Cavernous fibrous Peyronie's disease

　　The causes of penile fibrous cavernitis mainly include trauma, genetic factors, and immune factors, as follows:

　　First, trauma

　　Trauma is a promoting factor for Peyronie's disease. Many authors have elaborated on the fact that penile trauma caused by sensitive individuals during sexual intercourse can develop into Peyronie's disease. Kadioglu et al. reported that Peyronie's disease is related to penile vascular disease and erectile dysfunction: the author investigated 136 patients with Peyronie's disease, and 76.5% had penile vascular abnormalities; among those who reported a history of erectile dysfunction, 87.5% had penile vascular abnormalities, and arterial lesions lead to decreased penile rigidity, making them prone to Peyronie's disease.

　　Some patients develop Peyronie's disease after transurethral resection of the prostate (TURP), and the mechanism of penile curvature is also suitable for these patients, but the cause of penile curvature injury is due to the routine placement of a large-caliber catheter after surgery, which is prone to cause the above injury when the penis becomes erect at night.

　　In addition to penile curvature injury, other external force factors that cause trauma to the tunica albuginea may also lead to the same result. Some traffic accidents or industrial accidents can directly cause penile trauma, which can also gradually develop into lesions similar to Peyronie's disease. And some patients deny a history of penile injury caused by sexual intercourse or other triggers, and the exact pathogenesis of this group is still unclear.

　　Second, other possible causes

　　5, Genetic factors: Perichery et al. first discovered that the microsatellite instability (MSI) and heterozygous deletion (LOH) in the 3, 8, and 9 chromosomes of the plaque cells occurred frequently, suggesting that the occurrence of Peyronie's disease may be related to this.

　　4, Immune factors: Schiavino et al. detected the lymphocyte transformation test, serum IgA, IgG, IgM, anti-DNA antibodies, anti-nuclear antibodies, anti-smooth muscle cell antibodies, C3, C4 complement fragments, anti-streptolysin, and C-reactive protein titers in 64 patients with Peyronie's disease, and found that 75.8% of the patients had at least one abnormality, while only 10% of the control group had abnormalities.

　　Patients with penile fibrous cavernitis often suffer from psychological and sexual dysfunction. Sexual dysfunction refers to the inability to engage in normal sexual activity or to achieve satisfaction during normal sexual activity. Sexual dysfunction is generally divided into psychological sexual dysfunction and organic sexual dysfunction, with organic sexual dysfunction mainly referring to impotence, premature ejaculation, and anejaculation. Most cases of sexual dysfunction do not have organic lesions, meaning that there are no abnormalities or lesions in the sexual organs, but rather caused by psychological factors, hence often referred to as sexual psychological dysfunction in sexology.

　　The clinical manifestations of penile fibrous cavernous sinusitis include the appearance of hard nodules on the dorsal side of the penis, with varying sizes and numbers. There may be pain during erection, and the penis may bend during erection. In severe cases, it can affect sexual life and cause symptoms such as erectile dysfunction, pain during urination, and difficulty in urination. The local area of the penis may have a history of injury or inflammation. Physical examination can feel one or several hard nodules or strips behind the coronal sulcus on the dorsal side of the penis, which have the texture of cartilage and mild tenderness.

　　Penile fibrous cavernous sinusitis can be divided into acute and chronic stages. The former is characterized by acute inflammatory reaction and pain, with pain mainly occurring during penile erection. 30% to 40% of patients have significant pain symptoms. This period can last for several months, during which nodules can form in the penis, and the penis continuously bends towards the diseased side. When the active inflammation of the white membrane of the penis stops, it enters the chronic stage. During this period, the pain symptoms usually disappear, plaques form hard nodules, and the bent penis cannot be restored.

　　Preventing trauma is very important for the prevention of penile fibrous cavernous sinusitis. Men should drink more water in their daily lives to increase the frequency of urination, which can effectively prevent bacterial infection and reproduction in the urethra. At the same time, it can also reduce the chance of urinary tract infection. When necessary to exclude diseases, go to the hospital to exclude urological diseases such as chronic prostatitis, epididymitis, urethritis, or other diseases such as endocrine diseases, various systemic chronic diseases. Family care and harmony are conducive to eliminating tension in work and life. For the husband's decreased libido and sexual function, the wife should treat it calmly, be tolerant, show care and tenderness, eliminate concerns, and actively cooperate with treatment. Active treatment is beneficial for people with emotional disorders and discomfort, which is manifested as liver qi stagnation in traditional Chinese medicine, and can take Chinese patent medicine for soothing the liver and resolving depression.

　　The clinical examination methods for penile fibrous cavernous sinusitis mainly include X-ray examination, ultrasound examination, MRI examination, and dynamic injection of cavernosal pressure measurement. The specific methods are as follows:

　　First, X-ray examination

　　Penile cavernous angiography shows calcified shadows, and cavernous angiography can show that there is a filling defect in the lesion area.

　　Second, Ultrasound

　　1, Type I: White membrane thickening, without halo, and significant enhancement of the focus density.

　　2, Type II: Moderate calcification shadow, accompanied by a typical acoustic halo, and slightly stronger focus density.

　　3, Type III: Severe calcification shadow, accompanied by a typical acoustic halo, and significant enhancement of the focus density.

　　Third, Magnetic Resonance Imaging (MRI)

　　Indicates that there is an inflammatory reaction in the focus.

　　Fourth, dynamic injection of cavernosal pressure measurement and cavernous angiography

　　It can show the size of the hardening area.

　　Patients with penile fibrous cavernous sinusitis should eat foods that clear heat, anti-inflammatory, detoxifying, and rich in minerals and vitamins, and avoid eating spicy, hot, and stimulating foods, as well as seafood, grilled, and preserved foods.

　　The Western medical treatment methods for penile fibrous cavernitis mainly include drug treatment, physical treatment, and surgical intervention treatment. The specific methods are as follows:

　　First, drug treatment

　　1, Vitamin E 400mg, 2 times/d. It is inexpensive and has few side effects, and is a free radical scavenger that can improve the symptoms of some patients.

　　2, Aminobenzoic acid (para-aminobenzoic acid): In some scattered small sample reports, PABA is effective for Peyronie's disease. However, it must be taken at a dose of 12g per day, and the large dose is prone to significant gastrointestinal reactions.

　　3, Antihistamines: Based on the early inflammatory characteristics of Peyronie's disease being mediated by histamine, for some young patients with the main complaint of penile erection pain, non-specific antihistamines such as terfenadine (Terfenadine) can be used. Terfenadine can cause many side effects, so recently, non-sotalol has been used, the dosage is 60mg, 2 times/d, 1 course of treatment for 3 months. Although pharmacological studies have no supportive conclusions, some scattered reports support the efficacy of terfenadine or non-sotalol for Peyronie's disease.

　　4, Colchicine (colchicine): Colchicine can induce the activity of collagenase, reduce collagen synthesis. Some authors used colchicine 0.6mg, 2 times/d, for a total of 3-4 weeks, and then took peripheral blood for examination to see if there was any evidence of bone marrow suppression. If no abnormalities were found, the drug was continued at 0.6mg, 3 times/d, for a total of 3-4 months as a course of treatment. The drug has a negative impact on sperm count, and many patients cannot tolerate the treatment due to significant gastrointestinal side effects.

　　5, Steroid local injection: There are some scattered reports in China: satisfactory efficacy was achieved by injecting triamcinolone acetonide (Triamcinolone) into the plaque. However, many patients have a relatively stable period before using steroids locally, but due to the trauma caused by injection, inflammation further developed, and hardening and curvature worsened.

　　6, Calcium channel blockers: Levine (1994) injected calcium channel blockers into the plaques, although it did not alleviate penile curvature, but it seemed to slow down the scar formation process.

　　7, Collagenase: Gelbard et al. (1985) studied the use of collagenase for Peyronie's disease plaques. In the initial double-blind trial, the drug did not prove to have a significant improvement in the lesions. In another larger sample size parallel double-blind trial, it suggested that the injection of collagenase into plaques had a good therapeutic effect.

　　8, Huperzine (huperzine A): Chen Lin et al. performed local injections with huperzine in 12 cases, and 6 cases showed complete disappearance of the plaque.

　　9, Acetyl-L-camitine and tamoxifen: Biahiottig et al. reported that acetyl-L-camitine 1g, 2g/d, for a total of 3 months, can significantly alleviate penile curvature and pain, inhibit the progression of the disease, with few side effects. Tamoxifen (Tamoxifen) is used to treat Peyronie's disease, 20mg per time, 2 times/d, for a total of 3 months, can make the plaque shrink, but cannot alleviate the curvature of the penis, and has significant side effects.

　　10. Traditional Chinese medicine: Guo Yinglu used traditional Chinese medicine (Baihu, Chishao, Baizhi, Xiakucao, Zhijiao, Taoren泥, Zhiruimi, Yishu, Shengyiren) plus vitamin C, achieving certain efficacy.

　　Second, physical therapy

　　Culibrk combined ultrasonic, infrared, and iontophoresis (Iontophoresis) therapy treated 35 patients with Peyronie's disease, 10 were cured, and the rest had symptom relief. It seems that ultrasonic therapy is used to treat Peyronie's disease only to alleviate the inflammatory reaction of the plaques. Treatment with gamma rays from a linear accelerator requires extra caution, and the indications should be strictly limited, only those with persistent and early onset of erectile pain should be treated with radiotherapy.

　　Third, surgical intervention

　　1. Preoperative evaluation: The evaluation should include both the patient and their sexual partner. It is necessary to explain to the patient and their sexual partner that the penile lesion is not a tumor or cancer, and inform them that Peyronie's disease is treatable and that having the disease does not mean the end of sexual activity. Many doctors tell patients that Peyronie's disease is incurable, but if the goal of treatment is to restore or continue sexual activity, Peyronie's disease is treatable. It is also very important that doctors recognize that Peyronie's disease is a developing and changing disease, and some patients can significantly reduce or improve their condition, making surgical treatment unnecessary. Therefore, patients need to wait for a period of time, that is, during the initial onset to the period of definitive treatment, to observe the changes in the condition. The waiting period is quite important for them, as it can cause severe anxiety. Therefore, efforts should be made to make patients feel that during this period, the doctor is treating their disease, not just waiting, for example, by giving them medication.

　　When the Peyronie's disease lesion is stable, the penis is severely curved, and there is severe erectile dysfunction, it is the indication for surgical correction of Peyronie's disease. Based on this, it is necessary to evaluate the erectile function of pre-surgical patients before the operation. Some patients can improve their erectile function by using methods such as intracavernosal injection of vasoactive drugs or vacuum attraction, indicating that the curvature of the penis itself does not cause erectile dysfunction and does not require surgical treatment. Doppler examination and nocturnal penile tumescence test after intracavernosal injection of vasoactive drugs can evaluate the condition of erectile function, which is beneficial for judging whether surgery is needed and the postoperative efficacy.

　　Before surgical intervention, patients should be made aware of the ultimate effects of the surgery. Although most patients hope that the surgical operation can restore their penis to the level before the illness, they should be informed that this is impossible and they should be explained clearly without any hesitation. The best result is that the surgery can correct the curvature of the penis, even if there is a slight curvature, it will not affect sexual intercourse, and the erectile function may maintain the level before the operation. It is impossible to achieve any expectations beyond the actual. Patients must accept the advice to determine the expectations for the surgery.

　　2, Surgical correction:

　　(1) Corporal white membrane folding method: Pryor et al. (1979) described the excision and folding of part of the corpus cavernosum on the opposite side of the Peyronie plaque to correct penile curvature, the principle of which is to shorten the white membrane of the cavernous body of the penis on the opposite side of the lesion to counteract the effect caused by the lack of elasticity at the lesion site. Lue (1989) modified the Pryor method, omitting the step of excising the white membrane on the opposite side of the lesion and only performing the folding procedure, achieving good early effects in the treatment of Peyronie's disease. Savoca et al. followed up 157 patients with Peyronie's disease who underwent Nesbit surgery, with an average follow-up time of 72 months, 87.9% satisfaction with the surgery, 136 cases with satisfactory erections (IIEF-5 score greater than 21), 22 cases with penile shortening (1.5-3cm) but only 2 cases affected sexual intercourse; although the above two techniques have achieved good therapeutic effects in other patients, many patients are very concerned about the penile shortening caused by Peyronie's disease itself, and they are informed that these surgical procedures may further shorten the penis, so they may be unwilling to accept this type of surgical approach.

　　(2) Small incision technique for plaque: Gdlbard (1989) also described a surgical technique, making many small incisions on the Peyronie plaque, and then using temporal fascia grafts to fill the defects. He reported that good results were obtained. The theoretical basis of this technique is to make many small incisions on a single lesion and then fill it with some flexible materials, forming a smoother curvature after healing. The incidence of postoperative erectile dysfunction is low.

　　(3) Plaque excision and repair with substitute materials: After excising the plaque lesion, the following autologous tissues can be used for patch repair, such as skin grafts, tunica vaginalis, and venous sheets. Chun et al. reported that the pericardium of a cadaver was used for repair surgery after plaque excision, and the effect was similar to that of autologous skin transplantation, but the preoperative preparation was simple, complications were few, and the flexibility of the material was good. Hellstrom reported that using silicone patches to repair the defect after plaque excision achieved good results.

　　(4) Summary of surgery: The incision selection depends on the location of the plaque lesion. If the plaque is on the ventral side, an incision is made in the midline of the ventral side of the penis; for dorsal plaques, a circumcision incision is made, the skin of the shaft of the penis is peeled off to the root of the penis, which facilitates the exposure of the lesions located in the middle and distal parts of the penis. If the lesions at the proximal part of the penis or the foreskin are particularly long, a second incision is added at the root of the penis, extending laterally towards the scrotum, and the shaft of the penis is pulled out through this incision. When dealing with the dorsal vascular nerve bundle of the penis, it should be lifted together with Buck's fascia. The method is to make an incision on the side of the corpus cavernosum of the urethra, lift the Buck's fascia and the dorsal vascular nerve bundle of the penis together, and free them from the corpus cavernosum of the penis.

　　After exposing the white membrane on the dorsal or ventral side, the non-elastic plaques are clearly exposed. The scope of the plaques can be delineated on the white membrane. Artificial erection helps determine the degree of penile curvature. If plaque resection is chosen, elliptical or satellite-shaped incisions are made around the plaques as needed to reduce the tension at the edge of the defect and increase the defect area by 1.5 to 2 times. The area of the graft should be 30% larger than the area of the defect. The donor skin should be stripped of the epidermis and carefully defatted to obtain the dermal graft. The defect site is closed with PDS suture. Artificial erection tests are performed during the operation to see if the penis is straightened and if there is bleeding at the suture edges. If the penis cannot be straightened during the operation, further design of the incision and re-repair of the defect should be done. Finally, two thin silicone drain tubes are placed between Buck's fascia and the subcutaneous tissue to anatomically reset the penis. Two weeks later, encourage the patient to achieve penile erection (not to encourage sexual intercourse), the purpose of which is to prevent the transplanted skin from adhering to the deep layer of the penis and to help the survival of the graft. In the first 3 months after surgery, the contraction of the graft can cause a slight recurrence of penile curvature, but when the graft becomes soft, the penis recovers to a straight position, so patients must be informed of this before surgery.

　　Due to the lack of sufficient understanding of its etiology and mechanism, there is currently no definitive and effective treatment. Untreated patients may spontaneously relieve 20% to 50% within 2 to 3 years. The efficacy of interferon in drug treatment is not definite. Potassium para-aminobenzoate can reduce the size of nodules and the angle of curvature. Electroiontophoresis therapy is non-invasive and has definite effects, worthy of further study. The efficacy of extracorporeal shock wave therapy is yet to be further observed. For those who are ineffective with non-surgical therapy, surgical therapy can be adopted. The surgical method tends to resect the nodules in a small area, repair the defect with autologous skin flaps or venous valves, and the postoperative efficacy is definite.