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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 2  |  Page : 33-36

The Diagnostic Algorithm Patients Examination with Penile Deformation


1 Department of Urology, Nephrology and Andrology, Kharkov National Medical University, Kharkov 61022; Andrological Department, Regional Clinical Center of Urology and Nephrology Named by V. Shapoval, Kharkov, Ukraine
2 Andrological Department, Regional Clinical Center of Urology and Nephrology Named by V. Shapoval, Kharkov, Ukraine

Date of Web Publication26-Apr-2016

Correspondence Address:
Andrey Arkatov
Andrological Department, Regional Clinical Center of Urology and Nephrology Named by V. Shapoval, Moskovskiy av. 195, Kharkov - 61037
Ukraine
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2916.181216

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  Abstract 

Objective: The article outlines informational content of the methods used for treatment and diagnostic algorithm development for patients with different types of penile deformations. Materials and Methods: For last 10 years there 189 patients with penile deviations were examined and treated. For diagnostic we used questionnaires, US with Doppler, MRI and CT. According to erectile function, presence of inflammation in plaque methods of treatment (surgical or conservative) was chose. Results: Positive results were observed in 94% of patients after Nesbit operations (corporoplication) and in 82% of patients after corporoplastic. Effectiveness conservative treatment was about 70%. Conclusions: Pre-surgery examination of patients with penile curvature and any type of deformation must comprise ultrasound and pharmacodopplerography along with the medical history and physical examination. In controversial clinical cases in order to prove or discard possible inflammatory peri-process it is necessary to conduct MRI.

Keywords: penile deformation, Peyronie′s disease, ultrasound (US), magnetic-resonance imagination (MRI), diagnostic algorithm


How to cite this article:
Arkatov A, Knigavko O. The Diagnostic Algorithm Patients Examination with Penile Deformation. J Integr Nephrol Androl 2016;3:33-6

How to cite this URL:
Arkatov A, Knigavko O. The Diagnostic Algorithm Patients Examination with Penile Deformation. J Integr Nephrol Androl [serial online] 2016 [cited 2019 Aug 20];3:33-6. Available from: http://www.journal-ina.com/text.asp?2016/3/2/33/181216


  Introduction Top


It is difficult to argue that quality of life improvement is an essential task of contemporary medicine. One of the most important components of comprehensive life of the modern man is a sexual life which depends not only on the functional state of penis but also on its anatomical structure, which can be evaluated upon penis skin status, localization of the external urethra opening, penis size, and absence of any strains. [1]

Penis deformation is caused by changes of its any anatomical structures. In 1996, Dr. Scheplev systematized all penis deformation on the basis of two criteria: Physiological condition in which the penis appears deformed and penis anatomical structure defeat which causes deformation; that all allows to sum it up to the genesis of this pathology:

  1. Penis curvature that occurs only in the erectile state: Damage localized in the tunica albuginea; Peyronie's disease; congenital deformity of the penis; local fibrosis; and erectile deformation due to defect of inflatable cylinders prosthesis.
  2. Penis curvature appeared out of erection conditions: Congenital short urethra; epispadias; hypospadias; this type of deformation can be visualized in nonerect penis position and is enhanced during erection.
  3. Penis curvature appeared in nonerect penis and no enhanced during erection: Cavernous fibrosis; migration of penile prosthesis; glans penis diseases (ptosis, hemangioma); diseases of the skin and fascia (granuloma, twisted penis, scar deformity, and genital elephantiasis).
During the last years, detection frequency of the penis deformation has significantly increased, and the number of patients who wish to receive adequately both methods of conservative and surgical treatment is growing up. Not all types of penis deviation are applicable for surgical correction, in particular dorsal deformation <45° which allows patients to have a normal sexual life. However, lateral and ventral penile curvature <30° can significantly complicate introjection and require surgical intervention.

Surgical treatment of acquired penile curvature (Peyronie's disease, local fibrosis, diseases of the skin and fascia, etc.) must be conducted only in case of disease is stable for 3 months providing that duration of the disease is at least for 1 year that all can ensure adequate and long-term results of correction. [2] The choice of surgical treatment method of penile curvature is primarily dependent on the presence or absence of erectile dysfunction, as well as presence or absence of inflammation, level of deformation, and size of penis. [3] Preadmission it is important to identify possible organic genesis of erectile dysfunction. Provided that organic changes which influence on erectile mechanism are not revealed surgical correction should be focused on the elimination of erectile deformation. [4],[5]

At the moment, the following diagnostic methods are used to detect patients with penis deviation: Ultrasound (US), pharmaco dopplerography or pharm-induced duplex ultrasonography, magnetic resonance imaging (MRI), as well as X-ray of the penis using the soft rays and X-ray computer tomography (CT).

For the moment, US is the priority diagnostic method of patients with penis deviation and intracavernous fibrosis due to its low cost and noninvasive technique which allows to reveal changes in the intracavernous septum and possible localization, size, and calcification area of calcified fibrous on penis tunica albuginea. However, US does not provide high-quality images in all cases, especially the early stages of the disease when inflammation is dominant allows to visualize fibrotic induration only in 66-72%; [6],[7] in addition, it is low informative for evaluation of inflammation level. Duplex scanning allows to evaluate simultaneously the hemodynamics in the vessels and anatomical changes in the corpora cavernosa of penis. As a rule basic examination consists of sonography in B-mode of cavernous and spongy bodies, tunica albuginea, and both cavernous arteries. Then, it is evaluated the blood flow in at the same location using color Doppler. With the Doppler method, it is possible to assess microcirculation better. It is a must to evaluate blood vessels reactivity as a response to erection stimulation with medicaments for choosing a correct method of penis deviation treatment and patients selection for penis prosthetic repair. Therapy with prostaglandin E1 medicaments is used. Medication injections are administered intra cavernous with subsequent evaluation of blood flow in cavernous arteries for 20-30 min with 5 min intervals. As a response to pharmacological stimulation, the cavernous arteries diameter in normal conditions become approximately doubled, and quality assessment of blood vessel walls and its opening becomes possible for the whole length as well as spiral arteries of cavernous corpora and numerous collaterals between arteries are visualized.

The main quantitative indicators are the maximum (peak) systolic velocity (PSV) and end diastolic velocity.

On the basis of absolute values using the standard formulas following relative parameters are calculated: Resistance index and pulse index %. [8],[9] Deep dorsal vein is also easily accessible for visualization. As a response to vasoactive substances, blood flow in it is reduced or even completely subsided. Persistent blood flow in the dorsal vein after the administration of vasoactive substances is a specific sign of venous leakage.

MRI enables to provide expanded amount of information due to the high dimensional resolution and the possibility of multiple images. Initially, high tissue contrast of MRIs can be enhanced by the use of contrast agents. This method allows to make visible not only changes in the tunica albuginea but also to have judgment regarding of affection of corpora cavernosa, correlations of possible fibroplastic induration in the penis arteries. [10] The use of paramagnetic contrast agents significantly expands the range of diagnostic capabilities of MRI increasing its sensitivity and specificity. [11]

Penis survey X-ray makes it possible to visualize plaque only in case of availability of plaque's calcification areas. Taking in consideration relatively low informativity of this diagnostic method, especially on early stages of the disease, as well as availability of radiation exposure, X-rays of penis is recommended to be used only for differential diagnosis of Peyronie's disease. Cavernosography allows to evaluate the level of pathological process extension provided only availability of filling defect of contrast agent while spreading inside of corpora cavernosa and it is also used to examine venous hemodynamics of penis. Hence, taking in consideration invasiveness and radiation exposure the use of this method is limited.

Spiral CT of penis allows to estimate severity of clinical symptoms and morphological changes of penis. It enables determination of biomechanical characteristics of penis such as density of pathological areas, asymmetry degree for calculation of cross-sectional areas of corpora cavernosa, and pressure on adjacent undamaged areas of tunica albuginea. This information can be important for the determination of surgery volume and selection of grafts for corporoplastic. [12]

The object of this study was to determine the optimal diagnostic method of penile deviation according to its type for further treatment tactic selection and minimization of negative results of surgical treatment.


  Materials and methods Top


For the period from 2004 to 2015, there were 189 patients with penile deviations of the age from 18 to 74 years old in Andrological Department of Kharkov Regional Clinical Center of Urology and Nephrology named by V. Shapoval were examinated and cured. The largest group of patients had Peyronie's disease (n = 102), congenital deviation (n = 49), local fibrosis (n = 17), hypospadias, a congenital short urethra (n = 12), and cavernous fibrosis (n = 9). Presurgery examination comprised medical history, physical examination, US, pharmaco-dopplerography, and MRI upon necessity. X-ray of penis in the soft rays cavernosography and X-ray CT were performed in a few controversial and questionable clinical cases, as invasiveness and radiation exposure were taking into consideration.

Patients' examination has determined the choice of medical and surgical method treatment for penile curvature which was mainly depend on the presence or absence of erectile dysfunction, inflammation, as well as level of deformation and the dimension of penis.

One hundred and thirty-five patients had surgical treatment, and 54 patients were treated with medicaments only. The choice of surgery method was discussed together by doctor and patient, depending on level and type of penis deformation, erectile function ratio, clinical symptoms of the disease, as well as length of penis and patient's expectations.


  Results and discussion Top


In the group of patients with congenital deviation who underwent surgery corporoplication by Nesbit, as well as in patients with curvatures that are produced penile prosthesis, positive results were observed in 94% of patients. Unsatisfactory results indicated 6% of patients who are associated with a decrease in the length of the penis.

In the group patients who were operated corporoplastic without prosthetics, complete lack of deviation of the penis was observed in 82% of patients. The residual distortion (<15%), which does not reduce the functionality of the penis, was recorded in 18% of patients. Reducing the length of the penis marked 16%. After surgery, all patients erection remained at the preoperative level. However, after 2 years of observation, the deterioration of erectile function noted 19% of patients. We performed a retrospective analysis of preoperative examination and the results of surgical treatment.

It is noted that US in the early stages of the disease is not always possible to visualize fibroplastic induration tunica albuginea penis does not assess the activity of the inflammatory process. To identify structural changes in the cavernous fibrosis, and Peyronie's disease was carried US B-mode. Cavernous fibrosis in grayscale heterogeneity hypoechogenic looked like normal corpora cavernosa, which revealed echogenic foci. Peyronie's disease was noted local or diffuse thickening of the tunica iso - or slightly hyperechogenic, with possible acoustic shadows in the calcification of fibrous plaques. When Doppler lower maximum PSV in the cavernous arteries after pharmacological stimulation testified in favor of the arterial erectile dysfunction. It should be noted that in addition to PSV, indexes of arterial insufficiency were slow acceleration and low value of the acceleration. Duplex method made it possible to directly visualize vessels. The narrowing of the vessel lumen and wall calcification was typical of the atherosclerotic lesion. Lack of increase in cavernous artery diameter in response to pharmacological stimulation indicated the loss of elasticity of the walls.

MRI reveals patients with severe inflammation in the early stages fibroplastic induration, cavernous fibrosis leads to a deviation of the penis, and the predicted positive effect of conservative therapy.

When using contrast agents increase the focal magnetic resonance signal intensity during MRI indicative of active inflammation, and thus made it possible to obtain information about the severity of fibroplastic process.

In doubtful cases, the clinical carried spiral CT allows the penis to calculate the severity of clinical symptoms and morphological changes of the penis, however, taking into account radiation exposure, its use was limited to us.


  Conclusions Top


Presurgery examination of patients with penile curvature and any type of deformation must comprise US and pharmacodopplerography along with the medical history and physical examination. In controversial clinical cases to prove or discard possible inflammatory peri-process, it is necessary to conduct MRI and spiral CT of penis which allow calculating clinical symptoms severity and morphological changes of penis. Diagnostic results undervaluation of erectile dysfunction and inflammation after examination of patients with penile deviations on presurgery stages leads to its progress in postsurgery period and increases the amount of negative postsurgery results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Goryachev A, Scheplev PA. Treatment of Penile Curvature in the Third Millennium//Selection of Works of the 2 nd Symposium on Male Genital Surgery; 1999. p. 72.  Back to cited text no. 1
    
2.
Hurzhenko YM. Fibroplastyc penis induration. Kyyiv: Zdorov'e; 2004. p. 383.  Back to cited text no. 2
    
3.
Nicolai M, Carriero A, De Thomasis R, Iantorno R, Longeri D, Zefferini M, et al. Dynamic magnetic resonance imaging versus dynamic echography in the staging of Peyronie's disease. Arch Ital Urol Androl 1996;68 5 Suppl:97-100.  Back to cited text no. 3
    
4.
Dmitriev DG, Permjakova OV. Aspects of the pathogenesis of erectile dysfunction, Peyronie's disease. Theses of scientific works of the 1 st Congress of Andrology Professional Association in Russia, Kislovodsk-2001-Supplement to the journal. Andrology and Genital Surgery 2001. P1: S42.  Back to cited text no. 4
    
5.
Egydio PH, Lucon AM, Arap S. Treatment of Peyronie's disease by incomplete circumferential incision of the tunica albuginea and plaque with bovine pericardium graft. Urology 2002;59:570-4.  Back to cited text no. 5
    
6.
Pryor J, Akkus E, Alter G, Lue TF, Basson R, Rosen R. et al. Priapism, Peyronie's disease and penile reconstructive surgery. In: Giuliano F, Khoury S, Montorsi F, editor. Sexual Medicine and Sexual Dysfunctions in Men and Women. Plymouth, United Kingdom: Health Publications; 2004. p. 383-409.  Back to cited text no. 6
    
7.
Vosshenrich R, Schroeder-Printzen I, Weidner W, Fischer U, Funke M, Ringert RH. Value of magnetic resonance imaging in patients with penile induration (Peyronie's disease). J Urol 1995;153:1122-5.  Back to cited text no. 7
    
8.
Sánchez de la Vega J, Amaya Gutiérrez J, Alonso Flores JJ, García Pérez M. Erectile dysfunction in those under 40. Etiological and contributing factors. Arch Esp Urol 2003;56:161-4.  Back to cited text no. 8
    
9.
Scheplev PA, Kurbatov DG. Small penis. Moscow: Medicina; 2003.  Back to cited text no. 9
    
10.
Hricak H, Marotti M, Gilbert TJ, Lue TF, Wetzel LH, McAninch JW, et al. Normal penile anatomy and abnormal penile conditions: Evaluation with MR imaging. Radiology 1988;169:683-90.  Back to cited text no. 10
    
11.
Rink P, Sinitsyn VE. Contrast agents for CT and MRI. Basic principles. J Radiol 1995;V7:S51-9.  Back to cited text no. 11
    
12.
Scheplev PA, Chibisov MP, Al-Gas AG, Mufaged M, Garin N. Evaluation of the biomechanical aspects of damage to the penis during PD using multislice computed tomography. Androl Genit Surg 2004;V11:60-3.  Back to cited text no. 12
    




 

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