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Steroid Injection Therapy for Peyronie’s Disease: A 10-Year Summary and Review of 38 Cases
Vol. 97, Jan. Printed in U.S.A.
THE JO'CRNAL OF UROLOGY
Copyright© 1967 by The Williams & Wilkins Co.
STEROID INJECTION THERAPY FOR PEYRONIE'S DISEASE: A 10-YEAR SU=',UVIARY AND REVIEW OF 38 CASES PETER N. DESANCTIS
AND
CLEMENT A. FUREY, JR.
From the Department of Urology, Columbia-Presbyterian 1Vfedical Center, New York, New York
Past methods of treating Peyronie's disease have included a variety of therapeutic agents and regimens, generally found to be unsatisfactory. An earlier paper, giving the results of different modalities of treatment for this condition at the Squier urological Clinic, focused on the use of locally injected steroids. 1 • * We herewith submit a 10-year summary of results with this technique. CLINICAL INFORMATION
The following data concern 28 patients from the outpatient department at Presbyterian Hospital from 1954 through 1964 (some of these cases have been reported previously) and 10 patients seen in private consultation with one of the authors. The mean age of the patients studied was 53 years (table 1). The group included 27 Caucasians, 7 Negroes and 4 Puerto Ricans. The onset of symptoms before consulting a physician varied from 10 days to 3 years. Most patients were seen in less than 6 months after onset of symptoms. Painful erection and curvature on erection accounted for most consultations and most patients admitted that coitus was unsatisfactory. Some were primarily concerned with a newly found mass on the penis; others were entirely unaware of it. The incidence of prior trauma to the genitals was negligible. Plaque formation or thickening of the median septum ranging in length from 2.5 to 0.5 cm. was found in the initial examination of all patients. The thickness of the plaque was never more than 0.5 cm. ASSOCIATED FINDINGS
The size of our study precludes statistical conclusions as to the associated occurrence of Accepted for publication February 15, 1966. Read at annual meeting of New York Section, American Urological Association, Inc., New York, New York, April 30-May 1, 1965. *Dexamethasone generously supplied by Merck, Sharpe & Dohme. 1 Furey, C. A., Jr.: Peyronie's disease: Treatment by the local injection of meticortelone and hydrocortisone. J. Urol., 77: 251-266, 1957.
venereal disease, arthritis or diabetes, but such trends, where found, are noted. With regard to venereal disease, it is seen that 3 patients (8 per cent) did have syphilis or gonorrhea. However, a similar finding may be established in any review of patients routinely treated in a large metropolitan clinic. We noted that several patients ,vere, at a relatively early age, afflicted with arthritis which frequently required hospitalization. Thirteen patients (34 per cent) were found to have osteoarthritis. Of these, five were in their 30's or 40's. In 3 cases (8 per cent) diabetes was also found. A total of 4 patients (10 per cent) in our series was found to have Dupuytren's contracture. This is noticeably greater than the 2 to 3 per cent incidence found in the older population and substantiates Kirby's findings. 2 Of the 13 patients who had x-ray examination of the penis, four revealed calcium deposition in the plaque. The course of these few patients was generally good except for 1 patient who was resistant to all modalities of treatment. METHOD OF TREATMENT
Since 1954, it has been the policy of Squier Urological Clinic to use injection of sterioids when ever possible. We believe this mode is of particular value in cases where the plaques are discrete and of relatively recent origin. Our observation is that lesions consisting of thickened median septa or old lesions are refractory to therapy and tend to respond poorly. We have also used vitamin E in a small number of cases. Other methods used in combination with steroid in this series have included radiotherapy, potassium aminobenzoate (potaba) and testosterone preparations by mouth. 1 The steroid preparation which we use is dexarnethasone (decadron) in amounts of 2 to 4 cc per plaque, administered weekly. The number of injections depends entirely on response and we do not hesitate to initiate a second or even a 2 Kirby, J. V.: An. des. Mal. des Org. G. U., Dublin Med. J., 1849-1850.
114
'
E''L!BROID INJEC'rION THERAPY FOR PEYRONIE'S DISEASE
third :c,cries of'"''''"·"" In this study, the greate,t number of injections to any patient was 62, in three series of treatments. During the course of treatment, we now start our patients on 100 mg. vitamin E 3 times a day. This is continued fot minimum of 4 months i\·henever possible. Potassium aminoiJenzoate was given according to the schedule of 12 gm. µer day in three divided doses. R~jSULTS
.\. summary oi results includes all types of treatment used from 1954 through 1964 (table 2). The analysis of improvement obtained in relation to treatrnent is noted \ table 3). Since Peyronie's disease is commonly 1w·noTP.ss1vP. we have disregarded new plaque formation in tabulating the success rate. 1Ye do not hold that a medication need prevent extension of the disease to be con·· ,jclered effective. The degree of attained in this di~ease is diflkult to quantitate except for the ~ize and/or consistency oi the plaque. With regard to relief of pain and sexual relations, we are compelled to accept tbe word of the patient himself. Perhaps the best indication is his wi) .. .lingness to continu,~ treaunent. vVhile some have discontinued tbe p;reat majority have TABLE
.l
been faithful to appointments and fa,Upear to feel tha,t have benefited. We found that 81 per cent (2.'i trw 31 case~ reviewed) were beuefited to moderai', or a marked degree (table 2) Steroid alone. Of a total of 14 patic·ms received only steroid injection:-s, 9 per profited markedly, while another :3 per cew) achieved moderate success. The rombiw2cl success rate is thus 85 per cent. Steroid ancl vitamin E. \Yith the additimia1 use of vitamin E, six of a total of 6 per cent) received marked or moderat,e ment. Of these, two were markedly four attained a moderate degree oi Therefore, we were able to 18 nt the :2(: patients. Additional averaging could be dune the 5 patients who received steroid in ~ombinatim" 0
TABLE
L Age distribution
Age (Yrs.)
No.
,,
30
10
1.5
1
* Age of l po.tient not known.
2. Resnlts of treatment Marked Improvement
No, Treated
Type of }\eJ.tment
Sieroid alone
14
vitamin E
6
Steroid, pot. aminobenzoa,te
3
Steroid, rndiotherapy
2
S \;eroid~~-~min E, mdiotherapy-·--------i----- 2 !
l
i
1
Steroid~~tamin~ r,,,Ii,Jtherapy, pot. ami· I
l
Steroid, vitamin E, pot, ammobenzoate
2
'-i
-----i----__
1·..-----,-----···----·-·---..-,
--------1 ----1- ______ ,_,_ ------
radiothernpy, testosterone
nobenzoate Steroid, vitamin E, radiotherapy, testoste-
rone, pot. aminobenzoa.te
·
j
1·
1
· - - - -
,
i-------·-·.
I
.
i I
-I
----1-
.-------1------·-I----1
I I
- - - - - - - - - ·---------
116
DESANCTIS AND FUREY
with other therapy, but the number of patients is so small that the results can only be considered random. Analysis of table 3 reveals the way in which patients were helped. Steroid alone or in combination with vitamin E. Ten patients had relief from pain; nine noted less curvature on erection and in nine we found the plaques to have disappeared or to have become smaller and/or softer. We found that in those 12 patients who noted decreased pain on erection by use of any modality of treatment and in whom the duration of symptoms is known, most were seen less than 4 months after the onset of symptoms. The same result is noted with men who received relief from curvature on erection, although to a lesser degree. Finally, of those in whom definitive decrease in size or softening of the plaque was reported, 87 per cent were seen within 6 months or less. One patient in this latter group was helped even after 3 years. N ocenti and associates have recently published the results of their work on collagen formation and steroid injection. 3 They have been able to depress the collagen content in artificially produced granulomas in experimental animals by using steroid injections (cortisone and dexamethasone). In their series, they injected steroids into the developing granuloma, substantiating our belief that the best results will be obtained in cases of young plaques. (It appears to us that Peyronie's disease may be an expression of premature aging of connective tissue which has received repeated small vascular insults. In these men, other systems seem to be similarly affected, e.g. arthritis, Dupuytren's contracture.) In this series we had 6 patients who received no benefit after therapy. Of these, one received steroid, vitamin E, radiotherapy and potassium aminobenzoate, and another received all of the aforementioned therapy in addition to testosterone. In two of these six radiotherapy had also 3 Nocenti, M. R., Lederman, G. E., Furey, C. A. and Lopano, A. J.: Collagen synthesis and C14-
labeled praline uptake and conversion to hydroxyproline in steroid-treated granulomas. Proc. Soc. Exp. Biol. Med., 117: 215-218, 1964.
TABLE
3. Type of clinical improvement treatment Less Decrease Curin Pain vature
type of
Plaque Smaller/ Softer
- - --Steroid
~s_ _s_
6
1
Steroid, vitamin E
2
Steroid pot. aminobenzoate
2
I 1
1-
3 ---
1
--- - ----
Steroid, radiotherapy
1
1 - - ---
Steroid, vitamin E, radiotherapy
1
-Steroid, vitamin E, pot. aminobenzoate
1 ---
Steroid, radiotherapy, testosterone
1
---
l
- - --1
I
I
been used without success. This suggests that if steroids will not improve the process, additional types of treatment will be of no benefit. Of these 6 patients three were seen at 11 months, 12 months and 24 months, respectively, after first noting symptoms. SUMMARY
The Squier Urological Clinic has used steroid injections in cases of Peyronie's disease with gratifying results. The rationale of this treatment stems from the effect of this material on the metabolisrn of connective tissue and its wellknown anti-inflammatory properties. The results of using vitamin E in combination with steroid have been sufficiently good to encourage continued use, even though to date it has been included in relatively few cases. With other types of treatment, we have achieved only indifferent results. Relief of certain symptoms appears to be time related; therefore we are encouraged to initiate treatment as soon as possible after the onset of symptoms.
THE JO'CRNAL OF UROLOGY
Copyright© 1967 by The Williams & Wilkins Co.
STEROID INJECTION THERAPY FOR PEYRONIE'S DISEASE: A 10-YEAR SU=',UVIARY AND REVIEW OF 38 CASES PETER N. DESANCTIS
AND
CLEMENT A. FUREY, JR.
From the Department of Urology, Columbia-Presbyterian 1Vfedical Center, New York, New York
Past methods of treating Peyronie's disease have included a variety of therapeutic agents and regimens, generally found to be unsatisfactory. An earlier paper, giving the results of different modalities of treatment for this condition at the Squier urological Clinic, focused on the use of locally injected steroids. 1 • * We herewith submit a 10-year summary of results with this technique. CLINICAL INFORMATION
The following data concern 28 patients from the outpatient department at Presbyterian Hospital from 1954 through 1964 (some of these cases have been reported previously) and 10 patients seen in private consultation with one of the authors. The mean age of the patients studied was 53 years (table 1). The group included 27 Caucasians, 7 Negroes and 4 Puerto Ricans. The onset of symptoms before consulting a physician varied from 10 days to 3 years. Most patients were seen in less than 6 months after onset of symptoms. Painful erection and curvature on erection accounted for most consultations and most patients admitted that coitus was unsatisfactory. Some were primarily concerned with a newly found mass on the penis; others were entirely unaware of it. The incidence of prior trauma to the genitals was negligible. Plaque formation or thickening of the median septum ranging in length from 2.5 to 0.5 cm. was found in the initial examination of all patients. The thickness of the plaque was never more than 0.5 cm. ASSOCIATED FINDINGS
The size of our study precludes statistical conclusions as to the associated occurrence of Accepted for publication February 15, 1966. Read at annual meeting of New York Section, American Urological Association, Inc., New York, New York, April 30-May 1, 1965. *Dexamethasone generously supplied by Merck, Sharpe & Dohme. 1 Furey, C. A., Jr.: Peyronie's disease: Treatment by the local injection of meticortelone and hydrocortisone. J. Urol., 77: 251-266, 1957.
venereal disease, arthritis or diabetes, but such trends, where found, are noted. With regard to venereal disease, it is seen that 3 patients (8 per cent) did have syphilis or gonorrhea. However, a similar finding may be established in any review of patients routinely treated in a large metropolitan clinic. We noted that several patients ,vere, at a relatively early age, afflicted with arthritis which frequently required hospitalization. Thirteen patients (34 per cent) were found to have osteoarthritis. Of these, five were in their 30's or 40's. In 3 cases (8 per cent) diabetes was also found. A total of 4 patients (10 per cent) in our series was found to have Dupuytren's contracture. This is noticeably greater than the 2 to 3 per cent incidence found in the older population and substantiates Kirby's findings. 2 Of the 13 patients who had x-ray examination of the penis, four revealed calcium deposition in the plaque. The course of these few patients was generally good except for 1 patient who was resistant to all modalities of treatment. METHOD OF TREATMENT
Since 1954, it has been the policy of Squier Urological Clinic to use injection of sterioids when ever possible. We believe this mode is of particular value in cases where the plaques are discrete and of relatively recent origin. Our observation is that lesions consisting of thickened median septa or old lesions are refractory to therapy and tend to respond poorly. We have also used vitamin E in a small number of cases. Other methods used in combination with steroid in this series have included radiotherapy, potassium aminobenzoate (potaba) and testosterone preparations by mouth. 1 The steroid preparation which we use is dexarnethasone (decadron) in amounts of 2 to 4 cc per plaque, administered weekly. The number of injections depends entirely on response and we do not hesitate to initiate a second or even a 2 Kirby, J. V.: An. des. Mal. des Org. G. U., Dublin Med. J., 1849-1850.
114
'
E''L!BROID INJEC'rION THERAPY FOR PEYRONIE'S DISEASE
third :c,cries of'"''''"·"" In this study, the greate,t number of injections to any patient was 62, in three series of treatments. During the course of treatment, we now start our patients on 100 mg. vitamin E 3 times a day. This is continued fot minimum of 4 months i\·henever possible. Potassium aminoiJenzoate was given according to the schedule of 12 gm. µer day in three divided doses. R~jSULTS
.\. summary oi results includes all types of treatment used from 1954 through 1964 (table 2). The analysis of improvement obtained in relation to treatrnent is noted \ table 3). Since Peyronie's disease is commonly 1w·noTP.ss1vP. we have disregarded new plaque formation in tabulating the success rate. 1Ye do not hold that a medication need prevent extension of the disease to be con·· ,jclered effective. The degree of attained in this di~ease is diflkult to quantitate except for the ~ize and/or consistency oi the plaque. With regard to relief of pain and sexual relations, we are compelled to accept tbe word of the patient himself. Perhaps the best indication is his wi) .. .lingness to continu,~ treaunent. vVhile some have discontinued tbe p;reat majority have TABLE
.l
been faithful to appointments and fa,Upear to feel tha,t have benefited. We found that 81 per cent (2.'i trw 31 case~ reviewed) were beuefited to moderai', or a marked degree (table 2) Steroid alone. Of a total of 14 patic·ms received only steroid injection:-s, 9 per profited markedly, while another :3 per cew) achieved moderate success. The rombiw2cl success rate is thus 85 per cent. Steroid ancl vitamin E. \Yith the additimia1 use of vitamin E, six of a total of 6 per cent) received marked or moderat,e ment. Of these, two were markedly four attained a moderate degree oi Therefore, we were able to 18 nt the :2(: patients. Additional averaging could be dune the 5 patients who received steroid in ~ombinatim" 0
TABLE
L Age distribution
Age (Yrs.)
No.
,,
30
10
1.5
1
* Age of l po.tient not known.
2. Resnlts of treatment Marked Improvement
No, Treated
Type of }\eJ.tment
Sieroid alone
14
vitamin E
6
Steroid, pot. aminobenzoa,te
3
Steroid, rndiotherapy
2
S \;eroid~~-~min E, mdiotherapy-·--------i----- 2 !
l
i
1
Steroid~~tamin~ r,,,Ii,Jtherapy, pot. ami· I
l
Steroid, vitamin E, pot, ammobenzoate
2
'-i
-----i----__
1·..-----,-----···----·-·---..-,
--------1 ----1- ______ ,_,_ ------
radiothernpy, testosterone
nobenzoate Steroid, vitamin E, radiotherapy, testoste-
rone, pot. aminobenzoa.te
·
j
1·
1
· - - - -
,
i-------·-·.
I
.
i I
-I
----1-
.-------1------·-I----1
I I
- - - - - - - - - ·---------
116
DESANCTIS AND FUREY
with other therapy, but the number of patients is so small that the results can only be considered random. Analysis of table 3 reveals the way in which patients were helped. Steroid alone or in combination with vitamin E. Ten patients had relief from pain; nine noted less curvature on erection and in nine we found the plaques to have disappeared or to have become smaller and/or softer. We found that in those 12 patients who noted decreased pain on erection by use of any modality of treatment and in whom the duration of symptoms is known, most were seen less than 4 months after the onset of symptoms. The same result is noted with men who received relief from curvature on erection, although to a lesser degree. Finally, of those in whom definitive decrease in size or softening of the plaque was reported, 87 per cent were seen within 6 months or less. One patient in this latter group was helped even after 3 years. N ocenti and associates have recently published the results of their work on collagen formation and steroid injection. 3 They have been able to depress the collagen content in artificially produced granulomas in experimental animals by using steroid injections (cortisone and dexamethasone). In their series, they injected steroids into the developing granuloma, substantiating our belief that the best results will be obtained in cases of young plaques. (It appears to us that Peyronie's disease may be an expression of premature aging of connective tissue which has received repeated small vascular insults. In these men, other systems seem to be similarly affected, e.g. arthritis, Dupuytren's contracture.) In this series we had 6 patients who received no benefit after therapy. Of these, one received steroid, vitamin E, radiotherapy and potassium aminobenzoate, and another received all of the aforementioned therapy in addition to testosterone. In two of these six radiotherapy had also 3 Nocenti, M. R., Lederman, G. E., Furey, C. A. and Lopano, A. J.: Collagen synthesis and C14-
labeled praline uptake and conversion to hydroxyproline in steroid-treated granulomas. Proc. Soc. Exp. Biol. Med., 117: 215-218, 1964.
TABLE
3. Type of clinical improvement treatment Less Decrease Curin Pain vature
type of
Plaque Smaller/ Softer
- - --Steroid
~s_ _s_
6
1
Steroid, vitamin E
2
Steroid pot. aminobenzoate
2
I 1
1-
3 ---
1
--- - ----
Steroid, radiotherapy
1
1 - - ---
Steroid, vitamin E, radiotherapy
1
-Steroid, vitamin E, pot. aminobenzoate
1 ---
Steroid, radiotherapy, testosterone
1
---
l
- - --1
I
I
been used without success. This suggests that if steroids will not improve the process, additional types of treatment will be of no benefit. Of these 6 patients three were seen at 11 months, 12 months and 24 months, respectively, after first noting symptoms. SUMMARY
The Squier Urological Clinic has used steroid injections in cases of Peyronie's disease with gratifying results. The rationale of this treatment stems from the effect of this material on the metabolisrn of connective tissue and its wellknown anti-inflammatory properties. The results of using vitamin E in combination with steroid have been sufficiently good to encourage continued use, even though to date it has been included in relatively few cases. With other types of treatment, we have achieved only indifferent results. Relief of certain symptoms appears to be time related; therefore we are encouraged to initiate treatment as soon as possible after the onset of symptoms.