Penile fibrosis

Penile fibrosis Regular follow-up of patients, with careful examination of the penis, is strongly recommended to detect signs of penile fibrosis. 

Intracavernosal (4%-l%) Penile pain (37%), prolonged erection, hypertension, localized pain, penile fibrosis, injection site hematoma or ecchymosis, headache, respiratory infection, flu-like symptoms... 

Intracavernosal alprostadil was effective and well tolerated in the treatment of erectile dysfunction, according to the results of a 6-month study (funded by Pharmacia Upjohn) in 848 men (mean age 52 years) with at least a 4-month history of erectile dysfunction (12). This is provided that the individual dose is established by titration and patients receive training in injection techniques and periodic supervision during treatment. An initial dose was established for each patient and the patients then administered the alprostadil themselves at home. Of 727 evaluable patients, 682 (94%) had at least one erectile response after the injection of alprostadil, and 88% of injections lead to a satisfactory sexual response. The most commonly reported adverse event was penile pain, reported by 44% of patients, but only after 8% of injections. In just over half of the patients who had penile pain, the condition was reported as mild. Prolonged erection, penile fibrosis, and priapism occurred in 8,4, and 0.9% of patients respectively. Treatment was withdrawn because of medical events in 4% of patients, and drug-related events accounted for treatment withdrawal in 2% of patients. 

A 26-year-old man who had taken risperidone 3 mg/ day and sodium valproate 1500 mg/day for 1 year developed a persistent erection, dysuria, and urinary incontinence, which did not respond to irrigation of the corpora cavernosa on two occasions and required surgical treatment (196). Prolonged priapism also resulted in penile fibrosis, associated with a high risk of permanent erectile dysfunction. 

Prolonged erection, penile fibrosis, and priapism occurred in 8, 4, and 0.9% of patients respectively. Treatment was withdrawn because of medical events in 4% of patients, and drug-related events accounted for treatment withdrawal in 2% of patients. 

Chew KK, Stuckey BGA, Earle CM, et al. Penile fibrosis in intracavernosal prostaglandin El injection therapy for erectile dysfunction. Int J Impot Res 1997 9 225-229. 

Penile fibrosis is a histological diagnosis. Urologists, however, usually use this term in a non-specific way to describe increased penile consistency at physical examination. While localized corporeal fibrosis is usually firm at palpation, diffuse fibrosis is not always recognized. 

A significant association was found between penile fibrosis and diabetes mellitus. This may be explained by the fact that diabetes mellitus produces microangiopathy of the small blood vessels, leading to defective oxygenation to the cavernous tissue and subsequently helping in fibrosis development... 

A 10% incidence of distal penile fibrosis has been reported following long-term use of intracavernous... 

Other authors report the presence of diffuse hy-perechoic and hypoechoic foci within the corpora cavernosa of patients with systemic sclerosis and penile fibrosis (Aversa et al. 2006). However, air bubbles that can be incidentally injected in the corpora cavernosa along with the vasoactive substance may mimic these features. 

There is no accordance in the literature on the sensitivity of ultrasound in detecting corporeal fibrosis. Some authors do not find ultrasound a sensible technique to diagnose or confirm penile fibrosis, reporting a positivity in less than 60% of patients with clinically evident penile fibrosis, consequent to prostaglandin intracavernous injection (Chew et al. 1997). Other authors, however, suggest that ultrasound could be helpful in demonstrating subclinical fibrosis (Moemen et al. 2004). 

Fig. 18.7. Diffuse penile fibrosis following prolonged ischemic priapism. Color Doppler axial image obtained after prostaglandin injection shows small peripheral vessels feeding the outer portion of the corpora cavernosa. Cavernosal arteries are obliterated...

Fig. 18.9. Penile fibrosis. Axial T2-weighted MR image showing low signal intensity around the cavernosal arteries and high signal intensity under the tunica albuginea (courtesy of Pietro Pavlica, Bologna, Italy)...

Fig. 21.10a,b. Cavernosal tissue scar andfibrosis. Axial scans obtained after intravenous microbubble injection, a Cavernosal tissue scar within the left corpus cavernosum presenting as a circumscribed area ( ) in which contrast enhancement is lacking, b Diffuse penile fibrosis following ischemic priapism. Peripheral enhancement ofthe corpora cavernosa is appreciable, while the central portion does not enhance... 

Intracavernosal injections are associated with several local adverse effects. Cavernosal plaques or areas of fibrosis at injection sites form in approximately 2% to 12% of patients. When these occur, the patient should suspend further injections until the plaques resolve. These plaques may cause penile curvature, similar to Peyronie s disease, which make sexual intercourse difficult or impossible. The cause for corporal fibrosis and plaque formation is unknown. This adverse effect may be caused by poor injection technique or by... 

Also isolated fibrosis of the penile septum (Brant et al. 2007) and ventral curvature secondary to fibrosis and scarring of the corpus spongiosum, which can result from urethral instrumentation, should be considered (Afsar and Sozduyar 1992). The ultrasound features of these pathological conditions are described in other chapters. 

This situation is less common than low-flow priapism and can be classified as congenital due to arterial malformations, traumatic usually associated with penile, perineal or pelvic trauma, iatrogenic following revascularization procedures or idiopathic. The local blood gas tension in these patients is arterial, and therefore the penis is not at risk of ischemia and subsequent fibrosis. 

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