Induratio penis plastica - eine Übersicht

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Die Induratio penis plastica gehört zu den interessanten urologischen Erkrankungen, deren Ätiologie und Pathogenese und somit auch die Therapie noch nicht befriedigend geklärt sind. Veränderungen des Kollagenstoffwechsels werden diskutiert, traumatische Ursachen ebenfalls angenommen. Spontanremissionen werden beschrieben. Die Therapie unterscheidet eine konservative initiale Phase, die oft kein befriedigendes Ergebnis bringt, und verschiedene operative Eingriffe, die als wirksam aber symptomatisch anzusehen sind.

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We have reviewed the literature about the clinical use of alpha-tocopherol (vitamin E) in dermatology. A short introduction is given on tocopherol chemistry and pharmacology. Pharmacodynamic aspects of tocopherol action, such as its antioxidant, anti-inflammatory, mesenchymal, photoprotectant and membrane modulating activities, are discussed. The significance of oxidative stress in skin pathology is outlined and a specific role that tocopherol may play in this szenario is suggested. We provide a summary of various skin diseases, which have been treated with some success with tocopherol. The clinical efficiency of tocopherol in treatment of chronic cutaneous lupus erythematodes is evaluted in detail and the mechanism of action is discussed. An analysis of its cutaneous and systemic side effects is given and an extensive list of references presented.
The clinical and laboratory findings in 106 patients with Peyronie's disease as well as histopathological examinations of biopsies from the plaques were studied. The clinical symptoms and signs were in general similar to those found in previous studies, but bone marrow smears showed an increased number of plasma cells and lymphocytes in 18 of 24 examined. Biopsy of the plaque in cases of long-term symptomatology disclosed a fibrosis poor in cellular components. In patients with a short history of the disease and a tender induration, an inflammatory component of the specimens with perivascular accumulation of lymphocytes and balooning of endothelial cells in the small vessels was seen. Characteristic cells with "cross-banded" nuclei, described earlier only in Dupuytren's contracture and experimental fibrosis, was observed for the first time in Peyronie's disease. Based on these findings a combined traumatic-immunological etiology is suggested.
Five patients with Peyronie disease were treated successfully with a surgical technique derived from Nesbit's technique for the treatment of congenital curvature of the penis. Excision of ellipses of tunica albuginea from the convex side of the penis as described by Nesbit was not done, but instead the tunica was reeved with nonresorbable sutures to achieve straightening. The surgical technique combined with prior radiotherapy was successfully applied to patients with severe forms of Peyronie disease. More experience is necessary to establish the value of the proposed treatment concept.
Despite numerous studies, there has been no definitive HLA association with Peyronie's disease. Results of available studies have been reviewed and compared to determine if the cumulative evidence supports any immunogenetic, HLA association with Peyronie's disease. Data from reports of HLA associations with Peyronie's disease were reanalyzed by categories of reported HLA class I or class II antigens in comparison with recently available large population analysis of the frequencies of these antigens in the normal population. Data were also considered by whether they were derived from population or family analyses. The results of 4 series of patients testing an association of Peyronie's disease with the HLA class I antigens, in particular the B7 related antigens, were contradictory. A B7 association was not confirmed in 2 larger series and, in fact, the B7 related antigens were observed in frequencies expected in a normal population, suggesting that the associations observed in the smaller series were due to chance. An association with the HLA class II antigen, DQ2, was found in 1 of the larger series. Reported family studies suggest a genetic basis for Peyronie's disease but do not indicate a gene closely linked to the HLA complex. Considering all available data, Peyronie's disease appears to be multifactorial in pathogenesis. Because Peyronie's disease is likely heterogeneous and because available studies have analyzed serologically defined HLA antigens, future studies to define HLA alleles molecularly and to characterize patient subgroups may clarify an immunogenetic basis.
We define the cause of the occurrence of Peyronie's disease. Clinical evaluation of a large number of patients with Peyronie's disease, while taking into account the pathological and biochemical findings of the penis in patients who have been treated by surgery, has led to an understanding of the relationship of the anatomical structure of the penis to its rigidity during erection, and how the effect of the stress imposed upon those structures during intercourse is modified by the loss of compliance resulting from aging of the collagen composing those structures. Peyronie's disease occurs most frequently in middle-aged men, less frequently in older men and infrequently in younger men who have more elastic tissues. During erection, when full tumescence has occurred and the elastic tissues of the penis have reached the limit of their compliance, the strands of the septum give vertical rigidity to the penis. Bending the erect penis out of column stresses the attachment of the septal strands to the tunica albuginea. Plaques of Peyronie's disease are found where the strands of the septum are attached in the dorsal or ventral aspect of the penis. The pathological scar in the tunica albuginea of the corpora cavernosa in Peyronie's disease is characterized by excessive collagen accumulation, fibrin deposition and disordered elastic fibers in the plaque. We suggest that Peyronie's disease results from repetitive microvascular injury, with fibrin deposition and trapping in the tissue space that is not adequately cleared during the normal remodeling and repair of the tear in the tunica. Fibroblast activation and proliferation, enhanced vessel permeability and generation of chemotactic factors for leukocytes are stimulated by fibrin deposited in the normal process of wound healing. However, in Peyronie's disease the lesion fails to resolve either due to an inability to clear the original stimulus or due to further deposition of fibrin subsequent to repeated trauma. Collagen is also trapped and pathological fibrosis ensues.
All cases of Peyronie's disease in the files were reviewed to determine the chief microscopic findings and also to note the anatomical site of the disease process. The microscopic findings in 19 cases were evaluated using hematoxylin and eosin sections, and Masson trichrome was frequently used to highlight alterations of collagen structure. Movat elastic stain and fibrinogen immunostain for fibrin were used in some cases. A perivascular lymphocytic infiltrate was found in 6 of the 19 cases, located either within the tunica albuginea or on either side of it. A linear band of ossification was found in the tunica in 5 cases. Disorganization of the collagen of the tunica was present in all cases, usually associated with a slight increase in cellularity. In 3 of 10 cases fibrin was demonstrated in the affected area of the tunica. Peyronie's disease is characterized by an alteration in the appearance and cellularity of the collagen that comprises the tunica albuginea. Ossification in the middle or inner aspect of the tunica may occur, and a perivascular lymphocytic infiltrate may or may not be present within the tunica or on either side of it.
We studied the fine architecture of the tunica albuginea of the penis. The study included 6 human male cadavers and 10 surgical patients (5 with Peyronie's disease and 5 with normal penile anatomy). The tunica albuginea of the corpora cavernosa is a bi-layered structure with multiple sub layers. Inner layer bundles support and contain the cavernous tissue and are oriented circularly. Radiating from this layer are intracavernous pillars acting as struts, which augment the septum and provide essential support to the erectile tissue. Outer layer bundles are oriented longitudinally. These fibers extend from the glans penis to the proximal crura, where they insert into the inferior pubic ramus. There are no outer layer fibers between the 5 and 7 o'clock positions. Elastic fibers normally form an irregularly latticed network on which collagen fibers rest. In Peyronie's disease the well ordered appearance of the collagen layers is lost: excessive deposits of collagen, disordered elastic fibers and fibrin are found within the region of the plaque. The normal 3-dimensional structure of the tunica affords great flexibility, rigidity and tissue strength to the penis, which are lost consequent to structural changes in Peyronie's disease.