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Peyronie's disease treated



Peyronie's disease treated
In about 13% of cases, Peyronie's disease goes away without treatment. Many physicians recommend conservative (non-surgical) treatment for at least the first 12 months after symptoms present.
Men with small plaques, minimal penile curvature, no pain, and satisfactory sexual function do not require treatment. Men with active phase disease who do have one or more of the above problems may benefit from medical therapy. Unfortunately, very few well designed clinical trials of medications for Peyronie's disease have been performed and therefore the true effectiveness of many of these treatments is unclear.
Oral vitamin E: An antioxidant that is a popular treatment for acute stage Peyronie's disease because of its mild side effects and low cost. While studies as far back as 1948 have demonstrated decreases in penile curvature and plaque size from vitamin E treatment, most of these studies have not used placebo controls. Those few studies of vitamin E that have included a placebo treatment group have demonstrated that vitamin E does not appear to give better results than the placebo, which calls into question whether or not vitamin E is an effective treatment.
Potassium amino-benzoate: Also known as Potaba®. Small placebo controlled studies have shown that this B-complex substance popular in Central Europe yields some benefits with respect to plaque size, but not curvature. Unfortunately, it is somewhat expensive and use of the medication requires taking 24 pills a day for three to six months. This medication has also been associated with a high rate of stomach upset, which leads many men to stop taking it.
Tamoxifen: This non-steroidal, anti-estrogen medication has been used in the treatment of desmoid tumors, a condition with properties similar to Peyronie's disease. Unfortunately, placebo controlled trials of this drug are rare and the few that have been conducted have not shown that Tamoxifen is better than placebo.
Colchicine: An anti-inflammatory agent that decreases collagen development. Colchicine has been shown to be slightly beneficial in a few small, uncontrolled studies. Many patients taking colchicine over the long term develop gastrointestinal problems and must discontinue the drug early in treatment. It has not been proven to be superior to placebo.
Carnitine: An antioxidant medication that is designed to reduce inflammation and thereby decrease abnormal wound healing. Like many other Peyronie's therapies, uncontrolled trials have demonstrated some benefit to this treatment but a recent controlled trial has not demonstrated it to be superior to placebo.
Penile Injections
Injecting a drug directly into the plaque of Peyronie's disease is an attractive alternative to oral medications. Injection permits direct introduction of drugs into the plaque, permitting higher doses and more local effects. To improve patient comfort a local anesthetic is usually given prior to the injection.
Because plaque injection is a minimally invasive approach, it is a popular option amongst men with active phase disease and men who are reluctant to have surgery.
Verapamil Injections: Verapamil is a calcium channel blocker usually used in the treatment of high blood pressure. It has also been shown to disrupt collagen production and this property has made it of interest in the treatment of Peyronie's disease. Several uncontrolled studies have suggested that verapamil injection is an effective treatment for penile pain and curvature; unfortunately, there are no large scale placebo controlled trials of this treatment. Verapamil appears to be a reasonable and affordable treatment option for Peyronie's disease, but further controlled studies are needed to verify the effectiveness of this treatment.
Interferon Injections: Interferon is a protein that is normally made in the body and plays an important role in inflammation. It has been shown to have anti-fibrotic effects in the treatment of keloid scars and scleroderma, a rare autoimmune disease affecting the body's connective tissue. This effect is thought to occur by inhibition of collagen producing cells and by production of collagenase, an enzyme that breaks down collagen that has already been produced.
A large scale placebo controlled trial of interferon injection for Peyronie's disease was recently published. This trial demonstrated modestly better improvements in penile curvature, pain, and sexual function in men treated with interferon compared to those treated with placebo. While this is an encouraging result interferon is a relatively expensive treatment with flu-like syndrome side-effects.
Collagenase Injections: Direct injection of the enzyme collagenase to break down the plaque of Peyronie's disease has been a topic of interest among some researchers. A small trial from the early 1990's demonstrated some modest improvements in Peyronie's disease after treatment with collagenase injections. A larger trial is currently underway. The role of collagenase in the treatment of Peyronie's disease is at this time unclear.
Other investigative therapies:
Many alternative methods for treating Peyronie's disease have been reported. Examples include high-intensity focused ultrasound, radiation therapy, shock-wave treatment, topical verapamil, hyperthermia, and many others. While the scientific rationale for these other approaches is sound, at this time there is not enough data to support their use outside of a research setting at this time. A recent pilot study (2007) using external penile traction therapy demonstrated measured improvements in girth, length and curvature after 6 months of daily stretch therapy lasting from 2-8 hours per day.
Surgical Treatment of Peyronie's Disease:
Surgery is reserved for men with severe, disabling penile deformities that prevent satisfactory sexual intercourse. Most physicians recommend avoiding surgery until the plaque and deformity have been stable and the patient pain-free for at least six months. An evaluation of the penile blood supply using injection of erection producing medications is often done prior to any surgery. A penile ultrasound may be performed at the same time. These two tests permit assessment of whether or not the man has significant ED and may also provide important anatomical information that will help guide the choice of surgical procedure.
There are three general approaches to surgical correction of Peyronie's disease:
Procedures that shorten the side of the penis opposite the plaque/curvature
These procedures are generally safe, technically easy, and carry a low risk of complications such as bleeding or worsening erectile function. One particular disadvantage of these approaches is that they tend to be associated with some loss of penile length. For this reason shortening procedures are generally preferred in men with mild or no ED, mild to moderate curvatures, and long penises.
Examples of this type of procedure include the Nesbit procedure, in which small pieces of tunica tissue are excised from the convex (the side opposite the direction of the curvature) side of the penis. The edges of the tunica are then sewed together, causing penile straightening. There are several variations of the Nesbit procedure including tunica plication and the 16 dot penile plication, in which sutures are used to "cinch" (or bunch) together a segment of the tunica on the convex side of the penis.
Procedures that lengthen the side of the penis that is curved
These procedures are indicated when the curvature severe or there is significant indentation causing a hinge-effect or buckling of the penis due to the narrowed segment in the penile shaft. In these cases, the surgeon incises (cuts) the plaque to release tension. In some cases a segment of the plaque may be removed. After the plaque has been incised, the resulting hole in the tunica must be filled with a graft. These procedures can correct severe curvatures, in most cases without significant shortening of the penis. Unfortunately, this type of procedure is technically challenging and carries a risk of worsening erectile function. Therefore, lengthening/grafting procedures are typically not recommended except in cases of severe deformity in men with adequate erectile function at baseline.
A number of different materials are available as grafts and the choice of graft should be based on patient and surgeon preference.
Autologous tissue grafts: These grafts are made of tissue taken from another part of the patient's body during surgery. Examples of grafts used for Peyronie's disease include saphenous vein (taken from leg) and temporalis fascia (harvested from behind the ear). Autologous grafts are living tissue and generally incorporate into surgical sites much more readily than some other materials. Disadvantages of autologous grafts include the need for a second incision to harvest the graft.
Non-autologous allografts: These grafts are sheets of tissue that are commercially produced using human or animal sources. Prior to use they are sterilized and processed to remove all potentially infectious particles. These grafts are gradually digested by the body but they serve as scaffolds for the growth of fresh healthy tissues produced by the patient's own body. Allografts are uniformly strong, easy to work with and readily available because they are "off-the-shelf" in the operating room. They are generally well tolerated by most patients and negate the need for a second incision although they are somewhat expensive.
Synthetic inert substances: Materials such as Dacron® mesh or GORE-TEX® are seldom used for Peyronie's surgeries in the modern era. When used as a tunical grafts these substances often cause significant recurrent fibrosis and hence worsening of Peyronie's type deformities.
Placement of penile prosthetic devices
Placement of an inflatable penile pump or malleable silicone rods inside the corpora is a good treatment option for men with Peyronie's disease and moderate to severe erectile dysfunction. In most cases, implanting such a device alone will straighten the penis, correcting its rigidity. When device placement alone does not sufficiently straighten the penis, the surgeon may further straighten the penis by cracking the plaque against the rigid prosthesis or by incising the plaque and subsequently covering the incision with a graft material.
What can be expected after surgery for Peyronie's disease?
A light pressure dressing is typically left on the penis for 24 to 72 hours after the surgery to prevent bleeding and hold the repair in place. In some cases, patients will wake up with a catheter in the bladder but this is usually removed in the recovery room. Most patients are discharged later the same day or the following morning. The patient is also often given several days of antibiotics to reduce the risk of infection and inflammation and a pain medication for discomfort. In most cases surgeons recommend not engaging in sexual activity for at least 4-6 weeks after surgery, longer in some cases of complex repairs.