Peyronie’s Disease A Guide to Clinical Management

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A Guide to Clinical Management

Pentoxifylline is a nonspecific phosphodiesterase inhibitor with known anti-inflammatory and antifibrogenic properties 5. Because of these properties and the utility of pentoxifylline in the treatment of autoimmune diseases, Safarinejad et al. Over patients were randomized to receive mg of pentoxifylline sustained release PTX-SR or placebo over a 6 month period.

The results were promising as there were significant decreases in penile plaque size, curvature, progression in the treatment arm 5.

Peyronie's Disease

Patients also had subjective improvements as the IIEF score was also significantly higher in the treatment are 5. With these results there are sure to be further studies performed to evaluate its efficacy. Interferon injections, particularly interferon alpha 2b, have been explored on the basis of the ability of interferons to alter the metabolic activity of fibroblasts to cause a decrease in collagen production while simultaneously increasing collagenase activity.

Various studies have produced drastically conflicting results. Although interferon alpha 2b has been shown to be highly effective in decreasing the penile pain associated with PD, many studies show little to no benefit in decreasing plaque size or degree of penile curvature 6. Some of the trials were not free of side effects as there were high rates of myalgias, fevers, and flu like symptoms; especially in studies where the injections were intralesional.

At this time there is little evidence proving intralesional interferons to be an efficacious treatment modality. These drugs inhibit fibrosis and stimulate fibrinolysis by inhibiting type I collagen production and inhibiting the expression of vascular cell adhesion molecule-1 VCAM-1 as well as inter-cellular adhesion molecule-1 ICAM A small phase I study was conducted in Italy using weekly intralesional iloprost, a prostacyclin analogue, in PD patients with stable, late plaques.

This will certainly pave the way for future randomized trials using prostacyclins. This idea is based on the ability of calcium channel blockers to decrease platelet-derived growth factor B-dependent collagen deposition in the extracellular matrix. This was first proposed by Levine et al. However, this was a small, non-controlled study in patients with mild, small plaques.

This has been contradicted by a recent prospective, randomized, single blind study that showed no statistically significant change in pain, ED, penile curvature, plaque size, or plaque softening in patients also injected biweekly with intralesional verapamil 9. Intralesional collagenase was first studied by Gelbard et al.

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Jordan et al. However, this study was not blinded or placebo controlled with only 19 patients completing the study. At this time it is unknown how efficacious intralesional collagenase is but there is a current multicenter placebo-controlled study that is under investigation that should help clarify this.

This is popular due to the ease of administration as well as the minimal side effect profile because it allows one to bypass hepatic metabolism. Due to the inability of topical verapamil to achieve detectable levels in the tunica albuginea, iontophoresis using verapamil was proposed as an alternative treatment The early results were very promising with several studies showing large improvements in penile curvature but none of the studies were randomized, placebo controlled studies.

Greenfield et al. However, in Di Stasi et al. The treatment schedule was also different with the patients receiving 4 treatments a week for a 6 week period They found a significant decrease in both plaque volume from to mm 3 and penile curvature from 43 to 21 degrees while there was no change in plaque volume or curvature in the control group The results between these two studies are drastically different and it has been suggested that the reason could be the different treatment schedules, different treatment combinations and placebos, idea that lidocaine acts as a membrane stabilizer, different evaluation methods, and plaques in different stages.

At this point, iontophoresis is a safe treatment modality with varying degrees of success that will need further evaluation before being used as a first line treatment.

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Surgical intervention with penile prosthesis implantation has long been the standard of care with minimal success in less invasive modalities. A therapeutic effect was postulated on the ability of ESWL to possibly cause plaque damage directly and increase plaque vascularity to bring forth plaque resorption. The efficacy of ESWL is controversial with an exploratory meta analysis of 17 clinical studies revealing ESWL to be effective in subjective measures such as penile pain during erection and sexual function with no improvement in objective measures including plaque size and penile curvature The improvement in pain symptoms is thought to be due to direct disturbance of pain receptors and hyperstimulation analgesia.

This analysis was not without flaws as the meta analysis was only exploratory rather than confirmatory because of large differences in the subject medical history and symptoms severity between the study groups as well as inconsistent selection of outcome measures among the studies.

At the time of publication there were no controlled, blinded studies performed. The first prospective, randomized, placebo-controlled trial was finally conducted in Italy by Palmieri et al. Their study patients were randomized to either 4 weeks of ESWL therapy or a non functioning transducer. Results mirrored earlier studies with significant improvement in pain scores on IIEF-5 questionnaires and QofL questionnaires. No statistical significance was found between plaque size or penile curvature between the two groups.

Peyronie's disease. A guide to clinical management (with DVD)

However, there was a significant increase in both plaque size and penile curvature in the placebo group suggesting ESWL might be useful in halting plaque progression. Levine et al. Ten patients were enrolled and underwent daily treatment wearing the FastSize Penile Extender for a minimum of 2 hours daily for 6 months. All but one patient claimed improvement in sexual function as well. However, it should be noted that this was a small pilot study that was not controlled.

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Gontero et al. Nineteen patients were enrolled and subjected to a minimum of 5 hours of daily traction therapy using Androgens for a 6-month period. There was no statistically significant improvement seen in penile curvature or girth but there was a significant increase in length. The authors attributed their conflicting results to patient selection.

A Guide to Clinical Management

It remains to be seen how effective penile traction will be for management of PD patients. In , Raheem et al. This case series involved 31 patients that were subjected to two minute daily sessions using the Osbon ErecAid vacuum pump for a twelve-week period [ 21 , see Figure 3 below].

There were also significant decreases in penile pain and increases in penile length mean of 0. The treatment success was attributed to the thought that the device mechanically stretches the penis and allows for remodeling of the fibrous plaque, which would aid in penile straightening. This was shown to block TGF-B1 signaling as well as inhibit extracellular matrix production This has shown promise for future animal studies and clinical trials to follow. Multiple injections are required through multiple cycles and, between cycles, patients are required to undergo penile modelling exercises.

Patients need to be properly evaluated and informed before starting collagenase injections. Verapamil has been found to affect fibroblast cellular activity. Some studies have found that intralesional verapamil injection induces a significant reduction in penile curvature. Surgery remains the gold standard for correcting penile deformity. Surgery is indicated when the patient has: Various authorities have different recommendations on the minimum time for stable disease before surgery. Some patients may request surgery for psychological or body image reasons, even with lesser curvatures.

As some men have minor deformities that are functionally not significant, they need to fully understand the risks and realistic outcomes of surgery versus the minor deformity they may have and, in many cases, be dissuaded from surgery. Intralesional collagense is the only nonsurgical treatment that has good evidence to suggest that it may offer modest improvement in penile curvature. Surgical therapy is beneficial for properly selected and counselled patients, and can greatly improve their quality of life. To open click on the link, your computer or device will try and open the file using compatible software.

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Peyronie’s Disease A Guide to Clinical Management Peyronie’s Disease A Guide to Clinical Management
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Peyronie’s Disease A Guide to Clinical Management Peyronie’s Disease A Guide to Clinical Management
Peyronie’s Disease A Guide to Clinical Management Peyronie’s Disease A Guide to Clinical Management
Peyronie’s Disease A Guide to Clinical Management Peyronie’s Disease A Guide to Clinical Management
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