Peyronie

MR2 Silvia Acosta

Historia
Anatomista Falopio en 1561. Redescubierto por Francois Gigot de la Peyronie, cirujano real con el rey Louis XV de Francia, en 1743.

Definicin
Desorden adq de tnica albugnea Form. placa fibrosa

Comorbilidades comunes -Grado D

DE, HTA, DM, hiperlipidemia, baja testosterona Enfermedad de Dupuytren trauma peneano 30% Timpanoesclerosis Instrumentacin uretral gota

Estadsticas
Prevalencia 3 a 9% adultos Edad media 53 aos Entre los 50 a 59 a dx 66% casos Incidencia de 25,7/100,000 /ao Prevalencia de 0,39% (Lindsay et al 1991) Asociacin a DBT 3 veces y beta bloq propanolol hydrochloride Dupuytren 39%
Epidemiology of peyronies disease International journal of impotence research 2002

Etiologa
Desorden en la curacin de herida Cicatriz fibrosa inelstica de la tnica albugnea Genticamente susceptibles Trauma de pene 5 a 13 %

Patognesis
Tnica albugnea - reaccin proliferativa, fibrtica resulta en una cicatriz exuberante, inelstica.

 Aumento de la expresin de TGF B1 en placa fibrtica Aumento stress oxidativo potencialmente daa la tnica albugnea en fase aguda

Peyronies disease diagnosis and treatment International journal of impotence research 2008

Patologa
Fibrosis del tejido con desorganizacion de fibra elasticas, combinado con acumulo de fibrina y diferentes grados de inflamacion

Clnica
Cicatriz palpable Deformidad del pene Curvatura, acortamiento, estrechamiento, hinge effect Disfuncin erctil 58% Depresin 48% Baja autoestima Dificultades Relaciones
Risk factors for emotional and relationship problems in peyronies disease. J. Sex. Med 2008 Peyronies disease: a critical appraisal of current diagnosis and treatment. International Journal of Impotence Research 2008

Sntomas y relacin de sint

Fases de la enfermedad
Forma de comienzo de la enfermedad Tiempo de evolucin Etapa aguda Etapa crnica

Fase aguda
Dolor pene Progresin de curvatura El dolor pasa espontneamente 6 a 18 meses 3 a 13 % cura solo 40% igual 47% peor Peyronies disease: diagnosis and treatment
International journal of impotence research 2008

 Placa dorsal 2/3 Deformidad dorsal Placa lateral y ventral no son tan comunes Placas mltiples Placas en el septum

Diagnstico
Inyeccin intracaversona ag. Vasoactivo Fotografa Vacuum La medida de la placa es imprecisa Operador dependiente

ultrasonido
Identifica sitio y consistencia de la placa Eco doppler GRADE D Evala placa calcificada, flujo vascular, Medida objetiva de la deformidad Es til pero no necesario
The management of peyronies disease evidence based 2010 guidelines Journal Sexual Medicine 2010 Penile sonographic and clinical characteristics in men with peyronies disease. J. Sex Med 2009

 Eco doppler Evalua flujo vascular Caracteristica de la placa Objetiva la respuesta a drogas Objetiva la curvatura

Color doppler sonographic evaluation of men with peyronies disease. Journal of Islamic academy of sciences. 1993

Terapia conservadora
Fase aguda ( < 12 meses induracin) Deform inestable o progresiva Ereccin dolorosa No psicolg preparado No interesado en ciruga
The management of peyronies disease evidence based 2010 guidelines Journal Sexual Medicine 2010

 Limitada evidencia Reportes de estabilizacin o reduccin de deformidad EMDA, o inyeccin verapamilo o interfern Terapia traccin

The management of peyronies disease evidence based 2010 guidelines Journal Sexual Medicine 2010

TERAPIA ORAL

POTABA
Potassium Para-Aminobenzoate Complejo vit B act de monoamina oxidasa en tejidos. serotonina dism fibrogenesis antifibrtico y antiinflamatorio. tamao de la placa No cambia dolor o mejora de la curvatura Estabiliza la placa, previene nuevas placas Alto costo 3 gr 4v/d. Efecto GI
Treatment of Peyronies disease with potassium paraminobenzoate J. Urol 1959; 81 A multicentre doubleblind controlled clinical trial of potassium paraminoabnenzote in peyronies disease. Prog Reprod Biol Med 1983 POTABA in the treatment of peyronies disease: a prospective, placebocontrolled, randomized study. Eur Urol 2005

Vitamina E
Vitamina liposoluble Antioxidante Est controlados doble ciego no cambios sig en dolor curvatura o tamao de la placa comparado con placebo
Controlled clinical trial of vitamin E in peyronies disease. Prog reprod biol med 1983 Comparison of vitamin E and propionyl l carnitine, separately or in comibination in patients with early chronic peyrons disease. A doubleblind, placebo, controlled,randomized study. J. Urol 2007

Tamoxifeno
Antiestrgeno no esteroideo- compite con estrgeno Mec. de accin no claro Reduccin de prod de TGF B x fibroblastos de tnica albuginea. Inferior a l-carnitina 20 mg 2v/d puede mejorar tamao, cuvatura y dolor No confirmado-no recomendado
The treatment of peyronies disease with tamoxifen. Br. J. Urol 1992 Tamoxifen versus placebo in the treatment of peyronies disease J. Urol 1999

Colchicina
Propiedad antiinflamatoria. Inh fibrosis y deposito de colageno x inh de respuesta inflamat. Efectos GI, raro anemia aplsica - falta informacin para recomendar terapia con colchicina Estudios recientes: no es mejor q placebo
Is colchicine effective in peyronies disease? A pilot study Urology 1994 Treatment of peyronis disease with oral colchicine. Long term results and predictive parameters of successful outcome. Int j impot res 2000 Therapeutics effect of colchicine in the management of peyronies disease: a randomized double blind, placebo controlled study. In J. Impot Res 2004

L-carnitina
Aumenta respiracin mitocondrial, dism la formacin de radicales libres. Euforia leve, molestias GI Dism. tamao de la placa y curvatura Reduccin de dolor 3 a 3,5 g x dia
Acetyl-l carnitine vs tamoxifen in the oral therapy of peyronies disease. BJU Int 2001 Oral propionyl. L carnitine and intraplaque verapamil in the therapy of advanced and Resistant peyronies disease. BJU int 2002

Vitamin E + Colchicine
Estudios recientes doble ciego, combinacin de vitamina E + colchicina mejora significativa del tamao de la placa, curvatura y dolor durante la fase inicial

Combined treatment with vitamin E and colchicine in the early stages of Peyronies disease. BJU Int 2003

Pentoxifylline
Inh PDE 5 no especifico. Dism inflamacin y fibrosis Previene fibrosis corporal tras priapismo y dism calcificacin de inicio altos nivel de oxido ntrico efectivos en prevenir progresin de PD o revertir la fibrosis Necesita ms estudios
Treatment of peyronies disease with oral pentoxifyline. Nat.Clin. Pract. Urol 2006

Otras terapias no invasivas

LEOCH Estudios iniciales no demuestran eficacia Estudios recientes sugieren reduccin del dolor
Objective and subjective changes in patients with peyrons disease after management of with shock wave therapy. J. Endoruol2003 Questionable efficacy of extracorporeal shock wave thearpy in peyronies disease: results of a prospective approach. J. Urol 2004 Extracorporeal shcok kwave therapy for peryonies disease: exploratory meta analisis of clinical trails. J urol 2004 Long term results of extracorporeal shockwave therapy for peyronies disease. J. Endourol 2006 A first prospective randomized, double blind ,placebo-controlled trial evaluating extracorporeal shock wave therapy for the treatment of peyronies disease Eur. Urol 200 Treatment of peyronies disease by extracorporeal shockwave therapy: evaluation of our preliminary results. Journal of endourology 1999

Iontophoresis

Adm direct sobre el pene pequea corriente elctrica ayuda difundir y llegar directo a la placa fibrosa c/ sesin 20 minutos. placas < de 2.5 cm y < 30 grados contraindicado en pacientes portadores de marcapaso

Topical iontophoresis
nico rol mejorar el dolor - D No se recomienda tpico verapamilo- C Estudios controlados reduccin deformidad con iontophoresis verapamilo y dexametasona
Iontophoresis for treatment of peyronies disease J. Urol 2000 A prospective randomized study using transdermal electromotive administration of verapamil and dexamethasone for peyronies disease J. Urol 2004 Verapamil versus saline in electromotive drug administration for peyronies disease a double blind, placebo controlled trial J. Urol 2007

Inyeccin intralesional
Esteroides 6 estudios positivos No hay mediciones objetivas del tto Grado D efecto mecnico de la inyeccin?
Results with dermojet injection of dexamethasone. J. Urol 1975 Steroid injection therapy for peyronies disease: A 10 year summary and review of 38 cases. J. Urol 1967 Peyronies disease: A new approach. J. Urol 1954 The non-surgical treatment of peyronies disease Br. J. URol 1980 Peyronies disease: tratemt by the local injection of meticortelone and hydrocortisone J. Urol 1957 Betametasona vs placebo nella malatia di la peyronie. Arch Ital Urol 1998

Colagenasa
Estudio previo. Falla en demostrar beneficio Estudio recientedisminucin del ngulo y el tamao de la placa
Collagenase versus placebo in the treatment of peyronies disease. A double blind study. J. Urol 1993 The use of intralesional clostridial collagenase injection therapy for peyronies disease: a prospective, single center, non-placebocontolled study. J. Sex MEd 2008

Verapamilo
In vitro- interfiere en proliferacin cell fibroblastica Reduccin de la curvatura No hay estudios larga escala, placebo controlados- grado C
puede ser recomendado para el tratamiento de placas agudas o crnicas para estabilizar progresin de enfermedad y posiblemente reducir deformacin Intralesional verapamil injection for the treatment of peyronies disease. J. Urol 1994
Treatment of peyronies disease with intralesional verapamil injection. J. Urol 1997 Experience with intraplaque injection of verapamil for peyronies disease. J. Urol 2002 Inhibition of peyronies plaque fibroblast proliferation by biologic agents. Int. J. Impot Res 2000 Use of intralesional verapamil prevents the progresion of peyronies disease. J. Urol 2007 Open preliminary randomized prospective clinical trial of efficacy and safety of three different verapamil dilutions for intraplaque therapy of peyronies disease. Urology 2007

Interfern
Puede ser beneficio Ms costoso que verapamilo Sntomas de gripe Estudio reciente: falla en demostrar eficacia inyeccin intralesional

A single blind, multicenter, placebo controlled, parallel study to assess the safety and Efficacy of intralesional interferon alpha -2B for minimally invasive treatment for Peyronies disease. J. Urol 2006 Effect of intraleional interferon-alpha 2b combined with oral vitamina E for treatment of early stage pyeronies disease: A randomized and prospective study. Urology 2006

Terapia traccin

Terapia traccin
2 ensayos clnicos no controlados Gradual expansin del tejido x traccin Formacin de nuevo tejido conectivo Proliferacin celular Reduccin de deformidad y aumento de longitud del pene Grado C
L-type calcium channels mediate mechanically induced bone formation in vivo. J. Bone Miner Res. 2003 Regulation of pliferation and platelet-derived growth factor expression in palmar fibromatosis (dupuytren contracture by mechanical strain) J. Orthop Re 1996 The biochemical pathway mediating the prliferative response of bone cells to a mechaniccal stimulus. J. Bone Joint Surg Am 1996 Penile traction therapy for treatment of peyronies diease- a signel center pilot study. J. Sex med 2008 Use of penile extender device in the treatment of penile curvature as a result of peyronies disease. Results of a phase ii prospective study. J. Sex MEd 2009

OTROS

J Sex Med 2007;4:867877

Inh 5PDE

Coenzima Q 10
Quinona liposoluble, efecto contra el dao oxidativo de acidos grasos poliinsaturados Co Q10 suprime la expresion de TGF b1 (Ratas) 160 pac. 300 mg CoQ10

Safety and efficacy of coenzym Q10 supplementation In early chronic peyronies disease International journal of impotence research 2010

Indicaciones de Ciruga
Placa estable (6 meses) no dolor, deformacin estable imposibilidad de conseguir penetracin Extensa placa calcificada Falla del tratamiento conservador Quiere recuperacin rpida y resultados confiables

Conclusiones
No existe evaluacin estandarizada Se debe evaluar: Tiempo de enf. Estable ( no < 6 meses) Grado de dificultad para la penetracin Grado de la curvatura/ deformidad/ acortamiento Estado de capacidad retrctil Antes de decidir si hay que tratar, a quienes y como hacerlo The Management of Peyronies Disease:
Evidence-based 2010 Guidelines J. Sex. Med 2010

Conclusiones
NO: Vitamina E, potaba, colchicina,tamoxifeno, carnitina NO: litotripsia extracorporea NO: Verapamil topico

The Management of Peyronies Disease: Evidence-based 2010 Guidelines J. Sex. Med 2010

 Si: l-carnitina Via oral Si: verapamilo intralesional Agudo o cronico Si vitamina E+ colchicina

The Management of Peyronies Disease: Evidence-based 2010 Guidelines J. Sex. Med 2010