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Focus on treatment of erectile dysfunction and Peyronie’s disease

Presented by
Dr Uros Milenkovic, Dr Antonio Ruffo, Dr Amr Abdel Raheem
EAU 2019
In Peyronie’s disease (PD) two abstracts, one from Italy and one from the US (Gocci et al., and El-Khatib et al., respectively), reported substantial efficacy of intralesional collagenase injection in atypical or hourglass PD curvatures and ventral deformities.

While the initial studies were performed in typical PD with dorsal curvature [1], the Italian study demonstrated improvement of >20 degrees in 57% of their cohort; whereas in the US study 90% patients had an improvement of >20 degrees. Both studies convincingly showed that, for atypical PD patients, injection of this therapy seems to confer benefit and it can be used to avoid surgery in these cases. In more news about PD, we saw some exciting basic research from Dr Uros Milenkovic and colleagues (Catholic University Leuven, Belgium) who performed state-of-the-art RNA sequencing of the fibrotic plaques from PD. To their surprise, despite the fact that all plaques were taken from patients in the chronic phase of this disease where inflammation has presumably subsided, the data indicated that even though there is still a high turn-over of the extracellular matrix, it seems that this process is not necessarily maintained by myofibroblasts. Instead, a persistent immunological signature was apparent mainly involving macrophages. The novel hypothesis the authors proposed states that in PD fibrotic lesions, NF-kB-signalling can activate and maintain the presence of macrophages, which in turn activate the adaptive immune system involving T cells. The molecular understanding of PD pathophysiology might lead to the discovery of new targetables for pharmacological treatment, perhaps allowing an alternative to morbid surgery.

In terms of erectile dysfunction (ED), several treatment options are being explored. Shockwave therapy is an up and coming treatment for ED; treatment consists of non-invasive low-intensity sound waves that pass through erectile tissue, restoring natural erectile function by clearing plaques out of blood vessels and stimulating the growth of new blood vessels. Dr Antonio Ruffo and colleagues (Hospital Santa Maria delle Grazie, Italy) combined shockwave therapy with platelet-rich plasma (which is also being explored in this setting [1]) in a randomised control trial (n=60). They found that while shockwave therapy had a modest improvement in IIEF scores, the addition of platelet-rich plasma to shockwave therapy made these scores go up by about 8 points, allowing these men to have improved unassisted spontaneous erections. Percutaneous angioplasty for ED was tested in a small case series of only 6 patients by Marcer et al. (University Hospital Verona, Italy). This cohort was not responsive to pharmacological treatment before the experimental angioplasty. At 8 months after angioplasty, three men were fully responsive to PDE5 inhibitors, two men became responsive to intracavernosal injection therapy, and one patient did not respond at all but had to resort to a penile implant.

Dr Amr Abdel Raheem (Cairo University Hospitals, Egypt and University College London Hospital, United Kingdom) presented interim results (n=70, total will be 160) of his phase 2 randomised control trial that explored the efficacy and safety of botulinum toxin injection in the corpus cavernosum. He concluded that the botox-treated patients had a median improvement of 4 points in their IIEF5 scores over the placebo-treated group, indicating that this may be a promising treatment we may see emerge in the next few years.

  1. Epifanova MV et al. Sex Med Rev. 2019 Mar 19. pii: S2050-0521(19)30008-3.

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