Risk factors of Peyronie's disease. What does our clinical experience show?

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.

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

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

Chronic prostatitis as possible risk factor for Peyronie's disease: Psychological, sexual and prostatitis-like symptoms in patients with PD

OBJECTIVE

This study aims to investigate a possible relationship between chronic prostatitis (CP) and Peyronie's disease (PD) and to characterize the psychological profile of patients suffering from PD, with or without concomitant CP.

METHODS

We included 539 patients with PD, of which 200 were found to have underlying CP. As a comparator population, we selected 2201 patients without PD, referring to our tertiary care clinic. In this population, we detected 384 subjects with CP. All 539 PD patients underwent photographic documentation of the penile deformation, and dynamic penile eco-color Doppler with plaque and volume measurements and answered the following questionnaires: the Generalized Anxiety Disorder-7, the Patient Health Questionnaire-9, the Visual Analog Scale for penile pain measurements, the International Index of Erectile Function (IIEF), and the NIH-Chronic Prostatitis Symptom Index.

RESULTS

The overall prevalence of chronic prostatitis in PD patients was 37.1% compared to a prevalence of 17.4% in the non-PD control population (OR = 2.79 and p < 0.0001). The severity of CP symptom total scores (NIH-CPSI) correlated significantly with the severity of erectile dysfunction (p < 0.0001). Significant anxiety was present in 89.2% of PD patients and it is more prevalent in PD patients with CP than in PD patients without CP (93.0% vs. 87.0%, respectively; p = 0.0434). Significant depression was detected in 57.1% of PD patients and it is more prevalent in PD patients with CP than in PD patients without CP (64.0% vs. 53.09%, respectively; p = 0.0173).

CONCLUSION

Chronic prostatitis (CP) and Peyronie's disease (PD) are frequently associated. Our results demonstrate the strong impact of chronic prostatitis on the mental status of PD patients. Anxiety and depression were significantly more pronounced in PD patients with CP than in PD patients without CP.

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.

Significant familial clustering of Peyronie's disease in close and distant relatives

BACKGROUND

Peyronie's disease (PD) has previously been observed to co-aggregate in a small number of first-degree relative pairs (e.g., father-son). However, the familial aggregation of PD in more distant relatives, as well as the aggregation of Dupuytren's disease (DD) in probands and relatives, has not been thoroughly investigated.

OBJECTIVE

This study explored the evidence for familial clustering of PD and DD in close and distant relatives.

MATERIALS AND METHODS

The Utah Population Database, which includes genealogy information linked to electronic medical records (available since 1995), was used to identify men and their relatives with PD and DD based on ICD9/10 codes. All cases were required to have high-quality genealogy data. We estimated relative risk (RR) of PD and DD in first- through fifth-degree relatives compared to matched population rates of disease. We also investigated the average relatedness of cases compared to the average relatedness of sets of matched controls. Outcome measures include estimation of relative risk and excessive relatedness as measured by a Genealogical Index of Familiality (GIF) analysis.

RESULTS

We analyzed 307 individuals with PD, and their first- through fifth-degree relatives. Approximately 0.12% of the population had PD, 95% of these were diagnosed over the age of 30 years (age range: 10-92 years), and 1.3% of PD probands had a comorbid diagnosis of DD. RR estimates for PD were significant for first- and fifth-degree relatives. RR estimates for DD were significant only for probands. The average relatedness of cases was significantly greater than matched controls, even after removing first- and second-degree relatives. We also found that 74.9% of identified PD probands belonged to pedigrees with a statistical excess of PD.

CONCLUSION

Despite the low prevalence of PD in our healthcare records, the results provide evidence that support a genetic contribution to at least a subset of PD cases.

Fibroproliferative disorders and diabetes: Understanding the pathophysiologic relationship between Peyronie's disease, Dupuytren disease and diabetes

Introduction

Fibrosis is characterized by dysregulation and accumulation of extracellular matrix. Peyronie's disease and Dupuytren disease are fibroproliferative disorders of the tunica albuginea of the penis and fascia of the hand, respectively. Chronic hyperglycaemia due to diabetes mellitus can also lead to tissue injury and fibrosis. A meta-analysis has shown a relationship between Dupuytren disease and diabetes (overall odds ratio, 3.1; 95% confidence interval, 2.7-3.5). This review explores commonalities in the pathogenesis of Peyronie's disease, Dupuytren disease and diabetes.

Methods

A search of the PubMed database was conducted using the search terms "diabetes" AND "Peyronie's disease"; and "diabetes" AND "Dupuytren."

Results

Genome-wide association and gene expression studies conducted with tissue from people with Peyronie's disease or Dupuytren disease identified signalling pathways associated with wingless-type mammary-tumour virus integration site signalling, extracellular matrix modulation and inflammation. Biochemical studies confirmed the importance of these pathways in the pathogenesis of fibrosis with Peyronie's disease and Dupuytren disease. Dysregulation of matrix metalloproteinase activity associated with extracellular matrix breakdown was implicated in fibroproliferative complications of diabetes and in the aetiology of Peyronie's disease and Dupuytren disease. A notable percentage of people with diabetes have comorbid Peyronie's disease and/or Dupuytren disease.

Conclusions

Studies have not been performed to identify fibroproliferative pathways that all 3 conditions might have in common, but data suggest that common pathways are involved in the fibroproliferative processes of Peyronie's disease, Dupuytren disease, and diabetes.

Peyronie disease: a clinicopathologic study of 71 cases with emphasis on histopathologic patterns and prevalent metaplastic ossification

Peyronie disease (PD) is a benign, superficial fibromatosis involving the fascial structures of the penis, causing deformity, pain, and loss of function, for which there are few contemporary studies of the histopathology. We performed a multi-institutional review of 74 routine and consultation specimens submitted with clinical concern for PD. Of these, three non-PD lesions were identified and excluded (a myointimoma, a mammary-type myofibroblastoma, and fibrocalcific atherosclerosis). Of the 71 confirmed to be PD, the majority of patients were white (83%), with a median age of 55 years (range: 26-88). The dorsal aspect of the penis was the most common site involved (78%), followed by lateral (12%) and ventral (10%) aspects. The median degree of curvature was 70° (range: 20-360°). On review, three overall histologic patterns characterized the lesions resected: dense fibrotic plaque (61%), dense fibrotic plaque with focal or patchy metaplastic ossification (35%), and plaque composed predominantly of metaplastic ossification (4%). The fibrotic component was predominantly nodular (18%), hyalinized/lamellar (46%), or mixed (32%), excepting two cases consisting entirely of metaplastic bone. Chronic inflammation, when present, was most often focal and perivascular in distribution. In one case, an excision after collagenase treatment showed myxoid change and increased stromal cellularity. Overall, these findings define the range of PD histology, particularly emphasizing that the calcification noted clinically nearly always represents bona fide metaplastic ossification. Such context will be of value in evaluating specimens prospectively, in light of changing practices and the use of new technologies for treatment.

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.

The Impact of Peyronie's Disease on the Patient: Gaps in Our Current Understanding

Peyronie's disease results in a fibrous inelastic scar or hard plaque of the tunica albuginea of the penis that causes penile curvature deformity during erection that can be painful, distressing, and an impediment to sexual intercourse. In this article, the authors examine the knowledge gaps and research needs regarding the effect of Peyronie's disease on the patient's physical and psychological quality of life and on interpersonal relationships. On PubMed, the authors used the search terms Peyronie's disease, psychological, psychotherapy, male sexual dysfunction, partner, comorbid disease, satisfaction, and pain. Four categories describing the effect of Peyronie's disease were identified: (a) sexual dysfunction due to pain and altered penile shape, (b) psychological effects, (c) partner and relationship effects, and (d) effects of treatment options for Peyronie's disease. Results indicate that the examination of interventions aimed at education, coping, relationship distress, and sex therapy that may significantly improve patient quality of life is a core unmet need in Peyronie's disease. For many patients, the effect of Peyronie's disease is functional and psychological. Both aspects should be evaluated and treated in patients, which may require a referral. The physical pain, emotional distress and isolation, and partner and relationship discord that may be present require more attention.

Use of intralesional collagenase in the treatment of peyronie’s disease: A review

AIM: To review the relevant literature in an effort to examine the body of evidence available to date.

METHODS: Ovid MEDLINE search database was queried using MeSH terms “penile induration”, “peyronie’s disease”, “Collagenases” and “Collagenase” using various permutations. No temporal parameters were employed.

RESULTS: In all, 5 relevant clinical trials were isolated from 34 results. These trials were analyzed using the Oxford Centre for Evidence-Based Medicine criteria. They were further examined based on study design and methods; the primary and secondary outcomes were reviewed for treatment efficacy and collagenase-related side effects.

CONCLUSION: Intralesional collagenase appears to be safe and effective in the non-surgical treatment of Peyronie’s disease. However, the data remains limited and further inquiries into the safety of collagenase, treatment standardization and standardized outcomes reporting remain necessary. Furthermore, studies comparing intralesional collagenase to alternative medical and surgical therapy will be important in guiding the future treatment decision process.

Peyronie's disease: epidemiology, diagnosis, and management

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.

Peyronie's disease: A contemporary review of non-surgical treatment

In this review I discuss the current non-surgical treatment options for Peyronie’s disease (PD), which remains a therapeutic dilemma for the treating physician. This is despite a large array of treatments that have been used since the time of de la Peyronie in the mid-18th century. Part of the problem with finding an effective treatment is the incomplete understanding of the aetiopathophysiology of this scarring disorder. Published articles in peer-reviewed journals were assessed, recognising that most of the reported trials are compromised by being single-centre studies with no placebo control. Various treatment options have emerged, most with limited and unreliable benefit, but a few treatments have shown a consistent, albeit incomplete, response rate. Currently the only scientifically sensible oral agents appear to be pentoxifylline, l-arginine, and possibly the phosphodiesterase type-5 inhibitors. The current intralesional injection treatment options include verapamil and interferon, with a reported benefit in reducing deformity and improving sexual function. Intralesional clostridial collagenase is in the midst of phase-3 trial analysis by the USA Food and Drug Administration. External mechanical traction therapy has recently emerged as a technique to reduce the curvature, recover lost length, and possibly obviate surgery. Currently there is no clear, reliable and effective non-surgical treatment for PD, but it appears that several of the available treatments can reduce the deformity and improve sexual function, and might at least stabilise the disease process.

Peyronie's disease: contemporary review of non-surgical treatment

BACKGROUND

Peyronie's disease (PD) remains a therapeutic dilemma for the treating physician. This is in spite of a large array of treatments which have been used since the time of de la Peyronie in the mid 18(th) century. Part of this problem is due to an incomplete understanding of the etiopathophysiology of this scarring disorder. Having a better understanding of the how and why the scarring occurs may help prevent progression, but ultimately reversing the existing scar remains the real challenge.

METHODS

This review discusses the current non-surgical treatment options for Peyronie's disease. Published articles in peer-reviewed journals are used, recognizing that the majority of the published trials are compromised by being single-center studies without a placebo control.

RESULTS

A variety of treatments options have emerged, most with limited and unreliable benefit, but a few treatments have shown a consistent albeit incomplete response rate. Could this suggest that all PD is not the same and that the heterogeneous nature of this scarring disorder may account for why some patients respond and others do not? Further investigation of this diverse response rate may yield insights into the pathophysiology of PD. In the meantime, there have been many oral treatments offered for PD. Currently the only scientifically sensible treatments appear to be pentoxifylline, L-arginine, and possibly the phosphodiesterase type-5 inhibitors. Intralesional injection has been used for many years. The current treatment options include verapamil and interferon, with reported benefit with respect to reduced deformity and improved sexual function. Intralesional clostridial collagenase is in the midst of phase 3 trial analysis by the FDA in the USA and may become the newest and only FDA approved treatment for Peyronie's disease. External mechanical traction therapy has also recently emerged as a technique to reduce curvature, recover lost length, enhance girth, and possibly obviate surgery.

CONCLUSIONS

It appears at this time that there is no clear, reliable and effective non-surgical treatment for Peyronie's disease, but it does appear from the published literature that several of the available treatments can result in reduction of deformity, improved sexual function, and may at a minimum stabilize the disease process so that deformity does not get worse particularly during the acute phase of this scarring disorder. Combination therapy in an effort to create a synergy between the chemical effects of oral and injectable drugs with the mechanical effects of external traction therapy may provide the best opportunity today for reduction of deformity in the man with Peyronie's disease.

Surgical management of penile fracture and long-term outcome on erectile function and voiding

INTRODUCTION

Penile fracture is an emergency in urology. Surgical management is recommended, but objective data of postoperative long-term effects, especially regarding voiding and erectile function, vary.

AIM

To assess long-term results of patients undergoing surgical therapy for penile fracture.

METHODS

Patients presenting with suspicion of penile fracture were included in this study. Diagnosis of penile fracture was made by clinical assessment and surgery performed thereafter. The defect of the tunica albuginea was closed by absorbable suture. In case of concomitant urethral lesion, the defect was repaired simultaneously. Voiding and erectile function were evaluated at long-term follow-up by mail. Patients' status before penile fracture was assessed retroactively.

MAIN OUTCOME MEASURES

Erectile function was assessed by the International Index of Erectile Function questionnaire and voiding function by the International Prostate Symptom Score questionnaire.

RESULTS

N = 34 patients were included. Penile fracture was suspected in 28/34 (82.4%) patients. Twenty-six of the 28 (92.9%) patients underwent surgery. Only less than half of confirmed fracture patients presented with the classical triad of an audible crack, detumescense, and hematoma. Fourteen of the 26 (53.8%) patients after surgery were available for follow-up. Mean follow-up was 45.6 months (range: 3.6-128.4). In 13/14 (92.9%) patients, penile fracture was confirmed by surgery. At follow-up, 7/13 (53.8%) patients had impaired erectile function, with 3/13 (23.1%) patients needing medical treatment. Four of the 13 (30.8%) patients showed deterioration of voiding including occurrence of urethral fistula.

CONCLUSIONS

Penile fracture is an emergency for which surgery should be offered. Clinical suspicion of fracture should be high even with hematoma alone. Concomitant urethral injury is common, particularly with bilateral corporal rupture and/or initial hematuria. Preoperative counseling should include discussion of long-term erectile and voiding dysfunction, penile deformity, and urethral fistula both with and without surgery. Close patient follow-up is required.

The prevalence of Peyronie's disease in Japan: a study in men undergoing maintenance hemodialysis and routine health checks

INTRODUCTION

The incidence of Peyronie's disease (PD) in the general population is believed to be as high as 20%. However, most of the data concerning the prevalence of PD have been obtained from Caucasian populations.

AIM

The aim of this study was to examine the prevalence of PD in Asia and among men undergoing hemodialysis and discuss the pathophysiology of PD.

METHODS

A total of 1,090 men who received a routine health check at our hospital (control group) as well as 130 male patients undergoing maintenance hemodialysis were enrolled. The diagnosis of PD was based on a palpable penile plaque.

MAIN OUTCOME MEASURES

Hemodialysis patients were asked about their sexual activity and completed the International Index of Erectile Function-5 questionnaires. The differences between patients' and hemodialysis-associated factors, comorbidities, and medications were statistically assessed for patients with and without PD.

RESULTS

The prevalence of PD was significantly increased among hemodialysis patients (12 patients: 9.2%) relative the control group (six men: 0.6%) (P<0.0001, odds ratio: 18.4). In both groups, the plaques were primarily allocated dorsally. In the hemodialysis patients with PD, the frequency of masturbation (P<0.05) and the incidence of moderate or severe erectile dysfunction (P<0.01) were significantly higher than those among hemodialysis patients without PD. In comparison with patients without PD, the number of acetate dialysate users was significantly higher among patients with PD (P<0.05), and none of the PD patients used angiotensin-related antihypertensive drugs (P<0.05).

CONCLUSIONS

The prevalence of PD in healthy Japanese men is low (0.6%), which suggests the existence of racial differences in the prevalence of PD. Moreover, these results indicate that hemodialysis increases the incidence of PD. The differences in the characteristics between male hemodialysis patients with and without PD provide new insights into the pathophysiology and therapeutic window of PD.

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.