Mr. Karel Koci, M. D., Andrology Clinic Andromeda, Prague, CZ
Mr. Miroslav Prochazka, M. D., Rehabilitation Clinic Jarov, Prague, CZ

Therapy of Morbus Peyronie (Induratio Penis Plastica) with non - invasive laser was suggested by Necasova (Brno, CZ) already in the early nineties. Our study has followed the total of 45 patients suffering from this rather rare urological clinical complaint since 1996. Occurrence about one per cent in male population is reported.

So far aethiology of this affection has not been explicitly known, most probably it is an auto-immune inflammatory process in a way of proliferous inflammation, accompanied by an overproduction of fibrin together with its conversion, resulting in palpable indurations of cavernous corpora as well as in bizarre deformations of penis during erection. However, it is usually for the painfull erection, which is a typical concomitant, that patients are stirred to see a doctor. Similarly, most of our patients sought a doctor not because of deformities and deviations during erection, but their pain was the main reason. Certain analogy with Dupuytren´s contracture in palmar aponeurosis can also be seen. No wonder that we can detect both these clinicals accompanying each other, according to literature in 9 to 16 per cent (for our results see later).

So far therapy of Morbus Peyronie has been utilizing mainly medication (colchitine, E vitamin, antiestrogens...), certain success has been achieved also by injections of active matters into cavernous corpora, and some patients have profitted of surgical therapy. Since the late eighties we have experienced a renaissance of physiotherapy, mainly thanks to applications of non - invasive laser beam.

From the point of view of non - invasive laser therapy (LLLT) it is a typical test case for we are utilizing stimulative effect of LLLT (resorption of overproduced fibrin) as well as antiflogistic and analgetic effects. Our results have convictively proven that these theoretical postulates correlate with clinical practice more than successfully, too.

Our clinical group consisted of 45 patients aging from 24 to 79 years. Avarage age was 52.8 years, fourth to sixth age decades prevailing. Average duration of pathological changes, reported by the patients, was 12 months.

In full accordance with literature, 39 patients (86.7 per cent), who were not aware of the starting factor of their complaints, definitely prevailed. Six patients (13.3 per cent) were aware of the crux in the membrum - three patients (33.3 per cent of the group!) reported trauma during sexual intercourse, furthermore there was trauma after a long - term catheterization during unscousciousness after an accident, an impact of erected penis on a toilet seat, and condition after an intracavernous application of medicaments after a potency disorder.

Parallel occurrence of Dupuytren´s contracture (28.9 per cent = 13 patients of our group) was an interesting fact. We are of the opinion that the difference between our figures and generally reported statistics is a result of examination of patients by a rehab specialist with much more sensitivity to detect even initial phases of this diagnosis. Three patients (6.66 per cent) reported occurrence of Dupuytren´s contracture in family anamnesis.

Patients were examined by a urology specialist as well as by a doctor specialized in physiotherapy and rehabilitation. Medicamentous therapy was directed by the urologist, most frequently with medication based on colchicine (64.4 per cent), on E vitamin (usually simultaneously with colchicine - 53.3 per cent), on anti - estrogens (tamoxifen - 13.3 per cent) and on systemic enzymetherapy (6.7 per cent). Our paper is focussed on physiotherapy of the affection, and that is why it is not going to deal with the issue of medication. However, we consider necessary to mention that 13.8 per cent of patients with most frequent medication of colchicine had to leave out this medicament for unwanted side effects, mostly on the level of gastrointestinal tract.

Physiotherapy has been chosen as a combination of ultrasound and LLLT. Ultrasound (0.5 W/cm2 - 5 minutes per procedure) was added to the therapy of all patients as a routine, especially with regard to theoretical effect on erosion of syndesmotic bridges in emerging indurations. It must be stressed that our long - term experience has enlightened us about combination of these two techniques of physiotherapy being much more effective for patients than any of these techniques applied separately.

Ultrasound was combined with LLLT with the following parameters:

- wavelength: 830 nm (IR)
- power output: 200 and 300 mW
- emitted dosage of energy: individually according to the scope of indurations,
however minimum of 80 J/cm2 with continuous wave
and minimum of 30 J/cm2 with frequency of 5 Hz.

We have been duly using protective appliances (glasses) when applicating LLLT, and we avoided applications on the area of gonads.

At the beginning we decided for series of 20 procedures, applied twice a week, with the first checkup by a doctor after 10 procedures. In case of detection of no clinical improvement, meaning regression of indurations and deviations during erection, after 10 procedures, the therapy was abandoned. This was observed only in 4 cases. However, even with these patients antalgic effect could be noticed.

Further attendance was ordered strictly individually according to development of clinical state as well as to subjective complaints of patients. Most frequently this therapy was followed by little series of procedures (mostly 5 procedures) in weekly intervals, one to four times a year.

In average 24 procedures were applied (ranging from 8 up to 53 procedures).

Therapy has been accomplished (and thus being observed and visiting on are) 38 patients, i.e. 84.4 per cent. Seven patients, i. e. 15.6 per cent, have broken off attendance (1 patient moved off, the others for an unknown reason, probably due to problems with long term attendance).

Thirty three patients can be regarded to as to patients with terminated attendance (long - lasting unchanging state with checkups 1 or 2 times per year, with possible little series of procedures at a time). Six other patients are still being under dynamics of development of clinical progression and therefore have not been included in further classification. Following figures represent 33 patients with terminated attendance of intensive therapy, who are regularly observed by both urology and rehabilitation specialists.

Four patients (12.1 per cent) remained with no effect on resistance and deviations during erection. However, even those patients reported antalgic effect.

Minimum resistence (up to absence of palpable detection), but with lasting deviation of membrum during erection has 13 patients (39.4 per cent).

Minimum resistence (up to absence of palpable detection) without further deviation of membrum during erection has 16 patients (48.5 per cent).

It is more than interesting that after our therapy 100 per cent of patients suffer from no pain during erection! This also applies to patients, who had no other profit from our therapy. Prompt analgetic effect is a typical feature of LLLT, and it appears usually after second or third procedure! With regard to the fact that pain is obviously the constituent making the patient to visit a doctor, we see this point as the most interesting and attractive.

Discussion: There are several very interesting facts stemming from our study.

1. On a rather representative group of patients being followed for a long time, a frequent co - incidence of Morbus Peyronie and Dupuytren´s contracture has been demonstrated, with the occurrence of almost one third of patients (28.9 per cent). This point is important also for prognostic reasons - we can consider these patients more resisting the therapy, it was usually necessary to choose higher number of treatments, and results of therapy usually do not fully correspond with anticipations (persisting deviations during erection, ineffective therapy).

2. We consider rather surprising the unique analgetic effect of therapy in combination of these two methods of physiotherapy - ultrasound and LLLT. Similarly, this effect is reported from all medical offices which deal with this therapy, and this very clinical experience has also been corroborated by our colleagues from our country as well as from abroad (USA, Italy).

3. Furthermore, therapeutic effect on stimulation of indurations of cavernous corpora is also satisfactory. Frequent persistence of deviations of penis even with substantial resorption of infiltrates reaching up to subsidence of palpable indurations. We are of the opinion that this is a manifestation of spatial transformations of fibrinous stroma of cavernous corpora, persisting even after resorption of oveproduced syndesmatic matters ...

4. The best results have been obtained with patients, who were clearly aware of the irrigating incitement of aetiology of the ailments (in a way of a trauma nearly in all cases). Here full series of introductory 20 procedures have never been finished.

5. We regard as the crucial point of LLLT the emitted dosage of energy (which can be reached only with a sufficiently powerful probe).

6. Unfortunately, aetiology of the ailments cannot be induced by the therapy. That is why we keep following our patients regularly and apply at least once a year a little series of procedures on most of them. A rather sensitive signal to start therapy again is appearance of a pain during erection, even though absence palpable deformities or deviations of penis.

7. We consider very positive that no changes, which could be regarded to as to contrarious side effect of the therapy, have been noticed on any patient. Thanks to absence of any unpleasant feelings, as well as to clinical results, very good compliance of patients is a rule, with the only exasperation being necessity of more numerous procedures to reach sought-after effect.

Conclusions:
We have uncompromisingly proven clinical results of a combined therapy with the use of two methods of physiotherapy - ultrasound and LLLT - on a rather representative group of 45 patients suffering from Morbus Peyronie, followed in the period between 1996 - 2000.