Early-onset and uncontrolled diabetes mellitus factors correlate with complications of Peyronie's disease

BACKGROUND

Peyronie's disease (PD) is a connective tissue disorder that affects the penis and is characterized by abnormal collagen structure in the penile tunica albuginea, resulting in plaque formation and penile deformity. PD's overall prevalence is estimated at 3.2% to 8.9%, with rates as high as 20.3% among men with type 2 diabetes mellitus (DM). However, the characteristics of DM associated with PD complications remain unclear.

AIM

To explore clinical associations between DM characteristics and PD complications.

METHODS

We conducted a retrospective analysis of patients with DM and PD who presented at our institution between 2007 and 2022. We examined patients' clinical histories, DM- and PD-related clinical parameters, and complications. Penile deformities were assessed through physical examination, photographs, and penile Doppler ultrasound. Patients were categorized into subgroups based on age of DM onset: early (<45 years), average (45-65 years), and late (>65 years).

OUTCOMES

Outcomes included effects of DM characteristics on PD development, progression, and severity.

RESULTS

In total, 197 patients were included in the evaluation. Early-onset diabetes and elevated hemoglobin A1c (HbA1c) levels exhibited significant correlations with the early development of PD (ρ = 0.66, P < .001, and ρ = -0.24, P < .001, respectively). Furthermore, having DM at an early age was associated with the occurrence of penile plaque (ρ = -0.18, P = .03), and there were no significant differences in plaque dimensions (ρ = -0.29, P = .053). A rise in HbA1c levels after the initial PD diagnosis displayed positive correlations with the formation of penile plaque (ρ = 0.22, P < .006).

CLINICAL IMPLICATIONS

These findings emphasize the need for comprehensive assessments and personalized treatment strategies for individuals with DM and PD. Enhanced management approaches can improve outcomes for those facing both challenges.

STRENGTHS AND LIMITATIONS

Limitations include the single-site retrospective design with potential selection bias, inaccuracies in medical record data, and challenges in controlling confounding variables.

CONCLUSIONS

This study highlights that early-onset diabetes and poor diabetes control, as indicated by a subsequent rise in HbA1c levels following PD diagnosis, are significantly correlated with the onset and severity of PD. Revealing the mechanisms behind these findings will help us develop better management strategies for individuals with DM and PD.

Serum Testosterone Concentration Influences the Response to Extracorporeal Shock Wave Treatment in Men With Peyronie's Disease

OBJECTIVE

To assess the relationship between baseline total serum testosterone (T) and clinical outcomes in men affected by Peyronie's disease (PD) stable stage and treated by extra corporeal shockwave therapy (ESWT).

METHODS

In this study, 168 patients affected by PD in stable stage (≥12 months) and treated with ESWT, were divided into 2 groups. Group 1 (G1) counted 71 patients with low T levels (≤ 300 ng/dL); group 2 (G2) consisted of 97 patients with normal T that received ESWT with the same protocol of G1 for 6 weeks. There were assessed at baseline and follow-up: Erectile dysfunction (ED), presence and severity of painful erections, penile plaque size, and penile curvature degree. The results were evaluated at baseline and 3, 6, 12, months after the treatment.

RESULTS

Not statistically significant differences emerged between the 2 groups at baseline, except for higher presence of patients with ED in G1 (90%) vs G2 (52%). Three months after the treatment in G2 pain was resolved completely in 80.4% of the patients, compared with G1 (54.9%). G2 had a reduction of curvature degree after the 3-month treatment (P <.001). Mean plaque size decreased in both groups without statistically differences with baseline values. Mean ± SD International Index of Erectile Function-5 score progressively improved significantly in the eugonadal men.

CONCLUSION

This study demonstrated greater efficacy for the treatment of PD in men with normal T concentrations compared with men with low T concentrations. The results obtained from this study suggest that may be valuable in considering T therapy in men with PD prior to ESWT.

[Current treatment concepts for Peyronie's disease]

Plastic induration of the penis (PIP, Peyronie's disease) is an acquired and chronic disease of the penis, which is characterized by penile pain, distortion and deformation of the penis as well as the resulting impairments in sexual activity of the patient. The most probable causes are microtrauma and macrotrauma within the tunica albuginea of the corpora cavernosa, which due to an abnormal wound healing subsequently leads to the formation of fibrosis in this region. Various predisposing factors and also a genetic predisposition are discussed. The PIP occurs most frequently in the fifth to sixth decades of life. The prevalence is 0.3-20% depending on the investigated collective and the risk factors present. The PIP is subdivided into an acute inflammatory phase and a chronic postinflammatory phase. Various conservative and surgical treatment options include oral medication, penile traction therapy, intralesional injections and surgical procedures.

Molecular Mechanisms and Risk Factors Related to the Pathogenesis of Peyronie's Disease

Peyronie's disease (PD) is a benign condition caused by plaque formation on the tunica albuginea of the penis. It is associated with penile pain, curvature, and shortening, and contributes to erectile dysfunction, which worsens patient quality of life. In recent years, research into understanding of the detailed mechanisms and risk factors involved in the development of PD has been increasing. In this review, the pathological mechanisms and several closely related signaling pathways, including TGF-β, WNT/β-catenin, Hedgehog, YAP/TAZ, MAPK, ROCK, and PI3K/AKT, are described. Findings regarding cross-talk among these pathways are then discussed to elucidate the complicated cascade behind tunica albuginea fibrosis. Finally, various risk factors including the genes involved in the development of PD are presented and their association with the disease summarized. The purpose of this review is to provide a better understanding regarding the involvement of risk factors in the molecular mechanisms associated with PD pathogenesis, as well as to provide insight into disease prevention and novel therapeutic interventions.

Significant inverse association of testosterone level with penile deformity severity in Japanese males with Peyronie's disease

OBJECTIVES

We evaluated the relationship between penile curvature and testosterone in Peyronie's disease patients treated in Japan.

METHODS

Data were obtained from 109 patients with Peyronie's disease treated with surgery at our hospital between April 2004 and December 2019. Penile deformity assessment was based on findings of a rigid erection induced by intracavernosal injection. Low total testosterone level was defined as <300 ng/dl. Patients were divided into two groups according to curvature severity (I, <60°; II ≥60°), then clinical factors including total testosterone were compared. Uni- and multivariate logistic regression analyses were performed to identify factors predicting severe penile deformity (≥60°).

RESULTS

For all patients, mean total testosterone was 469 ng/dl and median curvature was 50°, with a significant inverse correlation found between curvature and testosterone level (p < 0.0001). Group I and II patients numbered 55 and 54, respectively. Mean total testosterone for Group II was 397 ng/dl, significantly lower than Group I (539 ng/dl). Median curvature in 15 patients with a low testosterone level was 80°, significantly higher than those with a normal testosterone range (50°). Univariable and multivariable logistic regression analysis indicated total testosterone, follicle stimulating hormone, and C-reactive protein as significant factors correlated with severe penile deformity, among which total testosterone was most relevant.

CONCLUSION

The present findings confirmed that penile deformity severity is correlated with testosterone level in Japanese males with Peyronie's disease.

Supporting the role of penile trauma and micro-trauma in the etiology of Peyronie's disease. Prospective observational study using the electronic microscope to examine two types of plaques

OBJECTIVES

The etiopathogenesis of Peyronie's disease (PD) remains not clearly understood. The most accepted theory attributes the histological lesions of PD to the effects of trauma to the corpora cavernosum of the penis. The aim of our study is to verify whether similar histological features exist between these two tissues, providing new evidence in favor of the traumatic theory in the etiopathogenesis of Peyronie's disease.

MATERIALS AND METHODS

A prospective observational study was carried out at our institution from January 2013 to June 2018, involving patients having undergone surgery for PD and those with delayed surgery for penile trauma. Both excised PD and post-traumatic plaques were analyzed by blind pathologists with an 80kV potential acceleration electron microscope.

RESULTS

Five patients were identified with a post-traumatic plaque (Group 1) and therefore an equal number of PD patients were enrolled for Group 2. The ultrastructural characteristics of the two types of preparations were very similar. In all the samples we showed an inflammatory reaction of the structure of the tunica albuginea, a production of the disorganized extracellular matrix, a proliferation of inflammatory cells and fibroblasts. Furthermore, we have found an increase in the density and collagen deposits grouped in the extracellular space and within the fibroblasts.

CONCLUSIONS

These findings support the theory that attributes lesions and symptoms typical of PD to the effects of cavernous body trauma.

The Natural History of Peyronie's Disease

Peyronie's disease (PD), a fibrotic disorder of the tunica albuginea fully described in 1793 by French physician Francois de la Peyronie, is characterized by pain, plaque formation, penile deformity, and ultimately sexual function decline. The epidemiological data on PD vary considerably across previous studies, with recent evidence reporting a prevalence of up to 9%. PD is generally divided into two different phases: active or acute and stable or chronic. Plaque formation generally occurs during the acute phase, while during chronic phase pain usually tends to complete resolution and penile deformity stabilizes. PD's pathophysiology is still subject of great discussion. Tunical mechanical stress and microvascular trauma are major contributory factors. However, better understanding of the molecular pathophysiology of this condition remains paramount towards an in-depth comprehension of the disorder and the development of newer and more effective disease-targeted interventions. In this review we provide a detailed overview of natural history of PD, specifically focusing on clinical manifestations and the underlying molecular regulation patterns.

The relationship between testosterone levels and Peyronie's disease

Aetiologic and predisposing factors are still controversial about Peyronie's disease (PD). However, it is thought to be the result of connective tissue disorder or healing defect. Androgens are known to affect collagen metabolism and wound healing in the body. The aim of this study was to investigate the relationship between PD and low testosterone levels. One hundred and forty-seven Peyronie patients and 137 healthy volunteers were included in the study. In both groups, demographic data, medical history, physical examination and erectile capacity were recorded. Blood samples were collected from all subjects in the early morning hours after an overnight fast. The mean level of serum total testosterone was lower in men with PD compared with the controls (3.9 ± 1.1 vs. 4.2 ± 1.7 ng/ml respectively) (p = .062). However, statistically significant relationship was not found between PD and low serum testosterone levels. There was no significant correlation between penile plaque dimension or penile curvature degree and testosterone levels. Large randomised-controlled prospective studies are needed to reveal this possible association.

[Non-surgical management of Peyronie's disease: State of current knowledge]

BACKGROUND

Peyronie's disease is an inflammatory disorder of the penis, where scar tissue creates a plaque at the level of the albuginea, limits its extension, and leads to a bent and shorter penis during erections. There are no international standards for the evaluation and the treatment of the disease. The aim of this article is to review the current knowledge about the management of Peyronie's disease and to suggest an algorithm to help physicians evaluate and manage this condition.

MATERIAL AND METHODS

A literature review was conducted through PubMed database following PRISMA guidelines using the Mesh terms: Peyronie, disease, treatment and diagnosis. Results are presented in a descriptive manner.

RESULTS

Multiple treatment strategies have been proposed, but no conclusive randomized clinical trial is done to assess their efficacies. The oral treatment was shown to be more beneficial in the setting of a multi-modal approach to treat the acute phase. The non-steroidal anti-inflammatories and the potassium para-aminobenzoate are superior to the other molecules of oral therapy for pain management. Local treatment with topical verapamil, iontophoresis and intra-lesional injection of verapamil, interferon alfa-2b and collagenase clostridium histolyticum (CCH) revolutionized the management of the disease by the modification of the plaque size and angulation. Alternative treatments using extra-corporeal shock wave or traction devices are promising. Intra-lesional injection of CCH is the only therapy approved by the Food and Drug Administration for this condition after the stabilization of the disease. The channeling of the plaque before CCH injections is making better results than the initial protocol, concerning angulation improvement.

CONCLUSION

Multiple therapeutic strategies exist for the management of the Peyronie's disease, but they lack evidence based data. Further randomized clinical trials are needed to evaluate the current practices and to study more efficient treatments.

Testosterone Levels Are Not Associated With Magnitude of Deformity in Men With Peyronie's Disease

INTRODUCTION

There are some data suggesting that there is a relationship between the magnitude of Peyronie's disease (PD)-associated penile curvature and low serum testosterone.

AIM

To evaluate the relationship between PD associated penile deformity and total testosterone (TT) and free testosterone (FT) levels.

METHODS

We identified patients diagnosed with PD who had early morning TT measurements. Because laboratories have different reference values, we analyzed testosterone values 2 ways, as raw values and as standardized values (TT and FT values converted into z-scores for each laboratory). Deformity assessment was conducted during an intracavernosal injection-induced rigid erection. The association between T levels and magnitude of penile curvature was analyzed in a number of ways. First, an independent measure t-test tested differences in curvature degree by TT groups (low T: <300 ng/dL; normal T: ≥300 ng/dL). Second, an association was sought between T levels based on quartiles of the normal range (<300, 300-450, 450-600, and >600 ng/dL). These analyses were conducted for both TT and FT levels and using both raw and standardized T values. Third, multivariable analysis using multiple linear regression was performed in an attempt to define predictors of the degree of penile curvature. Factors entered into the model included: TT level, FT level, patient age, race (white vs other), number of co-morbidities, body mass index, presence of erectile dysfunction, duration of PD, and prostatectomy (yes vs no).

MAIN OUTCOME MEASURES

The relationship between T levels and the magnitude of penile curvature.

RESULTS

184 subjects met all study criteria. Average age was 54 ± 12 years. Mean TT level was 425 ± 176 ng/dL, and mean curvature magnitude was 35° ± 19°. The percent of subjects in the first through fourth TT quartiles was 26%, 34%, 24%, and 16%. As a continuous variable, there was no association between TT levels (r = -0.01, P = .95) or FT levels (r = -0.08, P = .30) and the curvature magnitude. When examining TT groups, there was no difference in mean curvature between the low TT group and the normal TT group (35.4° ± 17° vs 34° ± 20°, P = .70). When analyzing the TT and FT levels standardized into z-scores, there was no association between degree of curvature and TT z-scores (r = -0.003, P = .95) and FT z-scores (r = -0.08, P = .43). There was also no association between testosterone levels and degree of curvature in the multivariable model.

CONCLUSIONS

There does not appear to be any association between testosterone levels and the magnitude of PD-associated penile deformity. Mulhall JP, Matsushita K, Nelson CJ. Testosterone Levels Are Not Associated With Magnitude of Deformity in Men With Peyronie's Disease. J Sex Med 2019;16:1283-1289.

Peyronie's disease and testosterone deficiency: Is there a link?

INTRODUCTION

Peyronie's disease (PD) and testosterone deficiency (TD) impact men at the same stage of life and can ultimately contribute to erectile dysfunction. There is speculation that low levels of testosterone (T) may predispose men to penile fibrosis; however, there is no published, up-to-date review summarizing the current evidence. Therefore, we conducted a narrative review of the literature exploring the relationship between PD and TD.

METHODS

A comprehensive systematic search of existing literature of five online databases from June 1990 to June 2018 examining the relationship between PD and TD was conducted. The Cochrane risk-of-bias tool for randomized trials and the risk-of-bias assessment tool for cohort studies were used to evaluate the quality of studies.

RESULTS

Six studies were identified (n = 675). Overall, five studies supported the link between PD and TD by demonstrating relationships in PD patients with low total T, free T, bioavailable T, greater penile curvature, and plaque development. However, one study demonstrated no connection between the conditions. The literature is restricted by small studies with methodological flaws.

CONCLUSION

There are a number of mechanisms to support the link between TD and PD. The literature on the topic is limited by small studies which are overall conflicting. The findings of this work suggest the need for larger, prospective studies to clarify the role of TD in the development, evaluation, and treatment of PD. Establishing such a relationship could change management of PD as a diagnosis of PD may encourage clinicians to evaluate a patient's testosterone levels.

The relationship between penile deformity, age, psychological bother, and erectile dysfunction in a sample of men with Peyronie's Disease (PD)

The aim of the present study was to investigate which PD specific factors (e.g., degree of penile curvature, levels of pain) cause most distress and to further explore whether there are specific subgroups of patients that report particularly high levels of psychological distress. Data were available for N = 119 men with a clinical diagnosis of PD presenting at a private Uro-Andrology in Germany. The strongest complaint of men with PD was being bothered by the look of the penis as opposed to being distressed by the pain (3.48 vs. 2.11). 75.4% reported having significantly less intercourse due to PD and for 61.4% this was very bothersome. Plaque size correlated positively with the level of symptom bother (r = 0.73, p < 0.05). Furthermore, men with a stronger curvature reported more concerns regarding size and form of the penis (r = 0.18, p < 0.05), more overall sexual dissatisfaction (r = -0.38, p < 0.001), and more PD related psychological and physiological symptoms (r = 0.58, p < 0.001). 44.4% of patients had a concurrent ED. Highest level of symptom bother was reported by men with a a strong curvature and a comorbid ED. Clinicians should pay special attention to patients presenting with extreme penile deformity and impaired sexual functioning, as they show the highest levels of psychological distress. Here, additional psychosexual support might be necessary.

Prospective study to evaluate the clinical outcome of intralesional interferon-α2b in the management of Peyronie's disease

Context:

Interferon (IFN)-α2b in Peyronie's disease (PD).

Aims:

This study aims to evaluate clinical efficacy of the IFN-α2b in both subjective and objective manner for the treatment of PD and compared with previously used intralesional verapamil in terms of cost-benefit analysis.

Settings and Design:

Prospective study.

Materials and Methods:

A prospective study conducted from January 2013 to July 2016 in the Department of Urology, Government Medical College, Kota, Rajasthan, India. We included patients with identifiable Peyronie's plaque with or without pain, curvature ranging between 30 and 90 degrees. We excluded patients with a calcified plaque and the ventral location of the plaque, any infective foci over the penis, erectile dysfunction due to other etiologies and patients who had received previous intralesional therapy. Patients were evaluated by clinical history, physical examination including plaque location, size, consistency, and penile curvature. Patients received intralesional IFN-α2b in a dose of 3 × 10⁶ IU. Patients completed the visual analogue pain (VAS) score for pain, and International Index of Erectile Function-5 (IIEF-5) questionnaire at first visit as well as at follow-up of 1 month and 3 months.

Statistical Analysis Used:

Comparisons were performed using the paired Student's t-test and Chi-square tests as appropriate. Patient's objective and subjective clinical characteristics were described as a means (standard deviation).

Results:

We included 86 patients in this study. Patients had a mean age of 48.6 years, mean plaque volume 256 mm³, and disease duration of 15.2 years. After 1 month of treatment, there was a significant change in plaque volume 256–60.8 mm³; P < 0.01) and penile curvature 34.8–24.6°; P < 0.01). The patients reported significant improvement in pain score VAS and IIEF-5.

Conclusions:

IFN-α2b, as minimal invasive (intralesional) options for the treatment of PD, demonstrated significant improvement in plaque volume, penile curvature with minimal complications. Patients subjectively reported significant improvement in pain on erection and sexual activities. IFN-α2b and verapamil had an almost similar clinical outcome, but verapamil at much lower cost.

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.

Collagenase Clostridium histolyticum in the management of Peyronie's disease: a review of the evidence

OBJECTIVES

Peyronie's disease (PD) is a connective tissue disorder resulting in the abnormal accumulation of scar or plaques in the tunica albuginea of the penis. The condition is characterized by two phases: an active, inflammatory phase, and a stable, chronic phase. Collagenase Clostridium histolyticum (CCH) was isolated in the mid-1900s and postulated as a potential pharmacologic strategy for breaking down the abnormal connective tissue plaques of PD. Prior to the introduction of CCH, a wide variety of treatment modalities for PD were used in clinical practice, including oral and topical medications, intralesional injections, electromotive drug administration, extracorporeal shockwave therapy, traction, and invasive surgery, all with variable results. This review aims to examine the known data surrounding the use of intralesional CCH injections in the treatment of PD.

METHODS

CCH is a recently US Food and Drug Administration approved pharmacologic treatment for PD. Clinical trials using intralesional CCH injection therapy for the treatment of PD were reviewed for clinical safety and efficacy of treatment.

RESULTS

Studies demonstrated that CCH treatment administered in multiple cycles led to significant benefit in both the psychological and physical aspects of PD. The strongest evidence for CCH's effectiveness was revealed in large, multicenter randomized controlled trials (Investigation for Maximal Peyronie's Reduction Efficacy and Safety Studies I and II) in which intralesional CCH was combined with manual modeling of the penis. Although adverse events from treatment are relatively common, the majority are mild to moderate in degree, including penile pain, swelling, and bruising, which all resolve spontaneously.

CONCLUSION

Overall, evidence indicates that CCH is a valuable, effective, and safe minimally invasive treatment option for men with PD.

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

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

Peyronie's disease: What's around the bend?

INTRODUCTION

Peyronie's disease (PD) is a fibrotic diathesis of the tunica albuginea that results in penile plaque formation and penile deformity, negatively affecting sexual and psychosocial function of both patients and their partners. In this review, we discuss the PD literature and PD treatment options, with special emphasis on potential future therapies.

METHODS

The PD literature was reviewed, and articles of interest were identified using keyword search in PubMed. Articles evaluating investigational and novel PD treatments were emphasized.

RESULTS

Existing PD treatment modalities are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Surgical treatment has high success rates and is indicated in men with significant, stable deformity. The United States Food and Drug Administration-approved intralesional collagenase Clostridium histolyticum injection therapy is a minimally invasive option with demonstrated efficacy in PD. Other nonsurgical therapies have been reported, including Botox and stem cell therapy, but these currently have little or equivocal evidence to support their efficacy.

CONCLUSIONS

Further research is essential to develop novel, safe, and effective minimally invasive PD treatment options. This work is ongoing, with the promise of specific, targeted, and highly effective therapies on the horizon.

Role of collagenase clostridium histolyticum in Peyronie's disease

Peyronie's disease is a localized connective tissue disease characterized by an active, inflammatory phase and a stable, quiescent phase, with the eventual development of collagenous plaques within the tunica albuginea of the penis. Risk factors primarily associated with Peyronie's disease include Dupuytren's contracture, penile trauma, and family history. A variety of treatment strategies have been utilized, including oral and topical agents, electromotive drug administration, intralesional injections, extracorporeal shockwave therapy, penile traction, and surgery. However, most of these strategies are ineffective, with surgery being the only definitive treatment. Collagenase clostridium histolyticum is a newly US Food and Drug Administration-approved agent for intralesional injection. It is thought to downregulate many of the disease-related genes, cytokines, and growth factors and degrade collagen fibers. It also suppresses cell attachment, spreading, and proliferation. Collagenase clostridium histolyticum has been clinically proven to be a safe and effective therapeutic option, demonstrating decreases in penile curvature and plaque consistency, as well as increases in patient satisfaction. During clinical evaluation, the Peyronie's Disease Questionnaire was validated as an effective tool for assessing treatment outcomes.

PEYRONIE'S DISEASE: A REVIEW OF ETIOLOGY, DIAGNOSIS, AND MANAGEMENT

Peyronie's Disease (PD) is a superficial fibrosing disorder of the penis resulting in plaque formation and penile deformity. Once considered rare, PD has more recently been found in up to 13% of men, and can negatively affect sexual and psychosocial function of both patients and their partners. While the etiology of PD is unclear, it is thought to result from an inciting traumatic event followed by aberrant fibrosis or dysregulated wound healing. The evaluation of men presenting with PD includes a detailed history and physical exam, focusing on the penis in both the flaccid and erect states. PD is often associated with erectile dysfunction (ED), as well as several other comorbidities. Laboratory testing is not needed to diagnose PD, although given the associations between PD and systemic diseases including hypogonadism, diabetes, and cardiovascular disease, screening and work-up for these conditions in men with PD may be warranted. Treatment modalities for PD are diverse and include oral, topical, intralesional, mechanical, and surgical therapies. Oral, topical, and mechanical therapies generally have little evidence supporting their efficacy. Several intralesional therapies, including interferon α2b and collagenase Clostridium hystiolyticum have demonstrated efficacy in the treatment of PD. Surgical treatment, indicated in men with significant, stable deformity, includes plication of the tunica albuginea, plaque incision/excision and grafting, and placement of inflatable penile prosthesis (IPP) with or without additional maneuvers to achieve desired results, and has high success rates.

Low testosterone has a similar prevalence among men with sexual dysfunction due to either Peyronie's disease or erectile dysfunction and does not correlate with Peyronie's disease severity

INTRODUCTION

Low testosterone (T) has been suggested as a risk factor for Peyronie's disease (PD) that may correlate with disease severity. Low T is common in men with sexual dysfunction but its role in the pathogenesis of PD remains unclear.

AIM

The aim of this study was to compare the prevalence of low T (<300 ng/dL) in patients presenting with PD or erectile dysfunction (ED), as well as disease severity between men with PD and either low T or normal T (≥300 ng/dL).

METHODS

Retrospective review of 300 men with either PD or ED was conducted. Men were excluded for combined PD and ED, psychogenic ED, or prior T use. For men with PD, plaque size, degree of curvature, and surgical correction rate were compared.

MAIN OUTCOME MEASURES

The main outcome measures were (i) mean T levels in men with PD or ED and (ii) plaque size, degree of curvature, and surgical correction rates among men with PD and either low T or normal T.

RESULTS

Eighty-seven men with PD and 98 men with ED were identified. Men with PD had mean total T and free T of 328 ng/dL and 11.5 ng/dL, while men with ED had mean levels of 332 ng/dL and 12.1 ng/dL, respectively (P > 0.05). Of PD men, 52.9% had low T, compared with 45.9% of men with ED (P = 0.35). T levels did not correlate with plaque size or degree of curvature in the PD group (P > 0.05).

CONCLUSIONS

Men with sexual dysfunction characterized by either PD or ED had similarly low T levels, and low T did not correlate with PD severity or surgical correction rate. The comparable prevalence of low T in men with PD or ED suggests the high rate of low T in PD men may be related to a common process among men with abnormal erectile physiology and not specifically causative in plaque formation.

Systematic Literature Review of the Epidemiology of Nongenetic Forms of Hypogonadism in Adult Males

This study summarizes the literature on the prevalence, incidence, and proportion of patients receiving treatment for male hypogonadism and a systematic literature search was performed for articles published in the last 20 years. Of the 97 studies identified, 96 examined the prevalence, 2 examined the incidence, and 4 examined the proportion of males with hypogonadism patients receiving treatment. Based on studies conducted in Europe and USA, the prevalence of hypogonadism in the general population ranged from 2.1% to 12.8% of middle-aged to older men, with an estimated incidence of 12 new cases per 1,000 person-years. Prevalence was higher among patients with comorbid conditions, such as type 2 diabetes mellitus and obesity. Approximately 10–12% of men with hypogonadism were receiving testosterone treatment. This literature review suggests that there is potentially a significant burden of hypogonadism in the general population. Burden seems to increase with age and in the presence of certain disease conditions. Data suggests that many hypogonadal men who may benefit from testosterone replacement are not receiving treatment. This may be the result of underdiagnosis of the disease, lack of awareness by patients or physicians, irregularities surrounding the diagnostic criteria, and deficiency of long-term safety studies.

Understanding the course of Peyronie's disease

AIMS

To correct common misconceptions about Peyronie's disease (PD) that present obstacles to early recognition and treatment.

METHODS

The prevalence, natural disease course, psychosocial effects and treatment considerations for patients with PD were reviewed.

RESULTS

Studies over the past decade have shown that the prevalence of PD may be higher (up to 20%) than previously thought. PD can lead to emotional and relationship distress. Nearly 10% of men who present with PD are younger than 40. Both younger age and comorbid vascular disease have been associated with more severe and progressive PD. In the majority of patients, symptoms will either deteriorate or remain stable. PD is often associated with erectile dysfunction (ED). Effective, minimally invasive treatments used early in the disease course include unapproved and/or investigational intralesional injection therapy with verapamil, interferon (IFN) α-2b, or collagenase clostridium histolyticum (CCH). Surgical intervention is considered in patients with ED and/or penile deformity that impairs sexual functioning; however, preoperative discussion of appropriate expectations is important.

DISCUSSION

The availability of effective minimally invasive and surgical therapies for PD suggests that active management should be considered over a 'wait-and-see' approach.

CONCLUSION

Providing early intervention and improved education/awareness of PD as a chronic and progressive disorder may result in improved physical and psychosocial outcomes for PD patients. As general practitioners are often the first contact for men with PD, they are well positioned to recognise symptoms early and promptly refer patients for further evaluation and treatment.

Standard operating procedures for Peyronie's disease

INTRODUCTION

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

AIM

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

METHODS

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

MAIN OUTCOME MEASURES

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

RESULTS

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

CONCLUSIONS

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

Does testosterone deficiency exaggerate the clinical symptoms of Peyronie's disease?

Serum testosterone (T) influences wound healing and levels are decreased in the age group at risk of Peyronie's disease (PD). The aim of the present study was to evaluate the severity of penile deformity in men with PD in relation to T levels. One-hundred and six patients with PD and T deficiency (serum T <3.5 ng/mL; Group 1) and those with normal T levels (Group 2) were compared according to the duration of PD, the size and location of the plaques, penile curvature, pain on erection, and the severity of erectile dysfunction. The mean degree of penile curvature in Group 1 was significantly greater than in Group 2 (32.0 ± 15.9° vs 21.8 ± 15.4°, respectively). The mean Group 1 score on the International Index of Erectile Function (IIEF)-5 was lower than the score for Group 2 (7.4 ± 3.7 vs 10.8 ± 4.8, respectively). The percentage of patients who complained of pain on erection did not differ between the two groups. Plaque size in Group 1 was larger than in Group 2 (3.0 ± 1.2 vs 2.0 ± 1.2 cm, respectively), whereas there was no significant difference in plaque location. Although there was a lower percentage of responders to medical treatment in Group 1, there were no differences in surgical outcomes between the two groups. These findings suggest that the presence of T deficiency in patients with PD exaggerates the severity of PD by affecting penile deformity, plaque size, and erectile dysfunction. Further studies are needed to confirm this relationship.

Current status and new developments in Peyronie's disease: medical, minimally invasive and surgical treatment options

INTRODUCTION

Peyronie's disease (PD) is a wound-healing disorder of the tunica albuginea of the penis which affects 3-9% of adult males. Clinically, any combination of plaque formation, penile pain, angulation and erectile dysfunction may appear. This condition may progress, stabilize or, uncommonly, regress during the initial acute phase (6-18 months).

AREAS COVERED

Information regarding this review was searched in PubMed until August 2010. Vitamin E, paraaminobenzoate and colchicine are sparingly employed oral medical therapies. Intralesional injections as a minimally invasive therapy for PD includes injection with verapamil, interferon-α-2b, and collagenase. Men suffering with PD who have significant penile deformity precluding successful coitus can be appraised for surgical correction. Surgery is considered the gold standard and includes plication, incision and grafting- or penile-prosthesis-related procedures.

EXPERT OPINION

This paper provides a broad overview of the subject of PD, available nonsurgical options and surgical approaches that will aid in the routine clinical diagnosis and management of PD. Increased public and medical awareness of PD prevalence, presentation, diagnosis and treatment options will serve well the large population of men who suffer in silence with this common condition.

Peyronie's disease: perspectives on therapeutic targets

INTRODUCTION

Peyronie's disease (PD) is an acquired benign connective tissue disorder of the penis, characterized by the development of fibrotic plaques, that can cause different degrees of bending, narrowing or shortening. Medical treatment for PD remains a major challenge. Impressive progress in our understanding of the molecular mechanisms of PD pathogenesis has uncovered several promising molecular targets for antifibrotic treatments.

AREAS COVERED

This review covers the literature pertaining to the exploration of therapeutic targets for PD. The search included: i) a MEDLINE search from 1941 to January 2011, limited to English-language medical literature, ii) relevant abstracts from 2009 and 2010, iii) relevant textbooks and iv) a pipeline search for therapeutics in development.

EXPERT OPINION

Rapid translational research depends on our ability to develop rational therapies targeted to penile tunical fibrosis, which necessitate a sound knowledge of the biology, biochemistry and the physiological role of fibroblasts, myofibroblasts and stem cells in PD. Much remains to be learned about the pathogenesis of PD. Although there are many interesting therapeutic targets, we are confronted with some questions when identifying new targets, or when validating potential therapeutic options.

The relationship between androgens, regulators of collagen metabolism, and Peyronie's disease: a case control study

INTRODUCTION

Changes in collagen metabolism have been postulated to play a pivotal role in the pathogenesis of Peyronie's Disease (PD). Androgens such as dehydroepiandrosterone sulfate (DHEA-S) and testosterone influence collagen metabolism by modulating the activity of matrix metalloproteases (MMP) and tissue inhibitors of metalloproteases (TIMP).

AIM

The aim of this study was to evaluate the interrelationship between androgens (DHEA-S and testosterone), key regulators of collagen metabolism such as insulin-like growth factor (IGF) 1 and IGF Binding Protein 3 (IGF-BP3), the MMP/TIMP system, and PD.

METHODS

Age matched PD patients (14) and healthy men (10) who acted as controls were recruited. Blood samples were collected from all subjects in the early morning hours after an overnight fast.

MAIN OUTCOME MEASURES

Serum levels of testosterone, sex hormone binding globulin, DHEA-S, 3-α-androstanediol glucuronide, pro-MMP-1, MMP-1, MMP-2, TIMP-1, TIMP-2, IGF-1 and IGF-BP3 were measured in both groups. Statistical methods included univariate, bivariate, and multivariate regression models.

RESULTS

Levels of DHEA-S (114.5 vs. 169.5 µg/dL; p = 0.03), IGF-BP3 (2.96 vs. 3.79 µg/mL; p = 0.01), and TIMP-1 (173.1 vs. 195 ng/mL; p = 0.01) were significantly lower in PD patients. In contrast, the level of TIMP-2 (102 vs. 85 ng/mL; p = 0.001) was significantly lower in the control group. Using stepwise regression analysis, only TIMP-2 (p < 0.001) and DHEA-S (p = 0.04) were significantly related to PD in the final model (R(2) = 0.63). TIMP-1 and DHEA-S (r = 0.55, p < 0.05) were positively correlated in the PD group, whereas IGF-1 and testosterone (r = -0.54, p < 0.05), and IGF-BP3 and testosterone (r = -0.68, p < 0.05) were negatively correlated in PD patients.

CONCLUSIONS

Our findings suggest that decreased levels of adrenal androgens may be implicated in the pathogenesis of PD. The mechanism and clinical relevance of this observation remain to be established.

A cross-sectional study for the analysis of clinical, sexual and laboratory conditions associated to Peyronie's disease

INTRODUCTION

Although Peyronie's Disease (PD) was first described over 250 years ago, its precise etiology remains obscure.

AIM

Analyze a variety of potential associated factors with PD, including erectile dysfunction.

MATERIALS AND METHODS

This cross-sectional study included 83 consecutive men with PD and 252 age-matched controls. All men completed the International Index of Erectile Function (IIEF) and were evaluated regarding their clinical and demographic characteristics, comorbidities, and used medications. Anthropometric measures included body mass index and waist circumference (WC). Fasting blood glucose, lipid profile, total testosterone, and dehydroepiandrosterone-sulfate were determined.

MAIN OUTCOME MEASURES

Clinical and laboratory characteristics associated to PD.

RESULTS

The mean age was 59.2 + or - 10 years in the cases and 59.7 + or - 12 years in the controls. Marital status, current smoking, and excessive consumption of alcoholic beverages were similar between groups (P > 0.05). PD was more common among white skin color males (P = 0.001). The mean score for each IIEF domain and the androgen levels were similar in the two groups. Thiazides were the only medication associated to PD (P = 0.03). Dupuytren's disease was more frequent among individuals with PD (P = 0.001). The distribution of all other comorbidities investigated was similar between groups (P > 0.05). The characteristics WC > 102 cm and levels of low-density lipoprotein (LDL) > 130 mg/dL were more prevalent in the controls (P < 0.05). After multivariate analysis, white skin color (OR: 8.47, 95%CI: 1.98-36.24) and thiazide use (OR: 2.29, 95%CI: 1.07-4.90) were associated to PD, and LDL > 130 mg/dL (OR: 0.55, 95%CI: 0.32-0.92) and WC > 102 cm (OR: 0.53, 95%CI: 0.29-0.96) were inversely associated to PD.

CONCLUSIONS

In this study, PD was more common among white skin colored males. An inverse relationship with the presence of elevated serum levels of LDL and WC was observed. We found no association with medications other than thiazides and comorbidities other than Dupuytren's disease. Androgen serum levels and sexual dysfunction had also no association to PD.