Induratio penis plastica

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Classification according to ICD-10
N48.6 Induratio penis plastica
ICD-10 online (WHO version 2019)

The Peyronie (IPP, latin induratio , induration ' , also Peyronie's disease ) is a connective tissue disease of the penis , when it fibrinous to form plaques comes shaft of the penis. The IPP is also counted among the superficial fibromatoses . Scar tissue, especially in the area of ​​the tunica albuginea , the connective tissue covering the erectile tissue , can lead to abnormal penile curvature with retractions, pain during erection and even erectile dysfunction with psychological problems. A number of conservative and surgical therapy options are available.

Symptoms

Patient with dorsal penile curvature in IPP
Laterally curved penis with IPP
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The scar tissue causes the penis to bend “unnaturally” during erection (mostly without a remembered injury), usually upwards, but also downwards or to one side (sometimes up to 90 °). IPP can, but does not have to, lead to (severe) pain during erection. If the plaque expands more circumferentially than longitudinally, the result is an hourglass-shaped constriction or a bottle neck-shaped tapering. Depending on the area affected, these symptoms can also occur in combination. Although it is usually assumed that the IPP is accompanied by penile curvature, there are also cases in which there is only retraction or hardening of the penis shaft. The scar tissue on the flaccid penis can usually be felt as plaque.

Due to the displacement and displacement of vessels and nerves, there is, in some cases, direct or with some delay, a reduction in sensation, especially on the penis head. In severe cases, severe curvature, decreased sensation and pain during erection can lead to erectile dysfunction .

Due to the drama of its symptoms and the effects on sexuality and partnership, IPP can often cause secondary psychological problems, such as B. declining self-esteem, depressed mood and irritability.

causes

The pathomechanism of the disease has not yet been conclusively clarified. Microtrauma within the tunica albuginea is believed to be the likely cause. Changes in the collagen metabolism or a bacterial genesis have not yet been proven

Some genetic changes related to IPP have already been demonstrated. In particular, IPP and Dupuytren have genetic changes on chromosome 7 (WNT2 locus) and microdeletions on chromosome 3 in common. However, why the disease breaks out in some with genetic predispositions and not in others has not yet been conclusively clarified.

In IPP patients, there are similar changes (contractures) in Dupuytren's hands in 30–40% . In addition, Ledderhose's disease , liver cirrhosis , rheumatic diseases , tympanosclerosis, penile or urethral trauma, urethritis , diabetes mellitus and Paget's disease are associated with the disease.

The role of the use of beta blockers , nicotine or metabolic diseases cannot currently be conclusively assessed. However, smokers and former smokers are 16 times more likely to develop IPP.

course

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Since considerable shear forces act on the transition zone between diseased, firm tissue and healthy, flexible tissue with every erection and especially during sexual intercourse, small tears in this transition zone occur again and again. Slowly and over many years, an IPP plaque continues to develop due to the mechanical irritation. This must be differentiated from the progression of the causative disease.

The natural course is progressive in the majority of cases. Gradual spontaneous improvements are seldom to be expected (around 20%) and are only very rarely described after definitive plaque formation.

In the final stage, in up to 27% of cases, calcifications and metaplastic bone formation can occur in addition to scars.

diagnosis

The urologist can generally make a diagnosis by taking a medical history and palpating the plaques on the flaccid penis. A penile ultrasound can help reveal plaques, estimate their size, and rule out differential diagnoses. The x-ray imaging of the erectile tissue with contrast medium used in earlier years is medically without additional therapeutic effect and should be avoided because of the radiation exposure of the penis and testicles.

treatment

Conservative treatment

Non-surgical therapy is difficult. Most patients do not turn to a urologist until they feel induration. However, these hardenings represent an advanced stage of the disease. At this point, the original tissue has perished and a scar has formed. In particular, if calcifications have already occurred, the success of drug therapy is low. The success of conservative therapies is also limited because the disease mechanism has not been conclusively elucidated.

In Germany, potassium paraaminobenzoate (Potaba) is approved for systemic therapy, although the mechanism of action is not known. Other preparations that are used off-label are vitamin E , carnitine , tamoxifen and colchicine . Also pentoxifylline and tadalafil come in systemic therapy for the application.

Verapamil , interferon , collagenase and cortisone can be used intralesally . In addition, radiation therapy , iontophoresis , extracorporeal shock wave therapy and vacuum pumps have been used so far

If conservative treatment does not improve, surgical treatment is possible.

Operative treatment

Surgical correction is not a causal therapy and cannot restore the original condition before the disease. It should only be carried out if the psychological strain is very high (e.g. impossibility of sexual intercourse). Before an operation, there should be a stable phase between 3 months and 1 year. In the active phase of the disease, there is a risk of further plaques appearing. The safety margin to the occurrence of the illness is also based on the fact that IPP is a benign disease and in this respect a generous safety margin to an operation does not harm the patient. Especially since the operation can involve risks such as shortening of the penis, permanent erectile dysfunction, unsatisfactory plastic results, plaque recurrence and the need for circumcision .

Patients who have unrealistic expectations of surgery may be dissatisfied with the outcome.

Surgical therapy is divided into simpler procedures - which do not remove the focus of the disease itself, but treat one of the possible symptoms - and more complex procedures to eliminate the cause.

Symptom treatment

  • Nesbit technique: This technique is used to straighten the penis if the penis is curvature. With this technique, which has existed since 1965, the diseased part is left and the healthy opposite side is damaged (shortened, duplicated) in order to straighten the penis again. An artificial plaque is created on the side opposite the focus of the disease by means of a gathering seam. Both sides of the penis are shortened evenly and the penis is straight again. Depending on the angle of curvature and the initial length, the penis can be shortened by up to 8 cm and often pain at the gathered seam. Before performing this technique, it must be objectively discussed with the patient whether the inevitable shortening of the penis with possible pain during erection would represent an improvement over the curvature.
  • Plaque separation cuts: In this procedure, also known as the incision technique or the technique of thinning, the plaque is not removed, but only incised and covered with replacement tissue (leg vein, collagen fleece, inert connective tissue).

Removal of the IPP plaque

Plaque removal: The complex, reconstructive procedure has existed since 1941. The IPP plaque is removed and the damaged erectile tissue is rebuilt. In contrast to the Nesbit technique, there is no significant penile shortening with the curvature correction. In specialized centers, biocompatible collagen is used for reconstruction, which the body can convert into new erectile tissue. This can offer advantages over the use of own tissue. Due to the degree of difficulty and the high demands placed on the surgeon, the operation can only be offered by a few centers worldwide with sufficient experience. In contrast to the simpler Nesbit technique and the plaque separation cut, plaque removal is uneconomical for many clinics due to the high level of effort and risk, so that this technique has not been able to gain general acceptance.

history

The phenomenon of the induratio penis plastica was depicted in Pompeii in 79 AD in grave goods and in Greek sculptures. In 1561 the clinical picture was mentioned by the anatomists Fallopius and Vesalius and described in 1687 in Les Emphemirides des Animaux de la Nature as a “benign fibrous tumor emanating from the divisions of the corpora cavernosa”. François Gigot de la Peyronie , a doctor at the court of Louis XV. , described the disease in 1743, which has since been described as Peyronie's disease, or in medical language Induratio penis plastica (IPP).

literature

Web links

Commons : Bent penis  - album with pictures, videos and audio files

Individual evidence

  1. ↑ Laurence A Levine: Peyronie's disease and erectile dysfunction: Current understanding and future direction . In: Indian Journal of Urology . 22, No. 3, 2010, pp. 246-50. doi : 10.4103 / 0970-1591.27633 .
  2. ^ Health Information on Peyronie's Disease . In: nih.gov . National Institute of Diabetes and Digestive and Kidney Diseases, USA. Archived from the original on October 20, 2007. Retrieved March 23, 2018.
  3. ↑ Peyronie's disease . Mayo Clinic. Archived from the original on May 22, 2013. Retrieved December 3, 2007.
  4. ^ Psychological impact of Peyronie's disease: a review . In: The Journal of Sexual Medicine . 10, No. 3, March 2013, pp. 653-660. doi : 10.1111 / j.1743-6109.2012.02999.x . PMID 23153101 .
  5. ↑ a b c d R. Zimmermann: Pathophysiology of Induratio penis plastica (IPP) Current state of knowledge . (PDF; 782 kB) In: Journal for Urology and Urogynaecology . 15, No. 2, 2008, pp. 22-29.
  6. ↑ Sultan Al-Thakafi, Naif Al-Hathal: Peyronie's disease: a literature review on epidemiology, genetics, pathophysiology, diagnosis and work-up. In: Translational Andrology and Urology. 5, 3, June 2016, pp. 280–289, PMC 4893516 (free full text).
  7. ↑ a b Induratio penis plastica (IPP) Peyronie's disease (Peyronie's disease) and penile curvature . European Institute for Sexual Health (EISH). Private Institute for Urology, Andrology and Sexual Medicine. Retrieved March 23, 2018.
  8. ^ GH Dolmans, PM Werker, IJ de Jong, RJ Nijman, C Wijmenga, RA Ophoff: WNT2 locus is involved in genetic susceptibility of Peyronie's disease. In: Journal of Sexual Medicine. 9, No. 5, (2012), pp. 1430-1434, PMID 22489561 .
  9. ↑ Online textbook of urology for doctors . In: urologielehrbuch.de . Dirk Manski. Retrieved March 24, 2018.
  10. ↑ Amin Z, Patel U, Friedman EP, Vale JA, Kirby R, Lees WR: Color Doppler and duplex ultrasound assessment of Peyronie's disease in impotent men . In: Br J Radiol. . No. 785, May 1993, pp. 398-402.
  11. ↑ a b Klotz T, Mathers J, Sommer F: Induratio penis plastica - a secret disease . In: Deutsches Ärzteblatt . No. 104, March 2007, pp. A-263 / B-234 / C-229.
  12. ↑ a b c Herbert Schorn: Induratio penis plastica How promising are conservative therapies? . (PDF; 402 kB) In: BJUI . February 2010, pp. 4–7.
  13. ↑ Safarinejad MR, et al .: A double-blind placebo-controlled study of the efficacy and safety of pentoxifylline in early chronic Peyronie's disease . In: BJUI . 106, No. 2, 2010, pp. 240-248. doi : 10.1111 / j.1464-410X.2009.09041.x .
  14. ↑ Dell'Atti L: Tadalafil once daily and intralesional verapamil injection: A new therapeutic direction in Peyronie's disease . In: Urol Ann . 7, No. 3, 2015, pp. 345-349. PMID 26229323 .
  15. ↑ Ciociola F, Colpi GM: Peyronie's disease: a “triple oxygenant therapy” . In: Arch Ital Urol Androl. . 85, No. 1, 2013, pp. 36-40. PMID 23695404 .
  16. ↑ Induratio penis plastica - Acquired penile curvature . In: porst-hamburg.de . European Institute for Sexual Health (EISH). Private Institute for Urology, Andrology and Sexual Medicine. Retrieved March 24, 2018.
  17. ↑ Raheem AA, Garaffa G, Raheem TA, Dixon M, Kayes A, Christopher N, Ralph D: The role of vacuum pump therapy to mechanically straighten the penis in Peyronie's disease . In: BJUI . 106, No. 8, 2013, pp. 1178–1180. PMID 20438558 .
  18. ↑ FE Kuehhas, P. Weibl, T. Georgi, N. Djakovic, R. Herwig: Peyronie's Disease: Nonsurgical Therapy Options. In: Rev Urol. 13, 2011, pp. 139-146, PMID 22110397 .
  19. ↑ Sternig P, Riedl C: Guideline Induratio penis plastica . (PDF; 625 kB) In: Journal for Urology and Urogynaecology . 15, no. Special issue 6, 2008, pp. 10–11.
  20. ^ Gerster Susanne: On the therapy of induratio penis plastica . Munich 2005 ( uni-muenchen.de [PDF; 883 kB ]).
  21. ^ François de la Peyronie: Sur quelques obstacles, qui s'opposent à l'éjaculation naturelle de la semence . In: Mémoires de l'Académie royale de médecine . Paris 1743, p. 425-434 .