Medical therapies can stabilize Peyronie’s disease
MONTREAL — There is no cure in sight for Peyronie’s disease, but medical management can offer stabilization in the early phase of this connective tissue disorder, Dr. Laurence A. Levine said at a congress sponsored by the Canadian Society for the Study of the Aging Male.
The condition that was first reported by French surgeon Francois de la Peyronie in 1743 is characterized by the development of a penile plaque in the tunica albuginea of the corpora cavernosa. Deformities including deviation, shortening, and an hourglass-like shape can result, and during the early inflammatory phase of the disease, patients can experience pain with erection.
Peyronie’s disease is a disorder of wound healing that occurs in a genetically susceptible patient, probably in response to some inciting event such as minor trauma, Dr. Levine said.
A proliferative fibrotic reaction results in the development of an inelastic scar. Disturbances of collagen and elastin are seen, along with overexpression of cytokines such as transforming growth factor [beta] and imbalances of nitric oxide and nitric oxide synthase.
The accepted standard of treatment is surgery, but that must wait until the disease stabilizes and pain no longer is present. In the interim, and for patients unwilling to undergo surgery, medical therapies that are based on current thinking about pathogenesis can help many patients.
“In a survey we did in Chicago, the most commonly used remedies were vitamin E and Potaba,” said Dr. Levine, of the department of urology at Rush Presbyterian–St. Luke’s Medical Center, Chicago. Yet studies have found no benefit for vitamin E and only reduction in plaque size for the antifibrotic Potaba (aminobenzoate potassium). Colchicine, tamoxifen, and carnitine also have been tried and found ineffective.
“The two oral agents I use are pentoxifylline and L-arginine,” he said. Pentoxifylline, given in a dosage of 400 mg three times a day, is inexpensive, has low toxicity, and appears to have antifibrotic activity. L-arginine is an over-the-counter amino acid that is a precursor to nitric oxide and has been shown in vitro to have antifibrotic activity.
The dosage is 500 mg twice a da).
Another approach is injection therapy. Numerous agents such as steroids and superoxide dismutase have been tried and found to be either ineffective or toxic. “‘Of all the agents we have for injection, verapamil makes the best scientific sense,” Dr. Levine said at the meeting, which was cosponsored by the International Society for the Study of the Aging Male. Studies have shown that verapamil can reduce fibroblast proliferation, resulting in reduced production of collagen and other extracellular matrix macromolecules, he said.
Uncontrolled studies have suggested that up to 60% of patients can be helped with verapamil injections. “I use a multiple puncture technique with a short, 5/8 inch, 25-gauge needle. You don’t want to use a smaller needle for fear of snapping it off in the scar,” he said. Verapamil 10 mg is mixed with 6 cc of saline to give a total volume of 10 cc, and the usual course of treatment is 12 injections at 2-week intervals.
Blood pressure should be monitored, particularly after the first injection. “I have treated 1,000 men with this approach and have had no cardiovascular side effects,” he said.
Intralesional interferon has been used with some degree of benefit, but “it does not appear to be as robust as what we see with verapamil,” he said.
Topical verapamil also is popular and manufacturers are making substantial claims about its efficacy, but there is no published evidence of benefit, according to Dr. Levine. It does not penetrate into the tunica albuginea, he said.
Medical therapies also Can be used in conjunction with mechanical stretching. Since natural history studies have shown that 50% of patients will get worse with no treatment, it’s important to treat the disease early, he added.
BY NANCY WALSH
New York Bureau
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