1.Non-surgical treatment
Sclerosis is a progressive disease that may resolve or heal spontaneously in some patients, and is observed to be active for one year, during which time it can be treated conservatively according to Ralph et al. Once fibrosis, calcification, or ossification occurs, it becomes irreversible, and neither medication nor physical therapy is effective.
Vitamin E (200mg, 3 times daily) Wang Weidong, Department of Urology, Affiliated Hospital of Shandong University of Traditional Chinese Medicine
Vitamin E, a free radical scavenger with antioxidant properties, was first published by Scardino et al. in 1948 in an uncontrolled study of 23 participants, with the following results: 78% of patients showed improvement in penile curvature, 91% had a reduction in hard nodes and a complete disappearance of pain. The next trials did not yield the favorable results described above. In particular, in a placebo-controlled study with 40 patients, only 35% of the patients showed improvement in pain and a small effect on the size of the nodules and penile curvature. Nevertheless, vitamin E is widely used because it is inexpensive and has no side effects.
Para-aminobenzoic acid (POTABA, 12g, once daily for 3 months)
POTABA reduces 5-hydroxytryptamine levels by increasing monoamine oxidase activity, inhibits abnormal fibrous proliferation, and improves tissue application of oxygen. This use was first reported in a study of 21 patients in 1959: all had a reduction in pain, 82% had an improvement in penile curvature, and 76% had a reduction in sclerosis. However, the only placebo-controlled, double-blind study of 41 patients did not show statistical significance, and the use of POTABA is limited, including a maximum dose limit (12 grams per day), high cost, and serious gastrointestinal side effects, and is therefore not recommended.
Tamoxifen
Tamoxifen is thought to promote the release of TGF- from fibroblasts, which plays an important role in the regulation of immune response, inflammation and tissue repair by inactivating macrophages and T lymphocytes. In the earliest study of 36 people treated with tamoxifen, 20 mg used twice daily for three months, 20 patients (55%) showed improvement, none had worsening, and there was a very significant improvement early in the disease (less than 4 months from onset). Biopsies were taken from the hard nodes of 12 patients with painful penile sclerosis, and 6 of the 8 who could measure acute inflammatory exudate responded very well to tamoxifen, while those who did not measure inflammatory exudate did not improve. CONCLUSION: Tamoxifen is beneficial in early inflammatory penile sclerosis. These results were not supported in the placebo-controlled trial of 25 participants, but the vast majority of patients in this trial had a long duration of disease in which any drug treatment was considered to be minimally effective.
Colchicine
Colchicine has an anti-inflammatory effect, affects collagenase activity, reduces collagen synthesis and inhibits fibroblast proliferation. The recommended dose is 0.6-1.2 mg twice a day for 3 months, and Kadioglu initiated a study of oral colchicine in 60 patients with penile sclerosis in the acute phase. Over the next 10.7 months, 30% of the patients had improved penile deformity and 95% had reduced pain. The best results were seen in patients with no cardiovascular risk factors, in the first six months of life, and in patients with a penile curvature of less than 30 degrees.
Verapamil (10mg in 10ml saline x 12)
Verapamil acts as a calcium channel antagonist to reduce intercellular calcium ion concentration and increase collagenase activity. It also inhibits fibroblast proliferation, and Levine et al. reported that verapamil was used in the treatment of penile sclerosis from 1994 and showed significant effects in a longer study at the same institute in the following years. Using a multipoint puncture technique, 10 mg of verapamil diluted to 10 ml was injected through the sclerotome once every two weeks for a total of 12 injections, with 60% of patients showing improvement in penile curvature and 71% showing improvement in sexual function. The main side effect is bruising, and this is currently the most commonly used topical treatment for penile sclerosis injuries
Interferon (Interferon)
Interferon reduces extracellular collagen synthesis and increases collagenase synthesis, softening the plaque and improving symptoms. For bending improvement is mild, with an average improvement of 20 degrees. Use is limited due to its high cost and cold-like side effects.
Extracorporeal shock wave therapy (ESWT)
Bellorofonte et al. have been using ESWT for penile sclerosis since 1989 and have reported that it is effective in reducing penile curvature and pain, as well as improving sexual function. Lebret et al. reported a recent study using the siemens lithotripter to treat 54 patients with penile sclerosis (3000 Hz). 91% of patients had reduced penile pain and 54% had improved penile curvature with a mean reduction of 31 degrees. Although the early results were good and well tolerated by the patients, the long-term efficacy needs to be observed.
Radiation therapy (13.5 GY)
Incrocci et al. reported that low-dose radiation therapy can be used to treat patients with persistent painful penile sclerosis, but it is not recommended for patients younger than 60 years of age because of the high incidence of ED (50%) after this treatment.
2.Surgical treatment
Indications for surgical treatment of penile sclerosis are: failure of conservative treatment; severe curvature of the penis during erection; accompanied by erectile dysfunction. The timing of surgery usually waits for the lesion to stabilize, usually 1 year after the onset.
The surgical methods are: penile white membrane folding; plaque excision, repairing the defect with skin, vein or fascia; plaque excision, skin and vein graft repairing the defect; penile sclerosis with erectile dysfunction, penile prosthesis implantation can be done while correcting the penile flexion deformity.
Penile white membrane folding
Nesbit’s original method was an elliptical excision of the contralateral flange and suture closure. During the period 1977-1992, 359 patients underwent this procedure and 295 (82%) had good results with successful intercourse. The main disadvantage of this procedure is the partial shortening of the penis, but in reality most of it does not affect intercourse. The satisfaction rate is 38%-100%.
Plaque excision
Sclerosing plaque excision was once the standard of care, but the pathologic process of penile sclerosing plaque often extends beyond the plaque, and removal of a large portion of the white membrane can impair erectile function. a study of 418 patients reported by Austoni et al. showed that 17% of patients required further surgery to correct penile curvature and 20% had erectile dysfunction after using the plaque excision skin graft approach. Due to the high incidence of erectile dysfunction, graft contracture, late recurrence and poor long-term results, plaque excision with grafting is rarely done at this time.
Plaque excision
Because plaque excision is prone to erectile dysfunction, plaque excision with graft patching is currently advocated internationally for the treatment of penile sclerosis. Glebard and Hayden 1991 recommended this procedure, and Leu et al. reported that in 112 patients with penile sclerosis who had saphenous vein grafts, 95% of the patients had successful extension, with 13% of those who had sexual intercourse complaining of reduced erectile function. The specific steps are: make parallel incisions on both sides of the penile corpus cavernosum, cut through Bucking’s fascia, free the vascular nerve bundle on the dorsal side of the penis, retract, expose the plaque and the surrounding white membrane, make a transverse H-shaped incision in the plaque, then take part of the saphenous vein and dissect it into a sheet vein, depending on the size of the defect, several veins may need to be combined and sutured, with the vein patch area slightly larger than the defect and the endothelial surface of the vessel facing the erectile tissue, using 3-0 PDS interrupted sutures. Commonly used grafts are mainly self-tissue, such as skin, vein wall, testicular sheath, and rectus abdominis tendon membrane.
Patients with erectile dysfunction that is not responding to pharmacologic treatment for sclerosis are commonly treated with prosthetic implants. In most patients with mild to moderate curvature, the penile prosthesis can be inserted to straighten the penis without additional surgery, but in patients with severe flexion deformity, a mesh incision must be made in the white membrane of the penile plaque before implanting the prosthesis to make the penis completely straight.