US Imaging in Peyronie's Disease

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.

Role of Shear Wave Elastography in the Diagnosis of Peyronie Disease

OBJECTIVES

The present study aims to explore the role of shear wave elastography (SWE) in the diagnosis of Peyronie disease (PD).

METHODS

A total of 59 PD patients and 59 age-matched healthy adult men were included in this study. The B-mode ultrasound (US) and SWE were performed for all subjects, and the Young modulus (YM) values of the corresponding regions of the penis in the PD and control groups were recorded and compared.

RESULTS

The mean age of the included PD patients and age-matched controls was 53.81 years (SD 9.52, range 32-73). On B-mode US evaluation, 41 (69.5%) of 59 included PD patients were found to have penile plaques, and the remaining 18 (30.5%) patients had no evidence of penile plaque. After evaluation using SWE, the YM values in the penile plaque region of these 41 patients with penile dysplasia were found to be significantly higher (60.29 kPa ± 19.95) than those outside the plaque (in the same patient) (21.05 kPa ± 4.58) and in the same penile region of the control group (20.59 kPa ± 4.65) (P < .001). In the remaining 18 PD patients, the results showed that the YM value of the abnormal penile region in the PD patients (56.67 kPa ± 13.52) was significantly higher than the YM value outside the abnormal penile region in the same patients (22.79 kPa ± 4.31) and in the same penile region in the control group (19.87 kPa ± 3.48) (P < .001; P < .001).

CONCLUSIONS

In conclusion, this study showed that SWE as a non-invasive technique is useful in identifying and differentiating penile plaques in PD patients and is a simple, rapid and complementary method to B-mode US.

Peyronie's Disease Presenting as Curvature of the Penis: A Case Report

Peyronie's disease (PD) usually affects middle-aged men. This condition is characterized by fibrosis and plaque in the tunica albuginea that results in deformity of the penis and makes sexual intercourse difficult. We report a case of a 52-year-old male who presented with complaints of curvature of the erect penis and erectile dysfunction. Based on our imaging findings, the patient was diagnosed with PD. ultrasonography (USG), elastography, and CT findings are described.

A Consistent Lack of Consistency in Defining the Acute and Chronic Phases of Peyronie's Disease: A Review of the Contemporary Literature

INTRODUCTION

Treatment recommendations for Peyronie's Disease (PD) differ based on whether a patient is in the acute/active versus chronic/stable phase of the disease, yet there are no agreed upon criteria for defining these clinical entities.

OBJECTIVES

To review the criteria used to define acute and chronic phase PD in modern PD intervention studies.

METHODS

We performed a search engine review to identify indexed publications for PD intervention studies and review articles / meta-analyses from the year 2011-2020. Outcomes results were catalogued and summarized across articles. As a result of the substantial heterogeneity of outcome measures and follow-up intervals, meta-analytic techniques were not applied to the data analysis.

RESULTS

We identified a total of 104 studies that met inclusion criteria and had available information for review (n = 79 primary intervention studies; n = 25 review articles/meta-analyses/guidelines). Among the queried studies, we were unable to identify a consensus with respect to the criteria used to define acute and chronic phases of PD. 33% of primary intervention studies did not specifically define their criteria for acute and chronic phase PD, despite referencing these populations as part of the inclusion criteria in many instances. Studies used heterogenous criteria including total symptom duration, duration of "stable" symptoms, and presence/absence of pain.

CONCLUSION

Due to varying definitions across the literature, we were unable to create a standardized definition of acute and chronic phase Peyronie's in terms of time. Our findings emphasize the need for greater consensus in defining the treatment cohorts with future studies that assess treatment for men with PD.

Use of penile shear wave elastosonography for the diagnosis of Peyronie's Disease: a prospective case-control study

BACKGROUND

To evaluate the stiffness of the tunica albuginea (TA), we used a new noninvasive diagnostic technique called shear wave elastography (SWE). We determined whether SWE values are correlated with the degree of penile curvature, the time of disease onset, and pain severity experienced by patients during erection. This study analyzed the elasticity of the TA of patients with Peyronie's disease compared to that of the control group. We also analyzed any correlations between the stiffness of the cavernous bodies and the degree of curvature, time from diagnosis to curvature onset, and erectile pain severity. This was a prospective case-control study involving 100 men enrolled from September 2020 to August 2021. Participants were divided into group A (case group, n = 50), which included men with PD, with or without pain, and with penile curvature, or group B (control group, n = 50), which included healthy patients older than 18 years who visited the urology clinic for reasons other than PD. The medical history was collected for all patients who also underwent objective examination, B-mode ultrasound evaluation, and SWE. The International Index of Erectile Function (IIEF-15) visual analog scale (VAS) questionnaire was administered to all participants.

RESULTS

There were no significant between-group differences regarding age, weight, and height (p > 0.05); however, there was a significant difference in the stiffness values (p < 0.05). An inverse correlation was observed between stiffness and the VAS score (p < 0.0001). A positive correlation was observed between the degree of curvature (p < 0.0001) and the time of curvature onset (p < 0.0001). The IIEF-15 scores were poorer in group A than in group B (p < 0.0001).

CONCLUSION

SWE is an inexpensive, noninvasive method that can be used to measure the stiffness of PD patients.

Discordant erectile function assessment between validated questionnaire scores and penile Doppler ultrasound in Peyronie's disease

Peyronie's disease results in curvature of the penis which may cause difficulty with penetrative intercourse. The diagnosis of Peyronie's disease is easily obtained through history and physical examination alone, but the severity of erectile dysfunction relies on patient history and use of validated questionnaires. However, erectile dysfunction questionnaires were not validated in the Peyronie's disease population and may not be a reliable assessment. Penile Doppler ultrasound is a noninvasive tool that assesses vascular function. We hypothesized that penile Doppler ultrasound will be discordant with International Index of Erectile Function (IIEF) results in men with Peyronie's disease and erectile dysfunction. In this cross-sectional study, we reviewed a prospectively collected database of men with Peyronie's disease. In total, 108 men had questionnaire and ultrasound data. Of them, 87 had erectile dysfunction based on IIEF-EF or IIEF-5 (SHIM). However, 48 (55%) of those men had normal vascular parameters. Interestingly, among a subgroup of 33 men with severe erectile dysfunction on IIEF-EF or IIEF-5, 20 (61%) had normal vascular parameters. Our study demonstrates significant discordance between questionnaires and penile Doppler ultrasound. Therefore, ultrasound may be a useful tool in the workup of men with Peyronie's disease and erectile dysfunction.

Penile Mondor's disease: Imaging in two cases

Penile Mondor's disease is a rare and under-recognized benign genital condition consisting of an isolated thrombosis of the dorsal superficial vein of the penis. Symptoms do not show distinctive features and there are asymptomatic cases. The patients usually present with a cord-like induration at dorsum of the penis. Diagnosis is usually made based on history and physical examination. The role of imaging in Mondor's disease is to identify the intravascular thrombus. In case of diagnostic uncertainty, Grey scale and Doppler ultrasound can be useful to detect the extent of thrombosis demonstrating echogenic material within venous lumen, vessel incompressibility and absence of flow, as well as painful selective pressure. The use of Magnetic Resonance imaging is controversial and not used routinely. Usually treatment is conservative: sexual rest, local anesthetics, anti-inflammatories, antibiotics in case of infection and anticoagulants. Sclerosing lymphangitis and Peyronie's disease have been described as possible differential diagnosis.

Sonography of the penis/erectile dysfunction

Erectile dysfunction (ED) is defined as the persistent inability to achieve and/or maintain an erection for a satisfactory sexual activity. It is secondary to several organic, psychogenic, and combined causes, and represents a serious health dilemma affecting both men and their partners. The diagnostic approach to erectile dysfunction has significantly changed in the last years with the advent of phosphodiesterase-5 (PDE5) inhibitors, and with the recognition that surgical treatment of both arterial insufficiency and penile venous leak have poor long-term clinical outcomes. Although imaging modalities have diminished in importance, differentiating among causes of erectile dysfunction remains mandatory in good medical practice, and ultrasound (US) still remains the cornerstone of the diagnostic workup. US provides an objective, minimally invasive evaluation of penile hemodynamics. Moreover, it provides an excellent depiction of the penile anatomy and of its changes in pathological conditions such as in patients with Peyronie's disease, priapism, and posttraumatic erectile dysfunction.

Prevalence, Risk Factors, and Erectile Dysfunction Associated With Peyronie's Disease Among Men Seeking Urological Care

INTRODUCTION

Peyronie's disease (PD) is a connective tissue disorder of the penis characterized by an abnormality in collagen structure of penile tunica albuginea.

AIM

We sought to investigate the prevalence, risk factors, and the relationship between erectile dysfunction (ED) and PD in male patients aged 30-80 years seeking urological care.

METHODS

This is a cross-sectional study using data collected from October 2016 to October 2017 in an outpatient clinic associated with the Brazilian Public Health System. All men aged 30 to 80 years were invited to participate. Data collected were related to the clinical history and sexual habits of patients using the International Index of Erectile Function, in addition to the physical examination of the penis and laboratory parameters.

MAIN OUTCOME MEASURE

Descriptive statistics and multivariate logistic regression models tested the prevalence, risk factors, and the relationship between ED and PD in male patients.

RESULTS

The study included 656 individuals, who were distributed as per age, marital status, race, educational level, and income. Of these participants, 86 (13.11%) presented with fibrous plaques compatible with PD at the physical examination. Among the risk factors evaluated, PD was associated with diabetes, smoking, and obesity in 43.02, 64.17, and 26.74% of patients, respectively. The presence of penile plaques compatible with PD was more prevalent in men with ED, history of penile trauma, and complaint of penile deformity. There was a higher prevalence of plaques in the distal penis.

CONCLUSION

The PD among the studied population was associated with risk factors such as diabetes, smoking, and obesity. Other clinical characteristics, such as history of penile trauma, penile deformity, and ED, were reported in patients with PD. There was a higher prevalence of plaques in the distal penis, specifically in the corona of the glans penis. The prevalence of PD was different from that in the published literature, our results show that numbers thus more studies are needed. Segundo A, Glina S. Prevalence, Risk Factors, and Erectile Dysfunction Associated With Peyronie's Disease Among Men Seeking Urological Care. Sex Med 2020;8:230-236.

Diagnostic utility of penile ultrasound in Peyronie's disease

PURPOSE

To review the literature regarding the use of penile ultrasound in the evaluation and management of Peyronie's disease.

METHODS

A literature review was performed using PubMed from 1980 to 2018 using the keywords: Peyronie's disease, ultrasound, sonography, calcification, penile fracture, and penile hematoma. Articles were reviewed for study size, image protocols, and findings. In addition, we reviewed images from 227 penile ultrasounds performed on Peyronie's disease patients at the Walter Reed National Military Medical Center between 2014 and 2018.

RESULTS

Through extensive urological and radiographic literature review over the last four decades, common patterns and characteristic of Peyronie's plaques were identified. These characteristics are not always delineated by physical examination alone. The ultrasound images often added objective information including etiology of erectile dysfunction and location or plaques, and presence of calcifications which aid in patient counseling and treatment protocols.

CONCLUSIONS

The use of B-mode ultrasound with color Doppler in the evaluation and management of Peyronie's disease is a quick, cost-effective process that provides objective information that can assist the urologist in the treatment of patients with Peyronie's disease.

MRI of the Penis: Indications, Anatomy, and Pathology

The purpose of this review is to discuss the role of magnetic resonance imaging (MRI) in the evaluation of penile pathology. Normal penile anatomy as well as the appearance of neoplastic and non-neoplastic entities on MRI will be reviewed. While ultrasound remains the first line imaging modality in evaluating most penile pathology, MR imaging has specific advantages owing to improved soft tissue resolution, ability to evaluate less accessible or complex anatomy (such as at the base of the penis), and the ability to detect subtle enhancement. Therefore, MRI is useful for when ultrasound and/or clinical findings are equivocal or incongruent. In addition, MR imaging is essential for preoperative surgical planning and is the imaging modality of choice in evaluating penile prostheses. The added value of MRI in these settings makes it an integral component to the management of many pathological entities affecting the penis.

Ultrasound on Erect Penis Improves Plaque Identification in Patients With Peyronie's Disease

OBJECTIVES

To compare the sensitivity of identification of penile plaques in the erect and flaccid penises by ultrasound in patients with Peyronie's disease (PD).

MATERIALS AND METHODS

A total of 75 PD patients were screened by palpation and ultrasonography for penile lesions in both flaccid and erect penises induced by prostaglandin E1 (PG-1) injection.

RESULTS

A total of 138 lesions were identified by ultrasound in the erect penises induced by injection of PG-1. However, only 74.6% of the lesions (103) were detectable by the palpation of the flaccid penises, and 84.1% (116) by ultrasound of the flaccid penises. The ultrasound confirmed 99 of the palpated lesions in the flaccid penises. The detection rate of lesions in drug-induced erect penises by ultrasound was significantly higher than those in the flaccid penises by the ultrasound (P < 0.01) or palpation (P < 0.0005) The type of penile lesions identified by ultrasonography included tunical thickening, calcifications, septal fibrosis, and intracavernosal fibrosis. The ratios of these lesions confirmed by ultrasound were 52.6, 33.6, 6.0, and 7.8%, respectively, in the flaccid penises, and 55.8, 28.3, 8.7, and 7.2%, respectively, in the erect penises.

CONCLUSION

Drug-induced erection can be used in suspicious PD patients when penile lesion is not identified by palpation or ultrasound in the flaccid penis.

Cavernosopatía traumática crónica. Un nuevo síndrome de fibrosis peneana

Introdución La llamada genéricamente «enfermedad de Peyronie» es un diagnóstico que explica un porcentaje de ciertos estados de fibrosis peneana grave, pero se queda corta para abarcar la amplia gama de grises de la fibrosis peneana secundaria a microtrauma sexual repetido.

Objectivo Describir un nuevo síndrome por trauma repetido en el pene al que se propone denominar «cavernosopatía traumática crónica» (CTC), con 4 componentes: fibrosis (leve, moderada o grave), disfunción eréctil, curvatura y fugas venosas peneanas.

Materiales y métodos Se realizó un estudio de corte transversal en una base de datos de 128 pacientes que tenían al menos una ecografía de pene con vasoactivo y en los que se había detectado algún grado de fibrosis cavernosa según la clasificación de Levine. Se evaluó la presencia de disfunción eréctil, curvas y fugas venosas según el grado de fibrosis. El estudio contó con la aprobación del Comité de Ética en Investigación.

Resultados Se estudió a 128 pacientes con fibrosis, con 51,3 años de edad promedio (DE = 13). El grado de fibrosis fue leve (Levine 1) en 30 (23,43%), moderado (Levine 2) en 23 (17,96%) y grave (Levine 3) en 75 (58,6%). Se demostró que, a mayor fibrosis, mayor disfunción eréctil, 66,6; 83,6 y 96% para Levine 1, 2 y 3, respectivamente (p ≤ 0,0001). La frecuencia de curvatura secundaria (n = 71) fue de 0; 4,2 y 95,7% para Levine 1, 2 y 3, respectivamente (p ≤ 0,0001). La frecuencia en los 44 pacientes con fugas cavernosas fue de 9; 20,4 y 70,4% (p = 0,0060) y en los 15 de fugas dorsales fue de 80; 13,3 y 6,6% (p < 0,0001) para Levine 1, 2 y 3 respectivamente. El grupo de 79 pacientes (64,03%) con mayor posibilidad de CTC, con presencia de 3 o 4 criterios que incluyeran curvatura secundaria y fuga cavernosa, tuvo un promedio de edad de 59,2 años (DE = 8,7), comparado con 41,7 años (DE = 11,7) en el grupo de menor posibilidad, diferencia estadísticamente significativa (p ≤ 0,0001).

Conclusiones Proponemos que existe un síndrome de microtrauma repetido en el pene, que puede denominarse CTC, análogo a la encefalopatía traumática crónica, con 4 componentes: fibrosis cavernosa, disfunción eréctil, curvatura peneana y fugas venosas. La fibrosis es un continuum que el paciente recorre por fases leves y moderadas, a menudo inapreciables para los clínicos. Las curvaturas secundarias y las fugas cavernosas están relacionadas directamente con el grado de fibrosis y con mayor riesgo de disfunción eréctil. La edad empeora algunos factores de la CTC.

Ultrasound evaluation of the penis

Ultrasound is an excellent method for the study of penis. In this article, using a critical review of the literature and teaching files, we present examples of the major findings in the ultrasound routine, focusing on trauma, priapism, Peyronie's disease, and erectile dysfunction.

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.

Surgical management of Peyronie's disease

Peyronie's disease (PD) has a significant impact on the quality of life of both patients and their partners due to the compromised sexual function and physical deformation resulting from the condition. PD is a connective tissue disorder marked by fibrotic healing of the tunica albuginea, leading to penile deformities including curvature, shortening, loss of girth, hourglass appearance, and hinging. Despite the multiple medical therapies available, surgery is the gold standard of treatment once the plaque has stabilized. We present a review of the disease process, preoperative evaluation, operative planning, surgical treatments with outcomes and complications, and nascent developments in surgical management and graft development. Options include tunical lengthening procedures, tunical shortening procedures, and penile prosthesis. Decision-making is governed by degree of curvature, erectile function, and associated penile deformities. In cases with curvature of less than 60-70 degrees, adequate penile length, and no hourglass deformity, patients are candidates for tunical shortening procedures. Patients with curvature greater than 60-70 degrees, penile hourglass or hinge-destabilizing deformities, and adequate erectile function should be counseled with regard to tunical lengthening procedures. Patients with poor preoperative erectile function should undergo inflatable penile prosthesis placement, with possible secondary straightening procedures. Technique selection should be based upon surgeon preference, expertise, and experience, as evidence does not necessarily support one procedure over another.

Penile sonoelastography for the localization of a non-palpable, non-sonographically visualized lesion in a patient with penile curvature from Peyronie's disease

INTRODUCTION

Sonoelastography is an emerging ultrasound-based technique that allows characterization of tissue stiffness.

AIM

The aim of this report is to present a case of significant penile curvature with a non-palpable, non-sonographically visualized plaque that was demonstrable with sonoelastography.

METHODS

A 60-year-old male presented with significant left penile curvature during erections. The penis was evaluated with physical exam followed by B-mode and color Doppler ultrasound. No evidence of plaque was identified with these modalities. Shear wave sonoelastography was pursued to further characterize the patient's Peyronie's disease.

RESULTS

An area of increased tissue stiffness that correlated with the site of maximum curvature was identified with shear wave sonoelastography and used to target intralesional injection therapy.

CONCLUSION

Sonoelastography provides an additional way to characterize, localize, and deliver therapy to a lesion in patients with Peyronie's disease and is particularly useful when palpation and B-mode ultrasonography have failed to demonstrate a plaque.

Peyronie's disease plaque calcification--prevalence, time to identification, and development of a new grading classification

INTRODUCTION

Peyronie's disease (PD) is a connective tissue disorder of the penis in which a fibrous scar in the tunica albuginea can result in multiple penile deformities.

AIM

The study aims to investigate the prevalence and time to identification of plaque calcification (PC) in our PD patient population and whether stratification of calcification based on severity seen on ultrasound would serve as a predictor of treatment progression to surgery.

METHODS

A retrospective review of 1,041 men presenting with PD from 1993 to 2009 was performed. Eight hundred thirty-four underwent penile duplex ultrasound.

MAIN OUTCOME MEASURES

PC was graded as: grade 1 (<0.3 cm), grade 2 (>0.3 cm, <1.5 cm), grade 3 (>1.5 cm; or ≥ 2 plaques >1.0 cm). A matched control group with noncalcified plaques (n = 236) was selected for comparison.

RESULTS

Two hundred eighty-four men (34%) were found to have PC noted on ultrasound, and 98 had fully documented dimensions of the PC. Forty-one percent were found to have grade 1, 28% grade 2, and 32% grade 3. When analyzed by grade and progression to surgery, 23% of grade 1, 32% of grade 2, and 55% of grade 3 patients had surgery. Those with grade 3 PC were more likely to undergo surgical intervention for PD (OR 2.28 95% CI 1.07-4.86) and more likely to undergo a grafting procedure than control patients (P < 0.0001).

CONCLUSIONS

Men with PC are not more likely to undergo surgery than those without PC (OR 0.95, 95% CI 0.58-1.57). PC is not uncommon, as it was found in 34% of our cohort. PC does not appear to be an indication of mature or stable disease, as it was identified by ultrasound in 37% of patients less than 12 months after onset of symptoms. Men with grade 3 PC have an increased likelihood of progression to surgical intervention and a higher likelihood of undergoing a grafting procedure.