Platelet-rich plasma in selected urological conditions: a narrative review of biological rationale, current evidence, and limitations

Introduction

PRP is increasingly promoted across several areas of urology, yet the clinical literature remains fragmented and uneven in quality. A major problem in this field is the gap between biologic enthusiasm and evidentiary maturity. Platelet-rich plasma (PRP) composition is highly variable, reporting standards are inconsistent, and some publications or marketing materials make claims that extend well beyond the data available (1-4).

The aim of this revised review is therefore deliberately modest: to provide a cautious narrative overview of PRP biology, preparation and classification, urology-relevant mechanisms, disease-specific clinical evidence, and the principal methodological and safety limitations that currently prevent broad routine adoption. We present this article in accordance with the Narrative Review reporting checklist (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0084/rc).

Methods

This article was prepared as a narrative review. It should not be interpreted as a systematic review or meta-analysis.

A focused literature search was performed in PubMed and Web of Science and updated to March 2026. We used combinations of controlled vocabulary and free-text terms related to “platelet-rich plasma”, “PRP”, “urology”, “erectile dysfunction”, “Peyronie’s disease”, “interstitial cystitis”, “bladder pain syndrome”, “urethral stricture”, “hypospadias”, and “urinary incontinence”. The search strategy summary is presented in Table 1, and an example detailed search strategy is provided in Appendix 1.

Representative English-language preclinical studies, clinical trials, cohort studies, and relevant evidence syntheses were reviewed. Particular attention was paid to study design, clinical endpoints, PRP preparation details, and whether the cited evidence directly supported the claims made in the text.

Because the purpose of this article was to provide a narrative overview rather than a formal evidence synthesis, we did not generate a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram, perform a formal risk-of-bias assessment, or grade certainty of evidence. The revised manuscript therefore avoids language implying systematic synthesis.

PRP preparation, classification, and why heterogeneity matters

One of the main reasons PRP studies are difficult to compare is that “PRP” is not a single uniform product. Reported formulations differ in platelet dose, efficiency of platelet capture, final plasma volume, the presence or absence of leukocytes, and whether exogenous activation is used before administration (5-7). The DEPA classification emphasizes platelet dose, efficiency of production, purity, and activation, whereas the PAW system classifies PRP according to platelet number, activation, and white blood cell content (6,7).

These variables are not merely technical details. Leukocyte-rich and leukocyte-poor preparations may differ in inflammatory signaling, protease content, and short-term tissue response, and studies that fail to report these features cannot easily be pooled or generalized (5). For the urologic literature, this heterogeneity is a major source of between-study inconsistency and should be treated as a methodological limitation rather than as a peripheral laboratory issue.

From a translational perspective, future urologic studies should report at least the blood volume processed, spin protocol, final injected volume, platelet enrichment, leukocyte content, activation method, injection schedule, and whether imaging or cystoscopic guidance was used. Without these details, even positive trials remain difficult to replicate in routine practice.

Urology-relevant mechanisms

The most plausible mechanisms of PRP in urology are tissue specific and should be distinguished from broader claims drawn from orthopedics or dermatology. In penile tissue, preclinical studies suggest that PRP may support endothelial integrity, reduce apoptosis, and facilitate recovery after cavernous nerve injury, thereby improving erectile tissue remodeling and nitric oxide-dependent signaling (2,8,9). However, the translational relevance of these animal data to heterogeneous human erectile dysfunction (ED) remains uncertain.

In bladder-centered disorders such as interstitial cystitis/bladder pain syndrome (IC/BPS), PRP has been proposed to enhance urothelial regeneration and barrier recovery. Human biopsy-based studies have reported improved expression of proteins associated with urothelial proliferation, cytoskeletal organization, and barrier function after repeated intravesical PRP injection, supporting a biologically plausible mechanism beyond symptom-only effects (10,11).

In urethral reconstruction and sphincteric dysfunction, the main hypothesized effects are improved angiogenesis, support for graft take, modulation of early inflammation, and attenuation of fibrosis (12-17). Nevertheless, mechanistic evidence in these indications remains incomplete, and human efficacy cannot be inferred from biologic plausibility alone.

Figure 1 is schematic and intended to summarize biologically plausible mechanisms rather than proven clinical pathways.

Figure 1 Proposed biological pathways by which PRP may influence urologic tissues. ED, erectile dysfunction; EGF, epidermal growth factor; IC/BPS, interstitial cystitis/bladder pain syndrome; IGF-1, insulin-like growth factor 1; PDGF, platelet-derived growth factor; PRP, platelet-rich plasma; TGF-β, transforming growth factor-beta; VEGF, vascular endothelial growth factor.

Clinical evidence by disease category

The available clinical literature is best interpreted by disease category. Across conditions, three recurrent problems limit certainty: small sample sizes, inconsistent PRP composition reporting, and variable use of controls or sham procedures. Selected clinical evidence is summarized in Table 2.

ED

ED is the most studied urologic indication for PRP, but it is also the indication in which placebo and expectancy effects are most difficult to disentangle. Early uncontrolled or small comparative studies reported improvements in International Index of Erectile Function (IIEF) scores after intracavernosal PRP, which led to rapid clinical uptake in some markets (2,3).

However, randomized evidence is mixed. In the prospective double-blind placebo-controlled trial by Masterson et al., 61 men were randomized and no difference was seen between PRP and placebo in the proportion of men reaching a minimum clinically important difference at 1 month (18). A later randomized placebo-controlled study reported benefit mainly in men with mild or mild-to-moderate vasculogenic ED, illustrating how results may depend on disease severity, protocol, and analytic choices (19).

The interpretation of pooled evidence also remains unsettled. Some meta-analyses have suggested short-term improvement, but a 2026 updated meta-analysis of randomized controlled trials found low-to-moderate certainty evidence that platelet-rich therapies were not superior to placebo overall (24). Taken together, the ED literature supports continued investigation, but not confident claims of established efficacy.

This cautious interpretation is consistent with society-level guidance. The Sexual Medicine Society of North America stated that restorative therapies such as PRP should be reserved for clinical trials (25). The American Urological Association similarly advises that PRP should not be offered for ED outside an institutional review board-approved research context (26), and the European Association of Urology (EAU) has recommended against ED use outside clinical trials (27).

Peyronie’s disease (PD)

PRP has also been explored in PD, usually through intralesional injection protocols. Current evidence is limited to small pilot studies, retrospective cohorts, and early randomized updates rather than mature multicenter trials. Schirmann et al. reported acceptable short-term tolerance in a pilot series but emphasized the need for placebo-controlled confirmation (20). Subsequent small studies suggested possible improvements in curvature, pain, or patient-reported symptoms, but protocols often combined PRP with penile modeling, tunneling, hyaluronic acid, or oral therapy, which complicates causal interpretation (3,28,29).

Recent EAU guidance remains cautious. Earlier guideline updates recommended not using intralesional PRP for PD outside clinical trials, and the 2026 guideline update continues to emphasize that the available data are limited (27). Accordingly, PD should be presented as an exploratory rather than proven indication.

IC/BPS

The IC/BPS literature is more coherent than some other urologic PRP fields because several studies come from a single research group using related intravesical protocols. A pilot case-control study reported symptomatic improvement after repeated intravesical PRP injection in refractory IC/BPS (21). Subsequent studies described changes in urinary biomarkers and improvements in bladder urothelial ultrastructure and barrier-associated proteins after repeated injections, lending mechanistic support to the clinical signal (10,11,30).

Even so, the evidence remains preliminary. Most studies are single-center, nonblinded, and protocol specific. A 2025 systematic review and meta-analysis including 13 studies and 426 patients found significant post-treatment improvements in pain and symptom scores, but also emphasized the limited number of controlled studies and the need for more rigorous trial designs (31). Therefore, IC/BPS is a promising but still investigational application.

Urethral reconstruction, urethral injury, and hypospadias repair

PRP has been investigated as an adjunct in urethral healing and hypospadias surgery. In preclinical urethral injury models, Aydin and colleagues found that intraurethral or submucosal PRP reduced inflammation, edema, and fibrosis, supporting further translational work (13,14).

Clinical evidence is still sparse. Scarcia et al. reported that PRP gel use during buccal mucosal urethroplasty was feasible in a small preliminary series, but the study was not designed to establish comparative efficacy (12). In pediatric hypospadias surgery, several randomized or comparative studies have reported lower fistula or infection rates when PRP was used as an additional covering layer, including recent trials published in 2025 and 2026 (15-17). These findings are encouraging, but they remain procedure-specific and require external validation before generalization to all urethral reconstruction settings.

Urinary incontinence

PRP injection has also been explored for sphincteric urinary incontinence. In post-prostatectomy incontinence, prospective single-center studies by Lee et al. reported symptomatic improvement after repeated urethral sphincter injections, with no major safety signal but without sham control (22). In intrinsic sphincter deficiency and female stress urinary incontinence, proof-of-concept and mid-term follow-up studies suggested improvement in selected patients after repeated sphincter injections (23,32).

Nevertheless, these data remain exploratory. A 2025 scoping review concluded that PRP may have potential in stress urinary incontinence, but stressed the scarcity of high-quality randomized data and the major heterogeneity of protocols and outcomes (33). As with other indications, routine clinical adoption would be premature.

Safety, regulation, and implementation barriers

Safety considerations

The safety profile of PRP is often described as favorable because the product is autologous, yet this should not be equated with proof of long-term safety. Reported adverse events in urologic studies are usually mild and transient, including injection-site pain, hematuria, dysuria, swelling, or short-term discomfort (18,20,22,23,32,33). However, most published series are small and underpowered to detect uncommon or delayed complications.

Several additional safety issues deserve explicit discussion. First, product contamination remains possible if preparation and handling are not performed under rigorous aseptic conditions. Second, the variability in leukocyte content and activation strategies may alter inflammatory response. Third, growth-factor-rich preparations raise a theoretical concern in oncologic settings, although convincing clinical evidence of tumor promotion in urology is lacking (34). These uncertainties reinforce the need for careful patient selection, transparent consent, and protocolized reporting.

Regulatory and implementation barriers are similarly important. PRP remains outside routine guideline-endorsed care for most urologic indications, reimbursement is inconsistent, and commercialization can amplify expectations beyond the evidence. In this context, clear counseling about investigational status is part of safe practice.

Why the evidence remains uncertain

The current PRP literature in urology is limited not only by study size but also by conceptual and reporting problems. Commercial uptake has preceded standardization, and many publications fail to document PRP composition, platelet dose, leukocyte status, or activation method. Clinical endpoints also vary substantially, ranging from symptom questionnaires to imaging or hemodynamic measures, which complicates synthesis across studies (1,6,7).

In sexual medicine, sham effects are especially important because the intervention is invasive, expectation-laden, and frequently marketed directly to patients. This context makes sham-controlled trials essential for ED and PD. Across all urologic indications, multicenter disease-specific trials, core outcome sets, and minimum reporting standards for PRP composition are urgently needed.

Future research directions

Future research should shift from broad enthusiasm to disciplined standardization. At a minimum, studies should report PRP characterization using a recognized framework such as DEPA or PAW, include disease-specific eligibility criteria, and prespecify clinically meaningful outcomes and follow-up intervals (6,7).

For ED and PD, sham-controlled trials with adequate concealment and longer follow-up are a priority. For IC/BPS, external validation of the current single-center experience is needed, ideally with standardized intravesical preparation and dosing protocols. For reconstructive and incontinence applications, PRP should be tested as a clearly defined adjunct rather than a loosely described biologic add-on.

Translational studies are also needed to determine whether particular PRP compositions are better matched to particular urologic indications. This is more plausible than assuming that one generic PRP product can be applied interchangeably across neurogenic, inflammatory, fibrotic, and reconstructive conditions.

Conclusions

PRP has a credible regenerative rationale and a growing experimental literature in urology. The strongest current message, however, is not that efficacy has been established, but that composition, protocol, and study design matter greatly.

At present, PRP should be described as investigational across most urologic indications. Early clinical signals justify further research, but the existing evidence does not support broad routine practice-facing claims. A more mature evidence base will require standardized reporting, cautious interpretation, and better controlled trials.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0084/rc

Peer Review File: Available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0084/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tau.amegroups.com/article/view/10.21037/tau-2026-1-0084/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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