ESWT and penile traction with a vacuum device for Peyronie’s deasease -a modest suggestion

Objective

The Peyronie's disease (PD) , also known as Peyronie's Disease ( IPP) is an acquired disorder characterized by the presence of fibrotic plaques in the tunica albuginea of the penis, whose presence causes a deformity of the ' body , with the same curvature as possible and / or retraction of a degree more or less high . It is estimated that the prevalence of the disease is of the order of 9% , with a peak incidence in the fifth decade of life , because in this age group is more than 50% of patients. The IPP consists of a structural alteration , localized or multifocal , connective tissue of the tunica albuginea of the corpora cavernosa , accompanied by an inflammatory process with subsequent abnormal deposition of collagen fibers in the thickened fibrotic first and then calcified .
There is no universally accepted treatment for this condition. We give our experience with 185 patients with shock wave (ESWT) and stretching with vacuum device (VD). In fact in recent years, penile traction therapy has gained considerable interest as a novel nonsurgical treatment option for men with Peyronie’s disease (PD) and short penises. It was a little risky so we have preferred the VD.The current published literature suggests that selected cases of PD may benefit from a conservative approach with VD, resulting in increased penile length and reduction of penile deformity

Methods and results

The treatment involves 5 applications of 3,000 shock waves each, every week. Each application lasts approximately 25 minutes. The patients ay home had to use a penile vacuum erectile device (the Androbath) .
VD was use as a mechanically straighten of the penis three times a week for 4 months.
In November 2010 we started to use this method with the aim of checking its tolerability and effectiveness. 185 patients with PD, aged between 44 and 74 (average age 53.8) were treated according to this protocol.
A case history was drafted for each patient and they all underwent an objective examination, a dynamic ultrasonic scan of the penis and a photograph of the penis in erection. The complaint had lasted for a period of time varying from a minimum of 3 to a maximum of 120 months (average time 23.3 months). 144 patients reported painful erections and 168 patients showed bending of the penis during erection. The pre-treatment dynamic ultrasonic scan of the penis revealed plaques with calcific features in 136 patients, while for the remaining 49 cases the ultrasonic images were compatible with fibrotic thickening. On completion of the 5th treatment session, the patients were given a questionnaire to fill in so that we could obtain a subjective evaluation of the results achieved. All the patients underwent photograph and dynamic ultrasonic scan of the penis (both performed after drug-induced erection, pre- and post treatment). Slight alteration often appeared on the skin of the penis (petechias), which disappeared spontaneously within 48 hours. On completion of the 5th treatment session, 137 patients out of 185 (65%) reported subjective improvement described as "stoppage" in the progression and/or partial regression of the disease" with a filling of a saller size of the plaque on-self examination. As far as concerns pain, this symptom disappeared in 131 out of the 144 patients concerned . At the clinical check, based on the ultrasonic scans carried out after ESWT, in 134 it was possible to note a reduction in the echogenicity or in the size of the treated plaque. In 61 patients an unchanged plaque was observed, and in 16 case a larger plaque or a calcific evolution was established. For what the bending of the penis concerns, the comparison between the photographs revealed a reduction of the curvature in 124 patients. Of the 49 patients in whom the disease had non-calcific characteristics, according to the ultrasonic scans, 25 showed improved disease, in 24 the treated plaque had stabilized or worsened. In the group of 136 patients with the calcific plaques, 93 improved while 33 resulted unchanged or worsened.
Mean pain score dropped from 4.2 to 1.3 in patients who suffered predominantly from painful erections.
Complication rate was low with only minor side effects such as minimal skin bruising; one urethral bleeding occurred.

Discussion

The use of therapy with ESWT (External Shock Wave Therapy) by means of a specific transducer , if on the one hand favors the crushing of the plate , on the other determines the release of substances pro – angiogenic , anti- inflammatory and anti -oxidants. These substances exert a local action that stabilizes plaque and prevents the disease from progressing . It also reduces the size and consistency of the plaque itself, which though small can even be reabsorbed . The mechanical action of the shock waves on the nerve fibers causes the disappearance of local pain, a phenomenon of "stunning" ( apraxia ) of the nerve fiber itself. Currently represents the most widely accepted therapy , before surgery , for the conservative treatment of plaque.
Although surgical correction of the angulation
or the plaque is still considered the gold standard for
treating Peyronie’s disease, it certainly presents some
important disadvantages. Some reduction in penile
length and de novo impotence are not uncommon after
surgery . As a result, minimally invasive treatments
have been tried, including ortho-voltage radiation, ultrasound,short wave diathermy, laser therapy and
shockwave lithotripsy. The exact mechanism of action
of ESWT is still unknown but there are 2 theories:
a direct damage to the plaque and an increased
of vascular density of the area caused by ESWT, leading
to an inflammatory reaction which results in lyses
of the plaque and removal by macrophages .
In previous studies, the proportion of patients
showing an improvement in their erection with
ESWT therapy ranged from 47% to 71% .
We associated stretching, a common treatment for
Peyronie’s disease, and ESWT in the attempt of improving the deformity in a non-invasive way,
the results was satisfying.

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