predict whether a penile plaque of PD will progress, regress, or remain stable. This represents a significant deficiency in contemporary management, one that may be addressed with newer technologies such as proteomic profiling.

AIM

This review assesses the potential use of protein alterations measured by various novel technologies, to predict progression, regression, or stabilization of PD in an affected individual.

METHODS

A comprehensive literature review of the past decade in the field of gene profiling and protein expression of PD was performed.

MAIN OUTCOME MEASURES

A critical analysis of the existing worldwide literature evaluating surface-enhanced laser desorption/ionization time of flight mass spectrometry (SELDI-TOF-MS or SELDI) and other proteonomic techniques.

RESULTS

SELDI and other technologies can provide the clinician with innovative data indicating the presence of unique individual factors that act to suppress or promote the fibrotic process in PD. Determining the clinical implications of altered protein expression in an individual is not yet defined.

CONCLUSIONS

The area of proteomics has begun to revolutionize the study of medicine in the postgenomic era, by allowing researchers to study the role that proteins play in health and disease. Applying this knowledge clinically has already led to innovative discoveries in early cancer detection in a number of malignancies, including prostate, ovarian, and bladder. Prior to the widespread use and acceptance of proteomic technology in PD, a critical assessment of its therapeutic and diagnostic value will be required.

Isolated Septal Fibrosis or Hematoma—Atypical Peyronie’s Disease?

PURPOSE

Classically Peyronie's disease presents with penile curvature and/or pain, and is associated with a palpable penile plaque. We frequently examine patients with suspected Peyronie's disease ultrasonographically and have noted a subset of patients in whom we could identify only a circumscribed septal lesion. We identified characteristics of these patients.

MATERIALS AND METHODS

Of our series of approximately 650 patients with Peyronie's disease 47 were identified with these lesions.

RESULTS

Of the 47 patients 22 presented with penile curvature with or without accompanying or preceding pain. Of the 47 patients 17 had a significant history of trauma, although only had the classic stigmata of penile fracture. A total of 16 patients had no history of curvature, 7 presented with only penile shortening or focal lack of rigidity and 5 were incidentally found to have lesions during assessment for other complaints. Three patients presenting after trauma were noted to have septal liquefied hematomas, which we aspirated under ultrasound guidance. Followup ultrasound revealed minimal septal thickening. In 1 of these patients the hematoma was adjacent to more typical-appearing septal fibrosis.

CONCLUSIONS

We theorize that these hematomas are due to septal fractures and may represent a forme fruste or possibly a precursor lesion of more typical septal fibrosis. Ultrasonographic evaluation may allow earlier identification and treatment of occult septal injuries or lesions and prevent subsequent fibrosis and its associated symptoms.

CASE REPORT: Nonpalpable Scarring of the Penile Septum As a Cause of Erectile Dysfunction: An Atypical Form of Peyronie’s Disease

INTRODUCTION

Men with nonpalpable isolated septal scars (ISS) identified with color duplex ultrasonography (CDU) comprise a group of previously unrecognized patients with wide-ranging sexual concerns.

AIM

We aim to identify the clinical characteristics of patients presenting with this atypical form of Peyronie's disease characterized by the absence of palpable deformity.

MATERIALS AND METHODS

Of 482 consecutive patients who presented to a tertiary care erectile dysfunction (ED) clinic and underwent CDU after satisfying inclusion criteria, 27 (5.6%) men with nonpalpable ISS and no dorsal or ventral plaque were identified.

MAIN OUTCOME MEASURES

International Index of Erectile Function (IIEF), CDU, and clinical characteristics.

RESULTS

The median age of the men with nonpalpable ISS was 49 years. The length of time from onset of symptoms to presentation was 22 months, and the pretreatment IIEF score was 14. The remaining 455 men who underwent CDU were of similar age (48 years) but had a markedly lower IIEF score of 9.5 (statistical median). ISS patients presented with decreased penile rigidity (20), penile shortening (13), chronic pain with erection (13; mean 33 months), and the inability to maintain an erection (7). Fourteen men had failed phosphodiesterase-5 inhibitor therapy, and four reported unsatisfactory results. Management options included retrial with oral agents, intracavernous pharmacotherapy, verapamil injections, and surgery.

CONCLUSIONS

The clinician should be suspicious for nonpalpable ISS in men with sexual concerns who present with decreased penile rigidity, length loss, and chronic pain with erection. Our findings support the use of CDU for this patient group, particularly when previous treatment has failed, because men with ISS had a greater likelihood of having no palpable deformity or curvature and ongoing penile pain.

New discoveries in the basic science understanding of Peyronie’s disease

Peyronie's disease is an acquired benign condition representing localized fibrosis of the penis. The disease is caused by microvascular trauma to the penis, with subsequent fibrin deposition resulting in aberrant wound healing and possibly other etiologies. Histopathologic studies of the Peyronie's plaque have demonstrated the role of transforming growth factor-beta 1 in the pathologic development of penile plaque. Animal models have been developed to test pathophysiology and therapeutics. The role of inducible nitric oxide synthase and nitric oxide has been established to limit and counteract fibrosis. Differential gene expression studies have identified candidate up-regulated or down-regulated genes that are involved in the pathophysiology of Peyronie's disease.

Peyronie's disease: an update of the medical management

Peyronie's disease (PD) is characterised by penile plaque formation, pain, penile deformity and erectile dysfunction. It is a fibrotic disorder of the tunica albuginea with a poorly understood aetiology and epidemiology. PD may be classified into inflammatory (acute) and chronic stages. Medical treatment is usually instigated during the inflammatory phase of the disease. A review of the literature reveals a wide range of oral, intralesional and alternative therapies that are discussed in relation to established pathophysiological mechanisms of the disease. The advantages and disadvantages of each treatment are summarised. This review also discusses the ongoing therapeutic dilemmas of PD and suggests a treatment strategy based on an analysis of the urological literature.

Peyronie's disease: a review

PURPOSE OF REVIEW

This review is aimed to summarize the most recent findings about this topic, by reviewing the literature published in 2002 and 2003 regarding the epidemiology, pathophysiology, diagnosis and treatment of Peyronie's disease.

RECENT FINDINGS

Although many aspects in pathophysiology, diagnosis, medical and surgical treatment of Peyronie's disease still remain under debate, recent interesting advances have been made regarding the different aspects of this condition. Topical and systemic medical therapies have been associated with varying degrees of results, depending on modalities and timing of the treatment itself. A wide range of surgical modalities have been recently developed, although the ideal surgical procedure especially in case of severe and complex curvature does not seem to be reached yet. Furthermore this condition is often associated with psychological distress that could be responsible for performance anxiety, leading to improvement of abnormalities in erectile functioning eventually associated with Peyronie's disease.

SUMMARY

Peyronie's disease consists of an acquired penile deformity caused by the formation of fibrous plaques within the tunica albuginea, leading to bio-mechanical and vascular abnormalities. In the last decade numerous advances have been made regarding pathophysiology, diagnosis and treatment of this condition, allowing for improved patient clinical prognosis. Nevertheless, although improvements in medical and surgical therapies have substantially increased the successful patients' outcome rate, Peyronie's disease is still not completely understood and its treatment remains often frustrating for the practicing urologist. Clinical presentations of this disease include penile deformities or shortening during erection, painful erection, palpable plaque or induration throughout the length of the penile shaft and erectile dysfunction.