Evaluation of penile hemodynamic status and adjustment of treatment alternatives in Peyronie's disease

Tibet Erdogru, Murat Savas, Namık Yılmaz, Mustafa Faruk Usta, Turker Koksal, Mutlu Ates, Mehmet Baykara

Asian J Androl 2002 Sep; 4: 187-190           

Keywords: Peyronie's disease; sexual function; penile vascular status; color Doppler ultrasonography

Abstract

Aim: Erectile dysfunction may be observed in up to 80 % of patients with Peyronie's disease. An objective evaluation of the erectile function is attempted to work out in patients with Peyronie's disease. Methods: Penile deformity, sexual function and penile vascular status were analyzed in 123 patients with Peyronie's disease, who had not received any pertinent treatment. Results: Penile deformity, palpable plaque and pain on erection were seen in 112 (91 %), 97 (78.8 %) and 27 (21.9 %) of the 123 patients, respectively. Of the 76 patients evaluated by color Doppler ultrasounography, veno-occlusive dysfunction as the vascular component for erectile dysfunction was found in 17 (22.3 %), arterial insufficiency in 10 (13.1 %) and a mixed picture in 23 (30.2 %). Conclusion: The documentation of penile erectile function and the determination of the vascular status using color Doppler ultrasonography can guide the appropriate therapeutic choice.

Induratio penis plastica, characterized by fibrotic plaque formation in the compliant tunica albuginea of the penis, is known as the Peyronie's disease described in the 18th century by Francois de la Peyronie [1]. Penile curvature or deformity, pain and palpable plaques or combinations of the above can be observed as clinical manifestations of the disease. The degree of impaired sexual potency among patients with Peyronie's disease has varied from 30 %-80 % [2,3]. The pathophysiology of erectile dysfunction in this process remains controversial despite some investigations of this phenomonen [4]. We evaluated patients with Peyronie's disease before treatment for their penile hemodynamic status, using penile color Doppler ultrasonography (CDU), and discuss their therapeutic approaches depending on the penile vascular status.

2 Materials and methods

2.1 Patients

In 123 patients (mean age 55.110.1 years, range 40-75) with Peyronie's disease (mean duration of symptoms 22.720 months, range 1 to 60), the detailed sexual history and physical examination (plaque localization and its dimensions) were assessed. In addition, CDU and nocturnal penile tumescence (NPT) were observed in 76 patients. None of the patients had previously received treatment for Peyronie's disease.

2.2 Examinations

Firstly, ultrasound scanning was performed when the penis was flaccid to observe the corporeal anatomy and echogenic structure and clarify the relation with caver-nosal arteries. Then CDU (Aspen Acuson 10 MHz imag-ing, 7 MHz pulsed Doppler linear probe in 95, and Toshiba SSA 5mHz linear probe in 28 patients) was performed with patients in the supine position. Electronic cursors were used to measure the penile peak systolic blood flow velocity (PSV) and end-diastolic blood flow velocity (EDV) and the resistance index (RI) of cavernosal arteries at the proximal penile shaft after intracorporeal injection (ICI) of 10mg of Prostaglandine E1 and 2.5 mg of Phentolamine mesylate in combination. The measurement of arterial blood flow velocity in the flaccid state is not accurate in the functional evaluation of penile vascular system and was therefore not done. Color imaging was performed to examine the blood flow in cavernous arteries in the initial phase of erection. Penile vascular assessment with CDU was performed as previously described [5,6,7].

All patients were inquired about the erectile response to vasoactive agents during CDU compared to erections achieved at home in privacy to assess levels of test-associated anxiety. If there was no significant difference in the quality of erection, we did not redose to achieve maximal cavernosal arterial and smooth muscle relaxation. If there was difference in the degree of erectile quality, we performed secondary ICI and sexual stimulation. An EDV >5 cm/sec and a RI <0.95 were considered to be diagnostic for veno-occlusive dysfunction (VOD). A PSV value of >30 cm/sec was taken to be indicative of a normal penile arterial system if the person could achieve an erection as good or better than his erectile capacity at home [7].

Data were expressed in meanSD, if applicable. One-way analysis of variance was used to compare the differences between groups. P<0.05 was considered significant.

3 Results

Penile deformity, palpable plaque and pain (during sexual intercourse) were seen in 112 (91 %), 97 (78.8 %) and 27 (21.9 %) patients, respectively. The distribution of the patients according to the type of penile deformity is shown in Table 1. Other risk factors apart from Peyronie's disease for erectile dysfunction included smoking 42 (34.1 %), diabetes mellitus 25 (20.3 %), and hypertension 14 (11.3 %). These are shown in Table 2.

Table 1. Distribution of patients depending on types of penile deformity.

Table 2. Risk factors for erectile dysfunction in addition to Peyronie's disease (some patients have more than one risk factors).

Forty-seven of 123 patients who were in the unstable phase of the disease (duration of symptoms =12 months) opted for medical treatment consisting of oral therapy with vitamin E plus colchicine without evaluation of penile vascular status. However, only 28 (59.5 %) had sexual impotence in their sexual history. Six of these 28 patients identified a problem with vaginal penetration as sexual dysfunction due to severe penile deviation or deformity in spite of achieving an adequate erection.

Of the remaining 76 patients who were in the stable phase of Peyronie's disease (52 had erectile dysfunction in their sexual history), who were evaluated by ultrasono-graphy, fibrotic tissue structures were located within the tunica albuginea and/or corporeal bodies in 67 (88 %), whereas in the remaining 9 (12 %) no ultrasono-graphic abnormality was observed at the same site of the plaques. According to the diagnostic criteria for CDU arteriogenic insufficiency, VOD, mixed type impotence and normal penile vascular system was found in 10 (13.1 %), 17 (22.3 %), 23 (30.2 %) and 26 (34.2 %) patients, respec-tively. The mean age of the patients and mean values for PSV, EDV and RI for the right and left cavernosal arteries for each type of vascular status are shown in Table 3.

Our therapeutic approaches included medical treatment in 65 patients in the form of combined vitamin E (600 IU per day) and colchicine (initial dose between 0.5 and 1 mg/day, maximum dose 2 mg daily), vacuum device in 8, penile prosthesis in 22 and penile reconstructive surgery in 19. We did not recommend self ICI therapy owing to its high risk of corporeal fibrosis [8]. Evidence of organic impotence and normal penile neuro-vascular system were demonstrated by means of NPT in those patients receiving either a penile prosthesis (n = 22) or penile reconstructive surgery (n = 19) groups. Eight patients who were in the stable phase of the disease (duration of symptoms >12 months) did not complete our diagnostic procedures and a treatment option was not offered.

Interestingly, one patient who coincidentally had systemic idiopatic myositis and was treated with 25 mg/day of prednisolone for this systemic inflammatory disease showed a complete resolution of the fibrotic plaque and erectile dysfunction after 6 months.

The elasticity of the involved area of the tunica albuginea in Peyronie's disease is markedly reduced by the fibrotic tissue reaction, thus causing penile bending during the erection. This is sometimes accompanied by pain [9]. Vaginal penetration is hindered due to severe penile deformity or decreased penile rigidity (as a result of hemodynamic abnormality). The penile hemodynamic status is a key factor in the selection of an appropriate treatment modality in these patients. For patients with organic erectile dysfunction and Peyronie's disease, penile prosthesis implantation combined with reconstruction are usually considered, whereas in patients with normal penile hemodynamics and erectile rigidity problems, medical treatments, including para-amino benzoic acid, vitamin E or colchicine, or penile reconstructive surgery are generally instituted [10,11]. In addition to the oral medi-cation, intralesional injection therapy consisting of interferon alpha 2B or verapamil can be performed during the inflammatory (unstable) phase of the disease [12].

Moreover, it may be emphasized that an improvement can be achieved in cases of mild to moderate corporeal VOD by performing penile reconstructive surgery combined with penile venous ligation. However, it is believed that in these patients global abnormalities of corporeal smooth muscle or fibroelastic component of the trabeculae may exist and, therefore abnormal venous drainage may recur into other venous system (especially spongial venous drainage) after the initial operation [13,14]. In addition, many procedures with non-prosthetic penile reconstruction may result in postoperative impotence as a common cause of treatment failure [15,16]. Thus, it is obvious that precise knowledge about the penile erectile function and penile vascular system is the most important factor in the determination of therapeutic opinions.

In our series we injected PGE1 combined with phentolamine as an alpha-blocker agent and asked the patients to perform tactile self-genital stimulation in privacy (to prevent the inhibitory effect of sympathetic activity and optimize penile vascular and corporeal smooth muscle relaxation) in an effort to obtain the best quality erection and the most reliable dynamic vascular response by CDU. CDU has some advantages compared to dynamic infusion cavernosometry and cavernosography (DICC) and cavernosal artery systolic occlusion pressure (CASOP) measurement because it is significantly less invasive and self-genital stimulation can be performed to prevent the inhibition of smooth muscle relaxation due to sympathetic overactivity. Moreover, color imaging gives detailed anatomical information about the dorsal and cavernosal arterial anastomoses and their relations with the fibrotic structures. These perforators between penile dorsal artery and cavernosal artery can be found in 32% of the patients and fibrotic structures might be crucial for cavernosal arterial blood flow [17]. This information is important in penile reconstructive approaches, especially in patients with dorsal penile curvature and hour-glass deformity.

In our series of 76 patients VOD was determined in 40 patients (52.6 %) and arterial insufficiency in 33 (43.4 %). Impairment in veno-occlusive function can be secondary to structural alteration in the fibroelastic component of the sinusoidal structure, resulting in a loss of compliance and inability to expand the trabeculae against tunica albuginea. This subsequently leads to the inability to compress subtunical venous system and activate the occlusion mechanism. This rate is similar to the findings of Kadioglu with 50 % [3] and Lopez with 59 % [18], while it is lower than that reported by Jordan and Angermeier (76 %) [15]. The difference between the rates might be explained by Jordan and Angermeier's diagnostic technique (DICC and CASOP) which was more invasive than CDU and may have resulted in sympathetic overactivity.

Our rate of penile arterial insufficiency was similar to the 48 and 40 % rate reported by Kadioglu and Monto-rosi, respectively [3,19]. Jordan and Angermeier [15] noted a 44 % incidence of decreased arterial inflow (defined as a cavernous artery systolic occlusion pressure of less than 90 mmHg). This rate is also similar to our penile arterial insufficiency ratio. However, their VOD rate was different (76 % vs 61.1 %) and the differentiation has been explained by sympathetic overactivity due to the invasive diagnostic procedure. The reason for the similarity in arterial component ratio between the two studies in spite of the different rates in VOD owing to inhibitory effect of sympathetic overactivity not only on corporeal but also on penile arterial smooth muscle structures, might be explained by their less rigorous criteria for the evaluation of the penile arterial system. If less than 35 mmHg CASOP values were considered for normal penile arterial system as algorithm of the patient evaluation. On the other hand; CDU allows a thorough determination of the structure of corpora cavernosa and tunica albuginea.

We conclude that cavernosal arterial insufficiency and/or corporeal veno-occlusive dysfunction can be detected in a large percentage of patients with Peyronie's disease if an adequate sexual history is obtained and specific diagnostic device is used as described by Kadioglu [3] and Tefekli [20]. During the inflammatory (unstable) phase, medical treatment should be the first choice; the documentation of penile erectile function and vascular status can safely guide the appropriate surgical therapeutic choice in Peyronie's disease during the chronic phase of the disease or stating a stable penile deformity for at least 6 months.

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Correspondence to: Dr. Tibet Erdogru, Associate Professor, Department of Urology, Akdeniz University Faculty of Medicine, Dumlupinar Bulvari, Kampus 07059, Antalya-Turkey.
Tel: +90-242-227 4480 Fax: +90-242-227 4482
E-mail: terdogru@med.akdeniz.edu.tr
Received 2002-03-06      Accepted 2002-06-07