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Peyronie’s-Like Plaque after Penile Injection of Prostaglandin E1
0022-534 7 /94/1523-0961$03.00/0 THE JOURNAL OF UROLOGY Copyright© 1994 by AMERICAN UROLOGICAL AssOC]ATION, INC.
Vol. 152, 961-962, September 1994
Printed in U.S.A.
PEYRONIE1 S-LIKE PLAQUE AFTER PENILE INJECTION OF PROSTAGLANDIN El JUZA CHEN, MICHAEL GODSCHALK, P. GARY KATZ
AND
THOMAS MULLIGAN
From the Department of Veterans Affairs, Hunter Holmes McGuire Medical Center, Richmond, Virginia
ABSTRACT
Intracavernous injection of vasoactive medication may cause fibrosis of the tunica albuginea or corpus cavernosum. These adverse effects have been clearly linked to papaverine and phentol amine but to our knowledge the development of fibrosis or a Peyronie's-like plaque after the injection of prostaglandin El has not been previously described. We report a case of intracav ernous hematoma, penile curvature deformity and Peyronie's-like plaque that developed after initiating intracorporeal self-injection of prostaglandin El for erectile dysfunction. KEY WORDS:
injections, subcutaneous; alprostadil; penile induration; hematoma; penis
Since the initial report of intracavernous injection of vaso active medication as treatment for erectile dysfunction, the use of penile self-injection has become widespread. Relatively minor self-limiting complications, including pain, local irri tation, hematoma and priapism, occur when papaverine, phentolamine and prostaglandin El are used. However, more serious complications, such as fibrosis of the tunica albuginea or corpus cavernosum, penile curvature deformity and Peyronie's disease, have been reported, primarily in asso ciation with the use of papaverine or phentolamine. 1-4 We report a case of penile curvature deformity and Peyronie's like plaque that developed after intracavernous injection of prostaglandin E 1. CASE REPORT
A 66-year-old white man with insulin-dependent diabetes mellitus presented with erectile dysfunction. Evaluations in cluded medical and sexual history, physical examination, and serum assays for testosterone, electrolytes, and liver, renal and thyroid function. Color duplex Doppler ultrasonog raphy was done before and after intracorporeal injection of prostaglandin El. Etiology of the erectile dysfunction was believed to be diabetic neuropathy. The optimal 7.5 µg. dose of prostaglandin El was deter mined by injecting the patient 2 times weekly with an incre mentally increasing dose (for example 2.5, 5 and 7.5 /.Lg.). The patient was taught the technique of self-injection. He was instructed to alternate the site of injection and to inject on
the lateral aspect of the penis. The patient was seen at followup every month for the first 3 months and every 3 months thereafter. During the first 8 months he injected himself approximately 20 times with no side effects. During a routine followup visit 9 months after initiating therapy the patient reported 1 painful injection and erection, which was followed by 2 painful episodes that prevented intercourse. Physical examination revealed painful indura tion along the dorsal surface of the tunica albuginea and fullness of the corpora cavernosa. Color duplex Doppler find ings suggested intracavernous hematoma (fig. 1). There was no evidence of cavernous fibrosis or a Peyronie's-like plaque. Accidental injection into the tunica albuginea with bleeding was suspected. The patient was instructed to discontinue injections and return for repeat evaluation in 1 month. One month after intracavernous injections were discontin ued painful induration of the penis had resolved. However, induration of the tunica albuginea and penile curvature de formity were noted. Repeat color duplex Doppler sonography showed no evidence of cavernous fibrosis or a Peyronie's-like plaque. Treatment with vitamin E was initiated to decrease fibrosis. Two months later a penile curvature deformity per sisted. On physical examination a 2 X 2 cm. Peyronie's-like plaque was present on the dorsal aspect of the tunica albuginea. Color duplex Doppler ultrasound demonstrated increased ve nous flow and a hyperechogenic calcified Peyronie's-like plaque (fig. 2). Surgical excision was recommended.
Accepted for publication January 14, 1994.
FIG. 1. Longitudinal (A) and sagittal (B) penile duplex Doppler scan after painful injection demonstrates hypoechogenic area in tunica albuginea and corpus cavernosum that proved to be hematoma (arrows). 961
.-,--.."f.
962
PEYRONIE'S-LIKE PLAQUE AFTER PENILE INJECTION OF PROSTAGLANDIN El
FIG. 2. Longitudinal (A) and sagittal (B) followup duplex Doppler scan shows increased venous flow and hyperechogenic calcified Peyronie's-like plaque in tunica albuginea (arrow). DISCUSSION
A penile curvature deformity, fibrosis and a Peyronie's-like plaque are serious adverse reactions to intracavernous injec tion of vasoactive drugs, which have been reported after injection of papaverine and phentolamine. 1-5 The possible cause of such complications includes fibrotic reaction to the low pH of papaverine (pH 3.2), hypertrophy of corporeal smooth muscle fibers, trauma of the tunica albuginea from the needle or vigorous intercourse with a less than rigid erection, irritation of the tunica albuginea and hematoma formation in the tunica albuginea or corpus cavernosum. 5 The prevalence of cavernous fibrosis after 1 year of papaver ine and phentolamine injection ranges from 1.5 to 57%. 5-7 Penile nodules and/or Peyronie's-like plaques after papaver ine and phentolamine injection were found in 12% of patients at 6 months and 31% after 12 months.6 Furthermore, com plications increased with time and the number of injections given. In our case the number of self-injections was relatively small (20) and, therefore, development of a Peyronie's-like plaque as a result of multiple needle punctures is unlikely. However, the patient did report 1 particularly painful injec tion, and induration of the tunica albuginea and intracavern ous hematoma were noted on examination. We suspect that the patient may have injected into the tunica albuginea. Intra-tunical injection may have caused local bleeding, irri-
tation and, ultimately, formation of a fibrous Peyronie's-like plaque. This complication emphasizes the importance of pa tient education regarding needle placement. REFERENCES
1. Fuchs, M. E. and Brawer, M. K.: Papaverine-induced fibrosis of the corpus cavernosum. J. Urol., 141: 125, 1989. 2. Raugei, A., Vici, I., Della Rose, A. and Ponchietti, R.: Fibrosis of the corpus cavernosum due to chemical prosthesis. Acta Urol. Ital., suppl., 4: 437, 1992. 3. Hu, K.-N., Burks, C. and Christy, W. C.: Fibrosis oftunica albu ginea: complication of long-term intracavernous pharmacolog ical self-injection. J. Urol., 138: 404, 1987. 4. Chan, J. C. K., Levenson, S., Payton, T. R., Krane, R. J. and Goldstein, I.: Five to seven year follow-up of patients in a pharmacologic erectile program: satisfaction and complica tions. J. Urol., 147: 309A, abstract 387, 1992. 5. Levine, S. B., Althof, S. E., Turner, L. A., Riser, C. B., Bodner, D. R., Kursh, E. D. and Resnick, M. I.: Side effects of self administration of intracavernous papaverine and phentol amine for the treatment of impotence. J. Urol., 141: 54, 1989. 6. Lakin, M. M., Montague, D. K., Vanderbrug Medendorp, S., Tesar, L. and Schover, L. R.: Intracavernous injection therapy: analysis ofresults and complications. J. Urol., 143: 1138, 1990. 7. Sidi, A. A. and Chen, K. K.: Clinical experience with vasoactive intracavernous pharmacotherapy for treatment of impotence. World J. Urol., 5: 156, 1987.
Vol. 152, 961-962, September 1994
Printed in U.S.A.
PEYRONIE1 S-LIKE PLAQUE AFTER PENILE INJECTION OF PROSTAGLANDIN El JUZA CHEN, MICHAEL GODSCHALK, P. GARY KATZ
AND
THOMAS MULLIGAN
From the Department of Veterans Affairs, Hunter Holmes McGuire Medical Center, Richmond, Virginia
ABSTRACT
Intracavernous injection of vasoactive medication may cause fibrosis of the tunica albuginea or corpus cavernosum. These adverse effects have been clearly linked to papaverine and phentol amine but to our knowledge the development of fibrosis or a Peyronie's-like plaque after the injection of prostaglandin El has not been previously described. We report a case of intracav ernous hematoma, penile curvature deformity and Peyronie's-like plaque that developed after initiating intracorporeal self-injection of prostaglandin El for erectile dysfunction. KEY WORDS:
injections, subcutaneous; alprostadil; penile induration; hematoma; penis
Since the initial report of intracavernous injection of vaso active medication as treatment for erectile dysfunction, the use of penile self-injection has become widespread. Relatively minor self-limiting complications, including pain, local irri tation, hematoma and priapism, occur when papaverine, phentolamine and prostaglandin El are used. However, more serious complications, such as fibrosis of the tunica albuginea or corpus cavernosum, penile curvature deformity and Peyronie's disease, have been reported, primarily in asso ciation with the use of papaverine or phentolamine. 1-4 We report a case of penile curvature deformity and Peyronie's like plaque that developed after intracavernous injection of prostaglandin E 1. CASE REPORT
A 66-year-old white man with insulin-dependent diabetes mellitus presented with erectile dysfunction. Evaluations in cluded medical and sexual history, physical examination, and serum assays for testosterone, electrolytes, and liver, renal and thyroid function. Color duplex Doppler ultrasonog raphy was done before and after intracorporeal injection of prostaglandin El. Etiology of the erectile dysfunction was believed to be diabetic neuropathy. The optimal 7.5 µg. dose of prostaglandin El was deter mined by injecting the patient 2 times weekly with an incre mentally increasing dose (for example 2.5, 5 and 7.5 /.Lg.). The patient was taught the technique of self-injection. He was instructed to alternate the site of injection and to inject on
the lateral aspect of the penis. The patient was seen at followup every month for the first 3 months and every 3 months thereafter. During the first 8 months he injected himself approximately 20 times with no side effects. During a routine followup visit 9 months after initiating therapy the patient reported 1 painful injection and erection, which was followed by 2 painful episodes that prevented intercourse. Physical examination revealed painful indura tion along the dorsal surface of the tunica albuginea and fullness of the corpora cavernosa. Color duplex Doppler find ings suggested intracavernous hematoma (fig. 1). There was no evidence of cavernous fibrosis or a Peyronie's-like plaque. Accidental injection into the tunica albuginea with bleeding was suspected. The patient was instructed to discontinue injections and return for repeat evaluation in 1 month. One month after intracavernous injections were discontin ued painful induration of the penis had resolved. However, induration of the tunica albuginea and penile curvature de formity were noted. Repeat color duplex Doppler sonography showed no evidence of cavernous fibrosis or a Peyronie's-like plaque. Treatment with vitamin E was initiated to decrease fibrosis. Two months later a penile curvature deformity per sisted. On physical examination a 2 X 2 cm. Peyronie's-like plaque was present on the dorsal aspect of the tunica albuginea. Color duplex Doppler ultrasound demonstrated increased ve nous flow and a hyperechogenic calcified Peyronie's-like plaque (fig. 2). Surgical excision was recommended.
Accepted for publication January 14, 1994.
FIG. 1. Longitudinal (A) and sagittal (B) penile duplex Doppler scan after painful injection demonstrates hypoechogenic area in tunica albuginea and corpus cavernosum that proved to be hematoma (arrows). 961
.-,--.."f.
962
PEYRONIE'S-LIKE PLAQUE AFTER PENILE INJECTION OF PROSTAGLANDIN El
FIG. 2. Longitudinal (A) and sagittal (B) followup duplex Doppler scan shows increased venous flow and hyperechogenic calcified Peyronie's-like plaque in tunica albuginea (arrow). DISCUSSION
A penile curvature deformity, fibrosis and a Peyronie's-like plaque are serious adverse reactions to intracavernous injec tion of vasoactive drugs, which have been reported after injection of papaverine and phentolamine. 1-5 The possible cause of such complications includes fibrotic reaction to the low pH of papaverine (pH 3.2), hypertrophy of corporeal smooth muscle fibers, trauma of the tunica albuginea from the needle or vigorous intercourse with a less than rigid erection, irritation of the tunica albuginea and hematoma formation in the tunica albuginea or corpus cavernosum. 5 The prevalence of cavernous fibrosis after 1 year of papaver ine and phentolamine injection ranges from 1.5 to 57%. 5-7 Penile nodules and/or Peyronie's-like plaques after papaver ine and phentolamine injection were found in 12% of patients at 6 months and 31% after 12 months.6 Furthermore, com plications increased with time and the number of injections given. In our case the number of self-injections was relatively small (20) and, therefore, development of a Peyronie's-like plaque as a result of multiple needle punctures is unlikely. However, the patient did report 1 particularly painful injec tion, and induration of the tunica albuginea and intracavern ous hematoma were noted on examination. We suspect that the patient may have injected into the tunica albuginea. Intra-tunical injection may have caused local bleeding, irri-
tation and, ultimately, formation of a fibrous Peyronie's-like plaque. This complication emphasizes the importance of pa tient education regarding needle placement. REFERENCES
1. Fuchs, M. E. and Brawer, M. K.: Papaverine-induced fibrosis of the corpus cavernosum. J. Urol., 141: 125, 1989. 2. Raugei, A., Vici, I., Della Rose, A. and Ponchietti, R.: Fibrosis of the corpus cavernosum due to chemical prosthesis. Acta Urol. Ital., suppl., 4: 437, 1992. 3. Hu, K.-N., Burks, C. and Christy, W. C.: Fibrosis oftunica albu ginea: complication of long-term intracavernous pharmacolog ical self-injection. J. Urol., 138: 404, 1987. 4. Chan, J. C. K., Levenson, S., Payton, T. R., Krane, R. J. and Goldstein, I.: Five to seven year follow-up of patients in a pharmacologic erectile program: satisfaction and complica tions. J. Urol., 147: 309A, abstract 387, 1992. 5. Levine, S. B., Althof, S. E., Turner, L. A., Riser, C. B., Bodner, D. R., Kursh, E. D. and Resnick, M. I.: Side effects of self administration of intracavernous papaverine and phentol amine for the treatment of impotence. J. Urol., 141: 54, 1989. 6. Lakin, M. M., Montague, D. K., Vanderbrug Medendorp, S., Tesar, L. and Schover, L. R.: Intracavernous injection therapy: analysis ofresults and complications. J. Urol., 143: 1138, 1990. 7. Sidi, A. A. and Chen, K. K.: Clinical experience with vasoactive intracavernous pharmacotherapy for treatment of impotence. World J. Urol., 5: 156, 1987.