The management of peyronie's disease: evidencebased 2010 guidelines

The Management of Peyronie’s Disease: Evidence-based
2010 Guidelinesjsm_18502359.2374

David Ralph, MD,* Nestor Gonzalez-Cadavid, PhD,† Vincenzo Mirone, MD,‡ Sava Perovic, MD,§Michael Sohn, MD,¶ Mustafa Usta, MD,** and Laurence Levine, MD†† *Institute of Urology, London UK; †Department Urology, UCLA, CA, USA; ‡University of Naples “Federico II”, Naples,Italy; §University of Belgrade, Belgrade, Serbia; ¶University Aachen, Germany; **Akdeniz University School of Medicine,Antalya, Turkey; ††Rush Medical College, Chicago, IL, USA A B S T R A C T
Introduction. The field of Peyronie’s disease is evolving and there is need for a state-of-the-art information in this area.
Aim. To develop an evidence-based state-of-the-art consensus report on the management of Peyronie’s disease.
Methods. To provide state-of-the-art knowledge regarding the prevalence, etiology, medical and surgical manage-
ment of Peyronie’s Disease, representing the opinion of leading experts developed in a consensus process over a
2-year period.
Main Outcome Measures. Expert opinion was based on grading of evidence-based medical literature, widespread
internal committee discussion, public presentation, and debate.
Conclusions. The real etiology of Peyronie’s disease and the mechanisms of formation of the plaque still remain
obscure. Although conservative management is obtaining a progressively larger consensus among the experts,
surgical correction still remains the mainstay treatment for this condition. Ralph D, Gonzalez-Cadavid N, Mirone
V, Perovic S, Sohn M, Usta M, and Levine L. The management of Peyronie’s disease: Evidence-based 2010
guidelines. J Sex Med 2010;7:2359–2374.

Key Words. Peyronie’s Disease; Guidelines; Surgery; Pathology
the patient and partner may be significantlyaffected, with an increased risk of depression, low P eyronie’s disease (PD) is currently consid- self-esteem, and relationship difficulties being ered a wound healing disorder that presents common [1–3]. Overall, approximately 30% of with a fibrous inelastic scar of the tunica albug- patients will have diabetes, which has been found inea that is currently believed to occur in the to be associated with advanced curvatures and vasculogenic ED [4,5]. Two thirds of patients trauma to the penis. It is characterized by the with PD are likely to have risk factors for arterial development of a palpable scar, which in the disease and therefore worsening long-term erec- erect state causes a variety of deformities, includ- tile function [5]. PD is a progressive disorder ing curvature, shortening, narrowing, and hinge with up to 48% of men having disease progres- effect. In the early phase there is often an inflam- sion if left untreated [6]. In most cases, PD may matory component that causes pain. PD is also be divided into an acute inflammatory phase and frequently associated with erectile dysfunction a chronic phase. During the former, there may be (ED), and a variety of other comorbid disorders, penile pain and curvature progression although including diabetes, hypertension, dyslipidemia, the pain typically resolves spontaneously within and low testosterone. The quality of life of both 6–18 months from onset in most patients [6].
2010 International Society for Sexual Medicine may cause penile shortening with or without PD—OVERVIEW GRADE A
a penile deformity [10]. The consistency of the PD is a physically and psychologically devas-
plaque, be it soft, tender, calcified, or ossified tating problem manifest by a fibrous inelastic
should be noted as this may act as a guide to scar of the tunica albuginea, which results in
management. Calcification may occur at initial a penile deformity (e.g., bending, narrowing,
presentation or develop over time. It appears hinging, shortening), as well as painful erec-
that calcification is not a manifestation of a more tions, all of which may lead to difficulty with
mature plaque as previously thought. Rather it intromission. There are relatively few high-
may represent a different genetic subtype of PD level evidence-based therapeutic studies.
An assessment of the curvature on erection is PREVALENCE OF PD GRADE B
best made by an intracavernosal injection of a Multiple demographic studies have been
vasoactive agent; a home photograph or a vacuum performed world-wide indicating a preva-
assisted erection test can be also useful in the diag- lence rate of 3–9% in adult men. Therefore,
nosis [12]. This also allows complex curvatures to PD is not a rare disorder.
be assessed and will aid in the decision for the typeof treatment best suited to the individual. The NATURAL HISTORY GRADE C
severe emotional distress that occurs is, in part, a The natural history of PD has been evaluated
result of the deformity, but mainly because of the in only a few level 2 and 3 studies indicating
penile shortening that occurs in almost all patients that spontaneous deformity resolution is not
with up to 50% of them being clinically depressed.
common and remains less than 13%.
It is imperative therefore that the stretched penilelength is measured preoperatively so that thepatients realize that the length loss postoperatively Patient Evaluation
is mainly a result of the disease itself and not to the The diagnosis of PD is usually apparent from the surgery [13–15]. ED associated with PD has been patient history and penile examination. The main reported in up to 58% of men [2,5]. It is not points to gather from the history are whether the uncommon for unsuspected PD to be diagnosed at disease is still active, the nature of the curvature the time of investigation of their ED [16,17]. Since and the presence of ED. Patients with short ED is a common finding in patients with PD [18].
disease duration (<12 months), penile pain, or a A detailed history of any arterial risk factors for recent change in penile deformity are still likely to ED should be noted and an assessment of erectile have active inflammatory disease and therefore are function best made by the validated International not surgical candidates and would be more likely Index of Erectile Function-5 questionnaire [19]. A to benefit from medical therapy. Penile pain may PD-specific questionnaire is in development and be persistent in the inflammatory stage of the should aid in the assessment of the man with PD disease but is usually only present during erection.
and may prove useful in evaluating quality of like- The pain is not usually severe in nature but may related changes following treatment.
interfere with sexual function although spontane-ous improvement usually occurs as the inflamma- tion settles within 6 months and almost all men Ultrasound is used to identify the site and con- will experience pain resolution by 18 months (94% sistency of the plaque and is a useful tool in the of 246 men treated conservatively) [6–9].
clinical trial setting to assess penile vascular blood- All the patients have either a well defined plaque flow parameters. It can also determine the extent or an area of induration that is palpable on phy- of plaque calcification as those men with extensive sical examination, even though patients may be calcification have historically been noted to not unaware of it [8]. The plaque is located on the respond well to nonsurgical therapies. Extensive dorsal surface of the penis in two thirds of patients calcification appears to be a primary indication for with a corresponding dorsal penile deformity [9].
surgical correction as these plaques do not respond Lateral and ventral sited plaques are not as to medical therapy. It is a minimally-invasive tech- common but result in more coital difficulties as nique that is more accurate than X-ray, CT scan, there is a greater deviation from the natural coital or MRI [20]. A vascular assessment should be per- angle. Multiple plaques located on opposite sides formed in all patients with ED as well as those of the penis or plaques appearing in the septum undergoing surgery and is best done using duplex ultrasound [21]. The results of this investigation affecting 39% of PD patients vs. only 1.2% in the can often show vascular disease in patients who report normal potency which may influence the Epidemiological studies showed that PD is significantly associated with diabetes [3,5,31,32,34,37,41–43]. Some of these reports provideddata supporting a significant association of PDwith obesity [34,38,43], hypertension [3,5,36,41], CLINICAL
hyperlipidemia [3,5,33,34,37,38], smoking [32,34, 37,38,42,43], and pelvic surgery [42].
There is no international standard for
evaluation or reporting on treatment out-
comes for PD. A detailed history should be

obtained focusing on onset, duration, pain,
Multiple comorbidities have been identi-
and deformity.
fied, including ED, hypertension, diabetes
mellitus, hyperlipidenia, low testosterone,

and Dupuytren’s disease. It remains unclear
whether any of these contribute to the
Suggested objective measures include: mea-
development of PD.
suring stretched penile length, and describ-
ing plaque location (dorsal, ventral, septal,
proximal, distal, etc.)

Etiology and HistopathologyA widely accepted hypothesis on the etiology CLINICAL DIAGNOSIS—PLAQUE SIZE
of the PD plaque is that it originates from trauma or microtrauma to the erect penis [44–55] in Plaque measurement is inaccurate by any
patients with genetic predisposition to form modality, as well as operator dependent and
localized fibrosis as a response to trauma.
therefore is not a reliable assessment for
[56–62]. The main pathological process is tissue treatment response.
fibrosis with disorganization of elastic fibers,combined in most cases with fibrin accumulation CLINICAL
and different degrees of inflammation [48,50, ULTRASOUND GRADE D
63–75]. Consequently, spontaneous regression is Dynamic duplex ultrasound provides assess-
ment of plaque calcification, vascular flow
Recent studies on an animal model suggest parameters, and objective measures of defor-
that transforming growth factor beta (TGFb1) mity. It is a useful but not necessary test.
74,81–83,87–95] play an important role in the for-mation of PD plaques. TGFb1 is also found in the Epidemiology: Prevalence and Comorbidities human PD plaque and is the main profibrotic Recent studies suggest a prevalence of PD in the factor in multiple tissues [84], while myofibro- population that can reach up to 9% [22–33], much blasts are a common feature in most tissue fibrosis and in abnormal wound healing [96], and their The mean age of onset of the condition in these persistence by the inhibition of programmed cell studies was 55–60 years, and penile curvature was death leads to scar formation [51]. Moreover, the present in over 80% of patients whereas pain- tunica albuginea is known to contain pluripotent ful erection was reported by over half of them stem cells that are potentially able to differentiate into myofibroblasts, smooth muscle cells, and History of a penile trauma has been reported by osteoblasts, and in a paracrine fashion to modulate the differentiation of a multipotent cell line into Some studies have revealed a significant asso- osteoblasts and myofibroblasts [11,97–109]. The ciation with ED in comparison to the non-PD presence of stem cells in the normal tunica albug- population [35,38,39,41]. The association with inea may explain the fibrotic and osteogenic pro- Dupuytren’s disease was only investigated since gression of the PD plaque upon the release of 1999 in two studies, where it was shown to be cytokines following microtrauma to the penis that highly significant in the older population [3], and would stimulate this cell lineage commitment.
the use of potassium paraminobenozoate, more PD—PATHOGENESIS GRADE C
recent articles showed a significant reduction in PD is a wound healing disorder occurring
plaque size but no change in pain or improvement in a presumed genetically susceptible in-
of the curvature [112]. These results, although dividual whose tunica albuginea responds
encouraging, will need to be confirmed in future inappropriately to an inciting event (i.e.,
trauma) with a proliferative, fibrotic reac-
tion resulting in an exuberant, inelastic scar.

A closer understanding of the etiopatho-
physiology is not yet established.
therapy prescribed by urologists for treating PD[113]. However, recent double-blind, placebo con-trolled, randomized studies showed nonsignificant improvement in pain, curvature, and plaque size, As a result of the lack of a clear understanding when compared with placebo [114,115].
of the etiopathophysiology, a cure has not beenfound. Therefore, a variety of treatment options have been used. The most current therapies are In 1992, Ralph et al. confirmed that the daily reviewed. The value of many published reports has administration of Tamoxifen 20 mg twice daily been questioned as most were not well controlled, can induce significant improvement in penile often had a small number of subjects in various pain, curvature, and plaque size in the early phases of stability and with limited reports on stages of the disease [116]. However, these objective measures of deformity change. Studies encouraging results have not been confirmed by focus on reduction of pain that appears to resolve with time untreated, and reduction of plaque size,which has never been found to correlate with curvature improvement. In the opinion of the Although initial studies showed that colchicine authors reduction of erect penile deformity (i.e., might be also effective in the early phase of the curve, narrowing, shortening) is the most critical disease according to the finding of two recent studies [118,119], recent series have showed thatcolchicine is no better than placebo [120].
Although the administration of vitamin E and Men with early phase disease (i.e., <12
colchicine in isolation has been proved to be inef- months induration) manifest by unstable or
fective, a recent double-blind randomized study progressive deformity and painful erections
has showed that the administration of a combina- as well as those not psychologically ready
tion of vitamin E and colchicine can induce sig- or interested in surgery may be considered
nificant improvement in plaque size, curvature, candidates for nonsurgical therapy.
and pain during the initial phase of PD [121].
Although initial studies fail to demonstrate any Nonsurgical treatment has limited evidence
efficacy of this combination in the treatment of benefit, but multiple reports of deformity
of PD, recent data suggest that propionyl-l- stabilization or reduction makes it reason-
carnitine and verapamil are effective in terms of able to offer EMDA, and/or intralesional
plaque size reduction, pain, and penile curvature injection of verapamil or interferon, and/or
traction therapy.
PentoxifyllineIncreased levels of nitric oxide levels may be effec- tive in preventing progression of PD or revers- ing its fibrosis as described by Brant et al. [124].
Although initial studies [110,111] showed only a Further studies will be required to confirm these minimal improvement in symptoms of PD with ORAL THERAPY GRADE B
There is evidence that there is no benefit
Intralesional injection may be used with the
with respect to deformity reduction with
any oral therapy, including Vitamin E,
Steroids—no objective measures of thera-
peutic benefit. GRADE D
tamoxifen, and carnitine.
Verapamil—appears to make scientific sense
but no large scale placebo-controlled
Although six studies using injectable corticoster- Interferon—One
oids for the treatment of PD showed positive out- controlled trial showed an outcome
comes from treatment, the authors believe that the interferon
therapeutic effects were because of the mechanical effects of the injection and not to the drug action Collagenase—Several small noncontrolled
trials showed limited benefit. It is cur-
rently being studied in a phase 2b trial.

Although the prospective, randomized, placebo-controlled study of Gelbard failed to demonstrate Other Noninvasive Therapy
any clinical benefit with the use of intralesionalinjections of collagenase [104], a recent study has reported significant decreases in deviation angle, Although initial studies failed to demonstrate any efficacy of extracorporeal shock wave therapy(ESWT) for the treatment of PD [142–144], more recent studies suggest a possible role of ESWL in In vitro studies verapamil has been shown to inter- fere with Peyronie’s plaque derived fibroblast cel-lular proliferation and Levine et al. reported that TREATMENT—SHOCK
intralesional verapamil injection induces a signi- THERAPY GRADE B
ficant reduction in penile curvature [133–136].
There is evidence that ESWT does not
These encouraging results have been confirmed by improve PD-related deformity.
two subsequent studies, while one failed to dem-onstrate any effectiveness of this treatment [137– Athough two studies proved the efficacy of ionto- Although large scale, placebo-controlled trials phoresis using dexamethasone, verapamil, and have not been conducted, intralesional Verapamil lidocaine in terms of reductions of pain, plaque size, injections could be recommended for the treat- and curvature [148,149], a recent series of Green- ment of noncalcified acute or chronic plaques to stein and Levine suggests that the only role for stabilize disease progression or possibly reduce iontophoresis is for the improvement of pain [150].
Hellstrom and associates conducted a singleblind, multicenter, placebo-controlled parallel study that As there are no independent controlled
showed that intralesional interferon alpha-2B may trials and no evidence of adequate levels
be beneficial for men with PD [140]. These find- within the tunica albuginea, no recommen-
ings offer the largest and best-controlled trial of dation is possible for topical Verapamil.
intralesional therapy for PD, as well as supports its TREATMENT—TOPICAL ENERGY–
use and demonstrates the lack of clinical benefit IONTOPHORESIS GRADE C
following intralesional injection of saline. It is sig- controlled
nificantly more costly than verapamil and has been of reduced deformity following ionto-
associated with flu-like side effects. However, a phoresis treatment using verapamil and
recent study failed to demonstrate any efficacy of dexamethasone.
It is well-documented that gradual expansion of I. When rigidity adequate preoperatively with or without tissue by traction, also known as mechanotrans- duction, results in the formation of new connective tissue by cellular proliferation in several tissue models including bone, muscle, and Dupuytren’s iii. Predicted loss of length < 20% erect length scar [151–153]. However, penile traction has B. Plaque Incision/ Partial Excision and grafting when proved to have insignificant role in the manage- TREATMENT—TRACTION THERAPY

of postoperative ED. The incision and grafting Early evidence from two small noncon-
technique appears to increase the risk of postopera- trolled prospective trials have reported a
tive ED, and therefore men who have borderline to reduction of deformity and increased penile
inadequate erections preoperatively, which do not length with traction therapy.
respond to pharmacological therapy, should avoidgrafting procedures or be prepared to need subse-quent penile prosthesis implantation [159]. Lastly, Surgical Treatment
there is a risk of decreased sexual sensation. This has been infrequently reported in the published Surgery is indicated when the curvature impedes literature, but it seems for the most part it rarely adequate sexual penetration or there is an associ- compromises orgasm and ejaculation. Surgical ated ED that fails to respond to medical treatment algorithms have been published to guide the choice and should be offered only once the disease has of surgical approach ([160], Table 2).
stabilized. In addition, patients who have extensive Two main preoperative factors contribute to plaque calcification are typically best treated with this decision, including penile rigidity and severity surgery, as nonsurgical approaches have not been of deformity [161–163]. When rigidity is adequate, shown to be beneficial in this circumstance. Lastly, with or without drug assistance, two approaches the patient who wants the most rapid and reliable have been suggested including tunica plication result should select a surgical approach [26,156] techniques, which are recommended when there is a simple curvature of less than 60–70°, and no hour Many of these men are depressed, have marked glass deformity, and when the presumed loss of reduction of self-esteem, and oftentimes have unat- length caused by the plication will be less than tainable expectations regarding the outcome from 20% of total erect length. For men who have more surgical reconstruction [15]. Therefore, a detailed complex curvature greater than 60°, and/or a discussion on persistent or recurrent curvature destabilizing hourglass or hinge effect then plaque should be initiated with the accepted goal of incision, or partial plaque excision and grafting making the patient “functionally straight,” which is is preferred. It is important to stress that this loosely defined as a curvature of less than 20° [157].
approach is recommended for men who have good Loss of length is most likely to occur with plication procedures, particularly in those with ventral cur-vature [158]. In addition, there may be diminishedrigidity, which has been shown to occur regardless SURGICAL TREATMENT GRADE C
of the surgical approach. Clearly, those who have Surgery remains the gold standard for cor-
suboptimal preoperative rigidity have a higher risk recting erect penile deformity in the man
with stable disease.

Stable disease (6 months with no pain and stable deformity) RECONSTRUCTION GRADE C
Compromised or inability to engage in coitusExtensive plaque calcification Surgical reconstruction is indicated in
the man who has stable disease for _ 6
months, painless deformity, compromised,
or inability to engage in coitus secondary
from the convex (longer) side, then the edges to deformity and/or inadequate rigidity,
are reaproximated to create the shortening effect when there is extensive plaque calcification,
[164]. Currently, there are many variations of the and for the man who desires the most rapid
plication procedure, which include procedures and reliable result.
where a portion of the tunica is not excised, butinstead plicated such as the Essed-Schroeder SURGERY—PREOPERATIVE
technique [165]. The Yachia technique utilizes CONSENT GRADE D
the Heinke-Mikowitz principle where a vertical The preoperative consent is critical to
incision is closed transversely so as to shorten the set proper outcome expectations for the
convex side of the penis [166]. The tunica albug- patient. It is imperative to have a discussion
inea plication technique corrects the deformity on the risks of persistent or recurrent
by plicating a series of paired incisions into the curvature, loss of erect length, diminished
tunica without exposing the underlying cavern- rigidity, and decreased sexual sensation.
osal tissue [157]. The 16-dot procedure utilizesan extended Lembert type of suturing technique SURGICAL ALGORITHM GRADE C
[167]. In this procedure, a dorsal curve is cor- Several surgical algorithms have been pub-
rected with sutures placed into the tunic on both lished with general agreement that for men
sides of the urethra, then progressively tied down with adequate preoperative rigidity, some
so as to create shortening and straightening.
form of tunica plication procedure is best
There is no tunica incision or tissue excision per- for those with curvature less than 60° and
formed; therefore, the correction of deformity with no hour-glass deformity resulting in
relies upon the nonabsorbable sutures. All these a hinge effect. For those with more severe
procedures appear to adequately straighten the deformity (>60° and/or hourglass) and good
penis with little risk of compromising erectile preoperative rigidity, incision or partial
function. It is critical that during the per- excision and grafting is recommended.
formance of any straightening procedure thesurgeon is able to induce an erection, usually byneedle injection of saline by pump or syringe(Table 3).
Surgical Approaches
The advantages to the plication approach are that they are simple, minimally invasive, and tend This review of surgical approaches begins with to preserve potency in most patients. The disad- the plication procedures, which are designed to vantages are that they can result in penile shorten- shorten the longer side of the penis. If the cur- ing, which has been shown to be exacerbated by vature is in a dorsal direction, the plaque causes correction of curvature greater than 60°, and/or shortening of the dorsal aspect, and therefore a ventral curvature where dorsal plication is to correct the curvature with plication, the ventral aspect is shortened. This approach is Lastly, plication procedures may worsen an based upon the Nesbit procedure where an erec- existing hour-glass or hinge effect, particularly if tion is created and a wedge of tunica is excised Peyronie’s Disease published reports-plication procedures most frequently used autologous graft currently SURGERY—PLICATION PROCEDURES
in use is saphenous vein, which requires a separate incision to harvest, adding a risk of local side There is no evidence that one surgical
effects, and longer operating time with a second approach provides better outcomes over
incision to heal. Synthetic grafts were used histori- another, but curvature correction can be
cally, including polyester and polytetraflouroe- expected with low risk of new ED or sensory
thylene, but these have not been met with enthusiasm because of the increased risk of infec-tion, an unnatural feel and may have the potential Incision or Partial Excision and Grafting Techniques for more local inflammation and fibrosis [179].
Surgical grafting techniques include plaque inci- The modern era of grafts include off-the-shelf sion or partial excision. Historically, total plaque processed human cadaveric tissue or xenografts.
excision was designed to “remove the diseased These are felt to be advantageous because they can tunica,” but this causes an unacceptably high rate reduce operating time substantially, they appear to of postoperative ED. This has been suggested to have similar midterm outcome results as compared occur as a result of a compromised veno-occlusive with autologous grafts, and there is no harvest mechanism, because of the changes in the relation- comorbidity. These grafts include human and ship between the cavernosal tissue and the overly- bovine pericardium, porcine small intestinal sub- ing tunic or graft [173]. Therefore, minimizing the mucosa, and porcine and human dermis. All these excision or making simple releasing incisions have grafts undergo an extensive processing to clear the been recommended so a smaller graft may be used tissue of cells, bacteria, viruses, and presumably prions. As of this time there has been no report The search for the ideal graft continues. As of of host viral infection secondary to processed this time, no ideal graft has been identified, which allograft or xenograft implantation. The operative would take reliably, not contract, be resistant to procedure is done essentially the same for all graft- infection and preserve erectile capacity [175] ing techniques—an artificial erection is created demonstrating the curvature and the penis is typi- Currently, it appears that the nature of the graft cally degloved using a circumcising incision allow- is less likely the determining factor with respect to ing exposure of the entire shaft of the penis. In the postoperative ED. On the other hand, it is most area of maximum curvature, Buck’s fascia contain- likely a result of patient selection with respect to ing the neurovascular bundle is elevated, either preoperative erectile status and operative tech- from a pair of parallel incisions lateral to the ure- nique [159]. Larger grafts, men older than 60 years thral ridge allowing elevation of Buck’s fascia old, and those with ventral grafting also appear to dorsally, or by coming through the bed of the have a higher risk of postoperative ED [162,175– deep dorsal vein. It is felt that the deep dorsal vein 177]. A variety of autologous grafts have been approach may not offer adequate lateral exposure, used including dermis, tunica vaginalis, temporalis which would be especially important for patients fascia, buccal mucosa, and fascia lata [178]. The who have severe lateral indentation or hour-glassdeformity. The elevation process is best performedwith loupe magnification and bi-polar electrocau- tery so as to reduce the likelihood of injury to theneurovascular tissues. Once Buck’s fascia is pro- I. Autologous
perly elevated an artificial erection is recreated, demonstrating the area of maximum deformity.
Surgeons differ in their approach as to whether a simple modified H-like incision should be made to II. Nonautologous; allografts
the area of maximum curvature or whether partial plaque excision is recommended, particularly Pericardium
when there is significant indentation and/or calci- Fascia lata
fication. Regardless, the goal is to remove as little Dura mater
plaque as possible, but to allow proper correction Bovine pericardium
of the deformity by expanding the tunic in both Porcine small intestinal submucosa
girth and length. Edygio has championed the geo- Porcine dermis
metric principle approach to graft sizing [180].
This technique has proven useful in his hands, but and a loss of length was noted in 35% [188]. At the a recent report suggested a higher risk of postop- 2004 Annual Meeting of the American Urological erative ED [177]. Once the graft is positioned, Association Society, Montorsi et al. reported on 50 Buck’s fascia is reapproximated to provide support patients with a 5-year follow-up after venous graft- and a vascularized cover over the graft.
ing where there was either persistent or recurrentcurvature in 12%, length loss in 100%, post- Postoperative Care and Rehabilitation operative ED in 22%, diminished orgasm in 41%, Following surgery, postoperative rehabilitation and overall patient satisfaction of only 60% [189].
is recommended to enhance recovery of erectile Taylor and Levine recently reported a mean function. Massage and stretch therapy, is per- follow-up of just short of 5 years on 111 patients formed by grasping the glans penis and pulling it undergoing partial plaque excision with processed gently and repeatedly away from the body while human pericardial grafting where the patients also gently massaging the graft area. This is initi- reported persistent or recurrent curvature of ated 2 weeks after surgery and performed twice a greater than 20° in 8% (none required surgical day for 4 weeks. It is advised that the patient’s correction), a measured loss of stretched penile partner get involved in the rehabilitation process to length was found in 47%, but was subjectively lessen the anxiety associated with the resumption of reported by 65% of patients. The postoperative sexual activity for both partners. Bedtime phos- ED rate was 24% with 31% noting diminished phodiesterase inhibitors have been recommended sensation, but 89% experienced normal orgasm.
to begin 7–10 days after surgery and to be main- Overall, patient satisfaction was reported at 76% tained for 6 weeks, in order to enhance nocturnal [157]. Postoperative traction therapy had not been erections, stretch the tissue, encourage nourish- ment of the graft [159], and possibly reduce the risk Recent studies have also examined the risk of of postoperative ED. Finally, the use of external postoperative ED following penile grafting proce- penile traction therapy has been noted to reduce dures [175,177]. For the most part, no significant postoperative penile shortening for patients who contribution was found because of the duration of have undergone either placation or grafting pro- disease, vascular risk factors (including diabetes, cedures. Traction is initiated 2–3 weeks post- hypertension, elevated lipids, and smoking), a operatively when the circumcising incision has dorsal or lateral curvature, graft or tunica defect adequately healed and is performed on a daily basis size, or whether there was preoperative narrowing for a minimum of 2–8 hours for 3 months [181].
or hinge effect. A higher risk of ED was found in Table 5 outlines the results from published those who underwent grafting for ventral curva- reports on grafting, on average 74–100% of ture and there was a trend toward increased ED patients were adequately straight, with a post- risk for men over the age of 60 [159]. In this published analysis, the primary component that Kalsi et al. studied 40 patients who underwent helped predict an increased risk of postoperative vein grafting and followed for at least 5 years.
ED was when the patient reported preoperative They reported a postoperative ED rate of 22.5% internal tissue expander and will likely result in SURGERY—GRAFTING PROCEDURES
correction of deformity in 6–9 months. On the other hand, if there is substantial residual curva- There is no evidence that surgical outcomes
ture, then releasing incisions can be made on the are consistently better with one graft type,
concave side, often times through the same scrotal and overall there is an increased risk of post-
incision or may require degloving of the penis with operative ED. Autologous grafts require
elevation of Buck’s fascia. If these incisions create more time and a second incision. Allograft
a tunic defect greater than 2 cm in any dimension, and Xenograft procedures appear shorter
patching is recommended to decrease the risk of in duration with no reported transmission
cicatrix contracture resulting in recurrent curva- of disease. Synthetic grafts increase the risk
ture or herniation of the cylinders. An off-the-shelf of infection and are not recommended.
graft is now recommended to fix the tunic defect.
Freshly harvested dermal grafts are not recom-mended as there is risk of transferring bacteria Penile Prosthesis Implantation with within the dermal tissue increasing the possibility Finally, for those men who have poor qualityerections and/or do not respond adequatelyto pharmacological therapy for their ED, penile SURGERY—PENILE
prosthesis implantation is recommended. Table 6 reviews the recommended surgical algorithm for Penile prosthesis implantation with addi-
tional maneuvers to correct the deformity is
Prosthesis alone may result in satisfactory recommended when there is preoperative
straightening of the penis for those with mild defor- ED not responsive to oral medication (phos-
mity, but when residual curvature is more than 30°, phodiesterase type 5 Inhibitors)
manual modeling is recommended [190]. Manualmodeling should be performed with care. Once SURGERY—PENILE
the prosthesis is placed and the corporotomies are closed, the prosthesis is inflated with a surrogate Following
(i.e., outside the body) reservoir of saline to dem- following maneuvers are recommended
onstrate the deformity. The surgeon will then including manual modeling followed by
model the penis by bending it in the contralateral plaque incision if the residual erect curva-
direction to the curvature maintaining the pressure ture exceeds 30°. If a tunica defect in excess
on the bent penis for 30–60 seconds. The tubing of 2 cm is noted after incision, then grafting
between the pump and the cylinders should be the defect is recommended to reduce the
occluded with rubber shod hemostats, so as to risk of postoperative recurrent curvature
protect the pump from high pressure damage. In or cylinder herniation. Autologous dermal
addition, when performing the modeling process, grafts should not be placed over a prosthesis
pressure on the glans penis should be avoided to as a result of the increased risk of infection.
prevent a urethral erosion by the cylinder tip. Analternative approach is to pre-place pliation sutures PD SURGERY—OVERVIEW GRADE D
in the 16-dot method before implanting the pros- Following published surgical algorithms is
thesis and then tying them down to correct the imperative, as well as obtaining a preopera-
curvature. Regardless of the approach, if there is tive consent to set proper outcome expecta-
residual curve less than 30°, no further treatment tions for the patient. A plication procedure
is recommended, as the prosthesis will act as an is indicated for less severe deformity (<60°)
and when there is borderline ED, while
grafting is reserved for severe deformity

Surgical algorithm with penile prosthesis (>60–70° Ϯ hinge with normal erectile func-
tion) and requires an experienced surgical
• Manual modeling if residual curve >30° team. Lastly, prosthesis placement is indi-
• Plaque releasing incision if residual curve after modeling >30° cated with additional maneuvers for those
• Graft tunica if defect >2.0 cm to prevent implant herniation or men with refractory ED and PD.
5 Kadioglu A, Tefekli A, Erol B, Oktar T, Tunc M, Tellaloglu S.
A retrospective review of 307 men with Peyronie’s disease.
This review is intended to be a guide to making decisions about surgical correction of PD. The 6 Mulhall JP, Schiff J, Guhring P. An analysis of the natural intent is that it will be useful to the practicing history of Peyronie’s disease. J Urol 2006;175:2115–8.
7 Levine LA, Greenfield JM. Establishing a standardized evalu- surgeon so that they may provide appropriate ation of the man with Peyronie’s disease. Int J Impot Res advice to their patients regarding the proper surgical procedure. The most critical part of 8 Pryor J, Akkus E, Alter G, Jordan G, Lebret T, Levine L, the surgeon’s role in the preoperative phase is to Mulhall J, Perovic S, Ralph D, Stackl W. Peyronie’s disease.
J Sex Med 2004;1:110–5.
set appropriate expectations for the patient and 9 Pryor JP, Ralph DJ. Clinical presentations of Peyronie’s to review the potential complications of surgery, disease. Int J Impot Res 2002;14:414–7.
including incomplete straightening, recurrent 10 Bella AJ, Sener A, Foell K, Brock GB. Nonpalpable scarring curvature, shaft shortening, diminished sensation, of the penile septum as a cause of erectile dysfunction: Anatypical form of Peyronie’s disease. J Sex Med 2007;4:226–30.
and ED. Although surgical correction of PD has 11 Vernet D, Nolazco G, Cantini L, Magee TR, Qian A, Rajfer historically had a negative reputation, the more J, Gonzalez-Cadavid NF. Evidence that osteogenic progeni- recent refinements in technique make it a viable tor cells in the human tunica albuginea may originate fromstem cells: Implications for peyronie disease. Biol Reprod and successful treatment option for the properly 12 Ohebshalom M, Mulhall J, Guhring P, Parker M. Measure- ment of penile curvature in Peyronie’s disease patients: Com- Corresponding
parison of three methods. J Sex Med 2007;4:199–203.
FRCS(Urol), Institute of Urology, 145 Harley St, 13 Rosen R, Catania J, Lue T, Althof S, Henne J, Hellstrom W, London W1G 6BJ; Tel: +44 207 486 3805; Fax: +44 207 Levine L. Impact of Peyronie’s disease on sexual and psycho-social functioning: Qualitative findings in patients and con- 14 Smith JF, Conti S, Walsh TJ, Turek P, Lue T. Risk factors for emotional and relationship problems in Peyronie’s disease. JSex Med 2008;5:2179–84.
15 Nelson CJ, Diblasio C, Kendirci M, Hellstrom W, Guhring Statement of Authorship
P, Mulhall JP. The chronology of depression and distress inmen with Peyronie’s disease. J Sex Med 2008;5:1985–90.
16 Amin Z, Patel U, Friedman EP, Vale JA, Kirby R, Lees WR.
(a) Conception and Design
Colour Doppler and duplex ultrasound assessment of Peyro- (b) Acquisition of Data
nie’s disease in impotent men. B J Rad 1993;66:398–402.
17 Kadioglu A, Oktar T, Kandirali E, Kendirci M, Sanli O, (c) Analysis and Interpretation of Data
Ozsoy C. Incidentally diagnosed Peyronie’s disease in menpresenting with erectile dysfunction. Int J Impot Res2004;16:540–3.
18 Gasior BL, Levine FJ, Howannesian A, Krane RJ, Goldstein I.
(a) Drafting the Article
Plaque-associated corporal venoocclusive dysfunction in idio- (b) Revising It for Intellectual Content
pathic Peyronie’s disease: A pharmacocavernosometric andpharmacocavernosographic study. World J Urol 1990;8:90–6.
19 Rosen RC, Riley A, Wagner G, Osterloh IH, Kirkpatrick J, Mishra A. The International Index of Erectile function(IIEF): A multidimensional scale for the assessment of erec- (a) Final Approval of the Completed Article
tile dysfunction. Urology 1997;49:822–30.
20 Hauck EW, Hackstein N, Vosshenrich R, Diemer T, Schmelz HU, Bschleipfer T, Schroeder-Printzen I, WeidnerW. Diagnostic value of magnetic resonance imaging in Pey- References
ronie’s disease—A comparison both with palpation and ultra- 1 Lue TF, Giuliano F, Montorsi F, Rosen RC, Andersson KE, sound in the evaluation of plaque formation. Eur Urol Althof S, Christ G, Hatzichristou D, Hirsch M, Kimoto Y, Lewis R, McKenna K, MacMahon C, Morales A, Mulcahy J, 21 Aversa A, Sarteschi LM. The role of penile colorduplex ultra- Padma-Nathan H, Pryor J, de Tejada IS, Shabsigh R, Wagner sound for the evaluation of erectile dysfunction. J Sex Med G. Summary of the recommendations on sexual dysfunctions 22 Kadioglu A, Tefekli A, Erol H, Cayan S, Kandirali E.
2 Schwarzer U, Sommer F, Klotz T, Braun M, Reifenrath B, Color Doppler ultrasound assessment of penile vascular Engelmann U. The prevalence of Peyronie’s disease: Results system in men with Peyronie’s disease. Int J Impot Res of a large survey. BJU Int 2001;88:727–30.
3 Deveci S, Hopps C, O’Brien K, Parker M, Guhring P, 23 LaRochelle JC, Levine LA. A survey of primary care physi- Mulhall JP. Defining the clinical characteristics of peyronie’s cians and urologists regarding Peyronie’s disease. J Sex Med disease in young men. J Sex Med 2007;4:485–90.
4 Kendirci M, Trost L, Sikka SC, Hellstrom GJ. Diabetes mel- 24 Müller A, Mulhall JP. Peyronie’s disease intervention trials: litus is associated with severe Peyronie’s disease. BJU Int Methodological challenges and issues. J Sex Med 2009;6:848– 25 Smith JF, Walsh TJ, Lue TF. Peyronie’s disease: A critical ronie’s disease. In: Levine LA, ed. Current clinical urology: appraisal of current diagnosis and treatment. Int J Impot Res Peyronie’s disease, a guide to clinical management. Totowa, 26 Bella AJ, Perelman MA, Brant WO, Lue TF. Peyronie’s 46 Sasso F, Gulino G, Falabella R, D’Addessi A, Sacco E, disease (CME). J Sex Med 2007;4:1527–38.
D’Onofrio A, Bassi PF. Peyronie’s disease: Lights and 27 Taylor FL, Levine LA. Peyronie’s disease. Urol Clin North 47 Devine CJ Jr, Somers KD, Jordan SG, Schlossberg SM.
28 Greenfield JM, Levine LA. Peyronie’s disease: Etiology, Proposal: Trauma as the cause of the Peyronie’s lesion. J Urol epidemiology and medical treatment. Urol Clin North Am 48 Somers KD, Dawson DM. Fibrin deposition in Peyronie’s 29 Smith CJ, McMahon C, Shabsigh R. Peyronie’s disease: The disease plaque. J Urol 1997;157:311–5.
epidemiology, aetiology and clinical evaluation of deformity.
49 Van de Water L. Mechanisms by which fibrin and fibronectin appear in healing wounds: Implications for Peyronie’s 30 Rhoden EL, Teloken C, Ting HY, Lucas ML, Teodósio da Ros C, Ary Vargas Souto C. Prevalence of Peyronie’s disease 50 Davila HH, Magee TR, Zuniga FI, Rajfer J, Gonzalez- in men over 50-year-old from Southern Brazil. Int J Impot Cadavid NF. Peyronie’s disease associated with increase in plasminogen activator inhibitor in fibrotic plaque. Urology 31 Mulhall JP, Creech SD, Boorjian SA, Ghaly S, Kim ED, Moty A, Davis R, Hellstrom W. Subjective and objective 51 Ehrlich HP. Scar contracture: Cellular and connective tissue analysis of the prevalence of Peyronie’s disease in a popula- aspects in Peyronie’s disease. J Urol 1997;157:316–9.
tion of men presenting for prostate cancer screening.
52 Davila HH, Ferrini MG, Rajfer J, Gonzalez-Cadavid NF.
Fibrin as an inducer of fibrosis in the tunica albuginea of 32 La Pera G, Pescatori ES, Calabrese M, Boffini A, Colombo F, the rat: A new animal model of Peyronie’s disease. BJU Int Andriani E, Natali A, Vaggi L, Catuogno C, Giustini M, Taggi F. SIMONA Study Group. Peyronie’s disease: Preva- 53 Davila HH, Magee TR, Vernet D, Rajfer J, Gonzalez- lence and association with cigarette smoking. A multicenter Cadavid NF. Gene transfer of inducible nitric oxide synthase population-based study in men aged 50–69 years. Eur Urol complementary DNA regresses the fibrotic plaque in an animal model of Peyronie’s disease. Biol Reprod 2004;71: 33 Kumar B, Narang T, Gupta S, Gulati M. A clinico- aetiological and ultrasonographic study of Peyronie’s disease.
54 Zargooshi J. Trauma as the cause of Peyronie’s disease: Penile fracture as a model of trauma. J Urol 2004;172:186–8.
34 El-Sakka AI. Prevalence of Peyronie’s disease among patients 55 El-Sakka AI, Selph CA, Yen TS, Dahiya R, Lue TF.
with erectile dysfunction. Eur Urol 2006;49:564–69.
The effect of surgical trauma on rat tunica albuginea. J Urol 35 Tefekli A, Kandirali E, Erol B, Tunc M, Kadioglu A. Peyro- nie’s disease: A silent consequence of diabetes mellitus. Asian 56 Schiavino D, Sasso F, Nucera E, Alcini E, Gulino G, Milani A, Patriarca G. Immunologic findings in Peyronie’s disease: A 36 Usta MF, Bivalacqua TJ, Tokatli Z, Rivera F, Gulkesen KH, controlled study. Urology 1997;50:764–8.
Sikka SC, Hellstrom WJ. Stratification of penile vascular 57 Noss MB, Day NS, Christ GJ, Melman A. The genetics and pathologies in patients with Peyronie’s disease and in men immunology of Peyronie’s disease. Int J Impot Res 2000; with erectile dysfunction according to age: A comparative 58 Hauck EW, Hauptmann A, Weidner W, Bein G, Hackstein 37 Usta MF, Bivalacqua TJ, Jabren GW, Myers L, Sanabria J, H. Prospective analysis of HLA classes I and II antigen Sikka SC, Hellstrom WJ. Relationship between the severity frequency in patients with Peyronie’s disease. J Urol 2003; of penile curvature and the presence of comorbidities in men with Peyronie’s disease. J Urol 2004;171:775–9.
59 Hauck EW, Hauptmann A, Haag SM, Bohnert A, Weidner 38 El-Sakka AI, Tayeb KA. Peyronie’s disease in diabetic W, Bein G, Hackstein H. Alpha-1-antitrypsin levels and patients being screened for erectile dysfunction. J Urol genetic variation of the alpha-1-antitrypsin gene in Peyro- nie’s disease. Eur Urol 2004;46:623–8; discussion 628.
39 Tefekli A, Kandirali E, Erol H, Alp T, Köksal T, Kadioglu A.
60 Hauck EW, Hauptmann A, Schmelz HU, Bein G, Weidner Peyronie’s disease in men under age 40: Characteristics and W, Hackstein H. Prospective analysis of single nucleotide outcome. Int J Impot Res 2001;13:18–23.
polymorphisms of the transforming growth factor beta-1 40 Carrieri MP, Serraino D, Palmiotto F, Nucci G, Sasso F. A gene in Peyronie’s disease. J Urol 2003;169:369–72.
case-control study on risk factors for Peyronie’s disease.
61 Ralph DJ, Schwartz G, Moore W, Pryor JP, Ebringer A, Bottazzo GF. The genetic and bacteriological aspects of 41 Perimenis P, Athanasopoulos A, Gyftopoulos K, Katsenis G, Peyronie’s disease. J Urol 1997;157:291–4.
Barbalias G. Peyronie’s disease: Epidemiology and clinical 62 Domes T, De Young L, O’Gorman DB, Gan BS, Bella AJ, presentation of 134 cases. Int Urol Nephrol 2001;32:691–4.
Brock G. Is there a role for proteomics in Peyronie’s disease? 42 Bjekic MD, Vlajinac HD, Sipetic SB, Marinkovic JM. Risk factors for Peyronie’s disease: A casecontrol study. BJU Int 63 Ferrini MG, Vernet D, Magee TR, Shahed A, Qian A, Rajfer J, Gonzalez-Cadavid NF. Antifibrotic role of inducible nitric 43 Arafa M, Eid H, El-Badry A, Ezz-Eldine K, Shamloul R. The oxide synthase. Nitric Oxide 2002;6:283–94.
prevalence of Peyronie’s disease in diabetic patients with 64 Iacono F, Barra S, de Rosa G, Boscaino A, Lotti T. Micro- erectile dysfunction. Int J Impot Res 2007;19:213–7.
structural disorders of tunica albuginea in patients affected by 44 Gonzalez-Cadavid NF, Rajfer J. Experimental models of impotence. Eur Urol 1994;26:233–39.
Peyronie’s disease: Implications for new therapies. J Sex Med 65 Anafarta K, Bedük Y, Uluoglu O, Aydos K, Baltaci S.
The significance of histopathological changes of the normal 45 Gonzalez-Cadavid NF, Rajfer J. Experimental models for the tunica albuginea in Peyronie’s disease. Int Urol Nephrol study of the cellular and molecular pathophysiology of Pey- 66 Brock G, Hsu GL, Nunes L, von Heyden B, Lue TF. The development of fibrotic plaques in a rat model of Peyronie’s anatomy of the tunica albuginea in the normal penis and Peyronie’s disease. J Urol 1997;157:276–81.
83 Cantini LP, Ferrini MG, Vernet D, Magee TR, Qian A, 67 Mirone V, Imbimbo C, Palmieri A, Longo N, Fusco F, Gelfand RA, Rajfer J, Gonzalez-Cadavid NF. Profibrotic role Tajana G. A new biopsy technique to investigate Peyronie’s of myostatin in Peyronie’s disease. J Sex Med 2008;5:1607– disease associated histologic alterations: Results with two dif- ferent forms of therapy. Eur Urol 2002;42:239–44; discussion 84 Wynn TA. Cellular and molecular mechanisms of fibrosis.
68 Somers KD, Sismour EN, Wright GL Jr, Devine CJ Jr, 85 Piao S, Ryu JK, Shin HY, Zhang L, Song SU, Han JY, Park Gilbert DA, Horton CE. Isolation and characterization of SH, Kim JM, Kim IH, Kim SJ, Suh JK. Repeated intratunical collagen in Peyronie’s disease. J Urol 1989;141:629–31.
injection of adenovirus expressing transforming growth 69 Gentile V, Modesti A, La Pera G, Vasaturo F, Modica A, factor-beta1 in a rat induces penile curvature with tunical Prigiotti G, Di Silverio F, Scarpa S. Ultrastructural and fibrotic plaque: A useful model for the study of Peyronie’s immunohistochemical characterization of the tunica albug- disease. Int J Androl 2008;31:346–53.
inea in Peyronie’s disease and veno-occlusive dysfunction.
86 Lucattelli M, Lunghi B, Fineschi S. A new mouse model of Peyronie’s disease: An increased expression of hypoxia- 70 Davis CJ Jr. The microscopic pathology of Peyronie’s induciblefactor-1 target genes during the development of penile changes. Int J Biochem Cell Biol 2008;40:2638–48.
71 Hirano D, Takimoto Y, Yamamoto T, Hirakata H, Kawata N.
87 Somers KD, Dawson DM, Wright GL Jr, Leffell MS, Rowe Electron microscopic study of the penile plaques and adjacent MJ, Bluemink GG, Vande Berg JS, Gleischman SH, Devine corpora cavernosa in Peyronie’s disease. Int J Urol 1997; CJ Jr, Horton CE. Cell culture of Peyronie’s disease plaque and normal penile tissue. J Urol 1982;127:585–8.
72 Vernet D, Ferrini MG, Valente EG, Magee TR, Bou-Gharios 88 Mulhall JP, Nicholson B, Pierpaoli S, Lubrano T, Shankey G, Rajfer J, Gonzalez-Cadavid NF. Effect of nitric oxide on TV. Chromosomal instability is demonstrated by fibroblasts the differentiation of fibroblasts into myofibroblasts in the derived from the tunica of men with Peyronie’s disease. Int J Peyronie’s fibrotic plaque and in its rat model. Nitric Oxide 89 Mulhall JP, Branch J, Lubrano T, Shankey TV. Perturbation 73 Eyden B. The myofibroblast: Phenotypic characterization as of cell cycle regulators in Peyronie’s disease. Int J Impot Res a prerequisite to understanding its functions in translational medicine. J Cell Mol Med 2008;12:22–37.
90 Mulhall JP, Thom J, Lubrano T, Shankey TV. Basic fibro- 74 Vernet D, Magee T, Qian A, Nolazco G, Rajfer J, Gonzalez- blast growth factor expression in Peyronie’s disease. J Urol Cadavid N. Phosphodiesterase type 5 is not upregulated by tadalafil in cultures of human penile cells. J Sex Med 91 Mulhall JP, Branch J, Lubrano T, Shankey TV. Radiation increases fibrogenic cytokine expression by Peyronie’s disease 75 Vande Berg JS, Devine CJ Jr, Horton CE, Somers KD, fibroblasts. J Urol 2003;170:281–4.
Wright GL Jr, Leffell MS, Dawson DM, Gleischman SH, 92 Mulhall JP, Anderson MS, Lubrano T, Shankey TV. Peyro- Rowe MJ. Mechanisms of calcification in Peyronie’s disease.
nie’s disease cell culture models: Phenotypic, genotypic and functional analyses. Int J Impot Res 2002;14:397–405.
76 El-Sakka AI, Hassoba HM, Chui RM, Bhatnagar RS, Dahiya 93 Mulhall JP, Martin DJ, Lubrano T, Moser M, Kwon E, Wojcik R, Lue TF. An animal model of Peyronie’s-like condition E, Shankey TV. Peyronie’s disease fibroblasts demonstrate associated with an increase of transforming growth factor tumorigenicity in the severe combined immunodeficient beta mRNA and protein expression. J Urol 1997;158:2284– (SCID) mouse model. Int J Impot Res 2004;16:99–104.
94 Mulhall JP. Expanding the paradigm for plaque development 77 El-Sakka AI, Hassan MU, Nunes L, Bhatnagar RS, Yen TS, in Peyronie’s disease. Int J Impot Res 2003;15(suppl 5):S93– Lue TF. Histological and ultrastructural alterations in an animal model of Peyronie’s disease. Br J Urol 1998;81: 95 Haag SM, Hauck EW, Eickelberg O, Szardening- Kirchner C, Diemer T, Weidner W. Investigation of the antifibrotic 78 El-Sakka AI, Bakircioglu ME, Bhatnagar RS, Yen TS, effect of IFN-gamma on fibroblasts in a cell culture model of Dahiya R, Lue TF. The effects of colchicine on a Peyronie’s- Peyronie’s disease. Eur Urol 2008;53:425–30; Epub 2007 Jun like condition in an animal model. J Urol 1999;161:1980– 96 Hinz B, Phan SH, Thannickal VJ, Galli A, Bochaton-Piallat 79 Bivalacqua TJ, Diner EK, Novak TE, Vohra Y, Sikka SC, ML, Gabbiani G. The myofibroblast: One function, multiple Champion HC, Kadowitz PJ, Hellstrom WJ. A rat model of origins. Am J Pathol 2007;170:1807–16.
Peyronie’s disease associated with a decrease in erectile activ- 97 Nolazco G, Kovanecz I, Vernet D, Gelfand RA, Tsao J, ity and an increase in inducible nitric oxide synthase protein Ferrini MG, Magee T, Rajfer J, Gonzalez-Cadavid NF.
expression. J Urol 2000;163:1992–8.
Effect of muscle-derived stem cells on the restoration of 80 Bivalacqua TJ, Champion HC, Leungwattanakij S, Yang DY, corpora cavernosa smooth muscle and erectile function in the Hyun JS, Abdel-Mageed AB, Sikka SC, Kadowitz PJ, Hell- aged rat. BJU Int 2008;101:1156–64.
strom WJ. Evaluation of nitric oxide synthase and arginase in 98 Gonzalez-Cadavid NF. Mechanisms of penile fibrosis. J Sex the induction of a Peyronie’s-like condition in the rat. J 99 El-Sakka AI, Hassoba HM, Pillarisetty RJ, Dahiya R, 81 Valente EG, Vernet D, Ferrini MG, Qian A, Rajfer J, Lue TF. Peyronie’s disease is associated with an increase in Gonzalez-Cadavid NF. L-arginine and phosphodiesterase transforming growth factor-beta protein expression. J Urol (PDE) inhibitors counteract fibrosis in the Peyronie’s fibrotic plaque and related fibroblast cultures. Nitric Oxide 2003;9: 100 Lin CS, Lin G, Wang Z, Maddah SA, Lue TF. Upregulation of monocyte chemoattractant protein 1 and effects of trans- 82 Ferrini MG, Kovanecz I, Nolazco G, Rajfer J, Gonzalez- forming growth factor-beta 1 in Peyronie’s disease. Biochem Cadavid NF. Effects of long-term vardenafil treatment on the Biophys Res Commun 2002;295:1014–9.
101 Wang Z, Lin G, Lue TF, Lin CS. Wogonin suppresses 119 Kadioglu A, Tefekli A, Köksal T, Usta M, Erol H. Treatment cellular proliferation and expression of monocyte chemo- of Peyronie’s disease with oral colchicine: Long-term results attractant protein 1 in Peyronie’s plaque-derived cells. BJU and predictive parameters of successful outcome. Int J Impot 102 Gonzalez-Cadavid NF, Rajfer J. The pleiotropic effects 120 Safarinejad MR. Therapeutic effects of colchicine in the of inducible nitric oxide synthase on the physiology and management of Peyronie’s disease: A randomized double- pathology of penile erection. Curr Pharm Des 2005;11:4041– blind, placebo-controlled study. Int J Impot Res 2004;16: 103 Del Carlo M, Cole AA, Levine LA. Differential calcium 121 Prieto Castro RM, Leva Vallejo ME, Regueiro Lopez JC, Anglada Curado FJ, Alvarez Kindelan J, Requena Tapia MJ.
and tissue inhibitors of matrix metalloproteinases by Combined treatment with vitamin E and colchicine in the early stages of Peyronie’s disease. BJU Int 2003;91:522–4.
beta in Peyronie’s plaque fibroblasts. J Urol 2008;179:2447– 122 Biagiotti G, Cavallini G. Acetyl-L-carnitine vs tamoxifen in the oral therapy of Peyronie’s disease: A preliminary report.
104 Gelbard MK, James K, Riach P, Dorey F. Collagenase versus placebo in the treatment of Peyronie’s disease: A double- 123 Cavallini G, Biagiotti G, Koverech A, Vitali G. Oral blind study. J Urol 1993;149:56–8.
propionyl-l-carnitine and intraplaque verapamil in the therapy of advanced and resistant Peyronie’s disease. BJU Int disease: New insights into the cellular and molecular pathology of Peyronie’s disease. Nat Clin Pract Urol 2005; 124 Brant WO, Dean RC, Lue TF. Treatment of Peyronie’s disease with oral pentoxifylline. Nat Clin Pract Urol 2006; 106 Magee TR, Qian A, Rajfer J, Sander FC, Levine LA, Gonzalez-Cadavid NF. Gene expression profiles in the Pey- 125 Winter CC, Khanna R. Peyronie’s disease: Results with ronie’s disease plaque. Urology 2002;59:451–7.
dermo-jet injection of dexamethasone. J Urol 1975;114:898– 107 Qian A, Meals RA, Rajfer J, Gonzalez-Cadavid NF.
Comparison of gene expression profiles between Peyronie’s 126 Desanctis PN, Furey CA Jr. Steroid injection therapy disease and Dupuytren’s contracture. Urology 2004;64:399– for Peyronie’s disease: A 10-year summary and review of 108 Ferrini MG, Kovanecz I, Sanchez S, Vernet D, Davila HH, 127 Teasley GH. Peyronie’s disease: A new approach. J Urol Rajfer J, Gonzalez-Cadavid NF. Longterm continuous treat- ment with sildenafil ameliorates aging-related erectile dys- 128 Williams G, Green NA. The non-surgical treatment of function and the underlying corporal fibrosis. Biol Reprod Peyronie’s disease. Br J Urol 1980;52:392–5.
129 Toksu E. Peyronie’s disease: A method of treatment. J Urol 109 Kovanecz I, Rambhatla A, Ferrini MG, Vernet D, Sanchez S, Rajfer J, Gonzalez-Cadavid N. Chronic daily tadalafil pre- 130 Furey CA Jr. Peyronie’s disease: Treatment by the local vents the corporal fibrosis and veno-occlusive dysfunction injection of meticortelone and hydrocortisone. J Urol (CVOD) that occurs following cavernosal nerve resection in 131 Cipollone G, Nicolai M, Mastroprimiano G, Iantorno R, 110 Zarafonetis CJD, Horrax TM. Treatment of Peyronie’s Longeri D, Tenaglia R. Betamethasone versus placebo in disease with potassium paraaminobenzoate (Potaba). J Urol Peyronie’s disease. Arch Ital Urol Androl 1998;70:165–8.
132 Jordan GH. The use of intralesional clostridial collagenase 111 Shah PJR, Green NA, Adib RS, Pryor JP. A multicentre injection therapy for Peyronie’s disease: A prospective, doubleblind controlled clinical trial of potassium-para- single-center, non-placebocontrolled study. J Sex Med 2008; aminobenzoate (Potaba) in Peyronie’s disease. Prog Reprod 133 Levine LA, Merrick PF, Lee RC. Intralesional verapamil 112 Weidner W, Hauck EW, Schnitker J. Potassium para- injection for the treatment of Peyronie’s disease. J Urol aminobenzoate (POTABA) in the treatment of Peyronie’s disease: A prospective, placebocontrolled, randomized study.
134 Levine LA. Treatment of Peyronie’s disease with intralesional verapamil injection. J Urol 1997;158:1395–99.
113 Shindel AW, Bullock TL, Brandes S. Urologist practice pat- 135 Levine LA, Goldman K, Greenfield J. Experience with intra- terns in the management of Peyronie’s disease: A nationwide plaque injection of verapamil for Peyronie’s disease. J Urol survey. J Sex Med 2008;5:954–64; Epub 2007 Nov 27.
114 Pryor JP, Farell CR. Controlled clinical trial of vitamin E 136 Anderson MS, Shankey TV, Lubrano T, Mulhall JP.
in Peyronie’s disease. Prog Reprod Biol Med 1983;9:41–5.
Inhibition of Peyronie’s plaque fibroblast proliferation 115 Safarinejad MR, Hosseini SY, Kolahi AA. Comparison of by biologic agents. Int J Impot Res 2000;12(suppl 3):S25– vitamin E and propionyl-Lcarnitine, separately or in combi- nation, in patients with early chronic Peyronie’s disease: A 137 Rehman J, Benet A, Melman A. Use of intralesional verapamil doubleblind, placebo controlled, randomized study. J Urol to dissolve Peyronie’s disease plaque: A long-term single- blind study. Urology 1998;51:620–6.
116 Ralph DJ, Brooks MD, Bottazzo GF, Pryor JP. The treat- 138 Bennet NE, Guhring P, Mulhall JP. Intralesional verapamil ment of Peyronie’s disease with tamoxifen. Br J Urol 1992; prevents the progression of Peyronie’s disease. J Urol 2007; 117 Teloken C, Rhoden EL, Grazziotin TM, Ros CT, Sogari PR, 139 Cavallini G, Modenini F, Vitali G. Open preliminary ran- Souto CA. Tamoxifen versus placebo in the treatment of domized prospective clinical trial of efficacy and safety of Peyronie’s disease. J Urol 1999;162:2003–5.
three different verapamil dilutions for intraplaque therapy of 118 Akkus E, Carrier S, Rehman J, Breza J, Kadioglu A, Lue TF.
Peyronie’s disease. Urology 2007;69:950–4.
Is colchicine effective in Peyronie’s disease? A pilot study.
140 Hellstrom WJ, Kendirci M, Matern R, Cockerham Y, Myers L, Sikka SC, Venable D, Honig S, McCullough A, Hakim LS, Nehra A. Single-blind, multicenter, placebo controlled, par- 158 Greenfield JM, Lucas S, Levine LA. Factors affecting the loss allel study to assess the safety and efficacy of intralesional of length associated with tunical albuginea plication for cor- interferon alpha-2B for minimally invasive treatment for Pey- rection of penile curvature. J Urol 2006;175:238–41.
ronie’s disease. J Urol 2006;176:394–8.
159 Levine LA, Greenfield JM, Estrada CR. Erectile dysfunction 141 Inal T, Tokatli Z, Akand M, Ozdiler E, Yaman O. Effect of following surgical correction of Peyronie’s disease and a pilot intralesional interferon-alpha 2b combined with oral vitamin study of the use of Sildenafil citrate rehabilitation for postop- E for treatment of early stage Peyronie’s disease: A random- erative erectile dysfunction. J Sex Med 2007;5:241–7.
ized and prospective study. Urology 2006;67:1038–42.
160 Dimitriou R, Levine LA. A surgical algorithm for penile 142 Michel MS, Ptaschnyk T, Musial A, Braun P, Lenz ST, Alken prosthesis placement in men with erectile failure and Peyro- P, Köhrmann KU. Objective and subjective changes in nie’s Disease. J Urol 1999;161:1014A.
patients with Peyronie’s disease after management with shock 161 Levine LA, Lenting E. A surgical algorithm for the treatment wave therapy. J Endourol 2003;17:41–4.
of Peyronie’s disease. J Urol 1997;158:2149–52.
143 Strebel RT, Suter S, Sautter T, Hauri D. Extracorporeal 162 Mulhall JP, Anderson M, Parker M. A surgical algorithm for shock wave therapy for Peyronie’s disease does not correct men with combined Peyronie’s disease and erectile dysfunc- penile deformity. Int J Impot Res 2004;16:448–51.
tion: Functional and satisfaction outcomes. J Sex Med 144 Hauck EW, Hauptmann A, Bschleipfer T, Schmelz HU, Altinkilic BM, Weidner W. Questionable efficacy of extra- 163 Ralph DJ, Minhas S. The management of Peyronie’s disease.
corporeal shock wave therapy in Peyronie’s disease: Results of a prospective approach. J Urol 2004;171:269–99.
164 Ralph DJ, al-Akraa M, Pryor JP. The Nesbit operation for 145 Hauck EW, Mueller UO, Bschleipfer T, Schmelz HU, Peyronie’s disease: 16-year experience. J Urol 1995;4:1362–3.
Diemer T, Weidner W. Extracorporeal shock wave therapy 165 Essed E, Schroeder F. New surgical technique for Peyronie’s for Peyronie’s disease: Exploratory meta-analysis of clinical 166 Yachia D. Modified corporoplasty for the treatment of penile 146 Srirangam SJ, Manikandan R, Hussain J, Collins GN, O’Reilly PH. Long-term results of extracorporeal shockwave 167 Gholami SS, Lue TF. Correction of penile curvature using therapy for Peyronie’s disease. J Endourol 2006;20:880–4.
the 16-dot plication technique: A review of 132 patients. J 147 Palmieri A, Imbimbo C, Longo N, Fusco F, Verze P, Man- giapia F, Creta M, Mirone V. A first prospective, randomized, 168 Bella AJ, Brock GB. Minimally invasive intracorpal incision double-blind, placebo- controlled clinical trial evaluating of peyronie’s plaque. Peyronie’s Disease. In: Levine LA, ed. A extracorporeal shock wave therapy for the treatment of Pey- guide to clinical management. Totowa, NJ: Humana Press; ronie’s disease. Eur Urol 2009;56:363–70.
148 Riedl CR, Plas E, Engelhardt P, Daha K, Pflüger H.
169 Daitch J, Angermeier K, Montague D. Modified corporo- Iontophoresis for treatment of Peyronie’s disease. J Urol plasty for penile curvature: Long-term results and patient satisfaction. J Urol 1999;162:2006–9.
149 Di Stasi S, Giannantoni A, Stephen RL, Capelli G, Giurioli 170 Rolle L, Tamagnone A, Timpano M, Destefanis P, Fiori C, A, Jannini EA, Vespasiani G. A prospective, randomized study Ceruti C, Fontana D. The Nesbit operation for penile cur- using transdermal electromotive administration of verapamil vature: An easy and effective technical modification. J Urol and dexamethasone for Peyronie’s disease. J Urol 2004;171: 171 Savoca G, Scieri F, Petropaolo F, Garaffa G, Belgrano E.
150 Greenfield JM, Shah SJ, Levine LA. Verapamil versus saline Straightening corporoplasty for Peyronie’s disease: A review in electromotive drug administration for Peyronie’s disease: of 218 patients with median follow-up of 89 months. Eur A double-blind, placebo controlled trial. J Urol 2007;177: 172 Syed AH, Abbasi Z, Hargreave TB. Nesbit procedure for 151 Li J, Duncan RL, Burr DB, Turner CH. L-type calcium disabling Peyronie’s curvature: A median follow-up of 84 channels mediate mechanically induced bone formation in vivo. J Bone Miner Res 2003;18:58–66.
173 Dalkin BL, Carter MF. Venogenic impotence following 152 Alman BA, Greel DA, Ruby LK, Goldberg MJ, Wolfe HJ.
dermal graft repair for Peyronie’s disease. J Urol 1991;146: Regulation of proliferation and platelet-derived growth factor expression in palmar fibromatosis (Dupuytren contracture) 174 Gelbard MK. Relaxing incisions in the correction of penile by mechanical strain. J Orthop Res 1996;14:722–8, 38.
deformity due to Peyronie’s disease. J Urol 1995;154:1457– 153 Brighton CT, Fisher JRS Jr, Levine SE, Corsetti JR, Reilly T, Landsman AS, Williams JL, Thibault LE. The biochemical 175 Kovac JR, Brock GB. Surgical outcomes and patient satisfac- pathway mediating the proliferative response of bone cells to a tion after dermal, pericardial, and small intestinal submucosal mechanical stimulus. J Bone Joint Surg Am 1996;78:1337–47.
grafting for Peyronie’s disease. J Sex Med 2007;4:1500–8.
154 Levine LA, Newell M, Taylor FL. Penile traction therapy for 176 Leungwattanakij S, Bivalacque TJ, Reddy S, Hellstrom WJ.
treatment of Peyronie’s disease: A single-center pilot study. J Long-term follow-up on use of pericardial graft in the surgi- cal management of Peyronie’s disease. Int J Impot Res 155 Gontero P, Di Marco M, Giubilei G, Bartoletti R, Pappagallo G, Tizzani A, Mondaini N. Use of penile extender device in 177 Choi JM, Alex B, Mulhall J. Erectile dysfunction after plaque the treatment of penile curvature as a result of peyronie’s incision and grafting: Incidence and predictors. Abstract 730.
disease. Results of a phase ii prospective study. J Sex Med Annual Meeting of the American Urological Association; 156 Kendirci M, Hellstrom WJ. Critical analysis of surgery for 178 Kadioglu A, Sanli O, Akman T, Ersay A, Guven S, Mamma- Peyronie’s disease. Curr Opin Urol 2004;6:381–8.
dov F. Graft materials in Peyronie’s disease surgery: A com- 157 Taylor FL, Levine LA. Surgical correction of Peyronie’s prehensive review. J Sex Med 2007;4:581–95.
disease using Tunica albuginea plication or partial plaque 179 Brannigan RE, Kim ED, Oyasu R, McVary KT. Comparison excision with pericardial graft: Long-term followup. J Sex of tunica albuginea substitute for the treatment of Peyronie’s 180 Edygio PH, Lucon AM, Arap S. Treatment of Peyronie’s 186 Breyer BN, Brant WO, Garcia MM, Bella AJ, Lue TF. Com- disease by incomplete circumferential incession of the tunica plications of porcine small intestine submucosa graft for Pey- albuginea and plaque with bovine pericardium graft. Urology ronie’s disease. J Urol 2007;177:589–91.
187 Hsu GL, Chen HS, Hsieh CH, Chen RM, Wen HS, Liu LJ, 181 Moncata-Iribarren I, Jara J, Martinez-Salamanca JI, Cabello Chua C. Long-term results of autologous venous grafts for R, Hernandez C. Managing penile shortening after Peyro- penile morphological reconstruction. J Androl 2007;28:186– nie’s disease surgery: A comprehensive review. J Sex Med 2007;177(suppl 4):252; abstract 750.
188 Kalsi J, Minhas S, Christopher N, Ralph D. The results of 182 Knoll LD. Use of small intestinal submucosa graft for the plaque incision and venous grafting (Lue procedure) to surgical management of Peyronie’s disease. J Urol 2007;178: correct the penile deformity of Peyronie’s disease. BJU Int 183 Hatzichristou DG, Hatzimouratidis K, Apostolidis A, 189 Montorsi F, Salonia A, Briganti A, Dehò F, Zanni G, Tzortzis V, Bekos A, Ioannidis E. Corporoplasty using tunica Luigi DP, Rigatti P. Five year follow up of plaque incision albuginea free grafts of penile curvature: Surgical technique and vein grafting for Peyronie’s disease. Abstract 1256.
and longterm results. J Urol 2002;167:1367–70.
Annual Meeting of the American Urological Association; 184 Lue TF, El-Sakka AI. Venous patch graft for Peyronie’s disease. Part I: Technique. J Urol 1998;160:2047–9.
190 Wilson SK. Delk 2nd JR. A new treatment for Peyronie’s 185 Levine LA, Estrada CR. Human cadaveric pericardial graft disease: Modeling the penis over an inflatable penile proth- for the surgical correction of Peyronie’s disease. J Urol



Site sponsored by Safe Harbor, a nonprofit corporation President, Institute for Optimum Nutrition (ION) Food and Mood Poster T-Shirts, Bumper Stickers Janet was diagnosed with manic depression at the age of 15. At times she would become completely hyperactive and manic, and at other times become completely depressed. She was put on three drugs - Lithium, Tegretol and

FEBRUARY 5 6 7 8 9 10 11 12 13 14 15 16 17 18 9 10 11 12 13 14 15 9 10 11 12 13 14 15 21 22 23 24 25 18 19 20 21 22 18 19 20 21 22 26 27 28 29 30 31 23 24 25 26 27 28 23 24 25 26 27 28 29 6 7 8 9 10 11 12 4 5 6 7 8 9 10 8 9 10 11 12 13 14 13 14 15 16 17 18 19 11 12 13 14 15 16 17 18 19 20 21 20 21 22 23 24 25 2

Copyright © 2010-2019 Pdf Physician Treatment