Peyronie's disease

Contributed by Dr Rowland Rees, locum consultant andrologist and Mr David Ralph, consultant andrologist, the Institute of Urology, UCLH, London.

Section 1: Epidemiology and aetiology
Peyronie's disease is an acquired disorder of the tunica albuginea characterised by the formation of fibrous plaques. It was initially described by Francois de la Peyronie in 1743.

In the initial inflammatory stage patients present with pain, at later stages they may present with a palpable lump, erectile dysfunction, or penile curvature and consequent difficulty with sexual intercourse.

Peyronie's disease can result in penile shortening. It may cause concerns about appearance, and can have a significant impact on quality of life.

Epidemiology
There have been a number of epidemiological studies to determine the prevalence of Peyronie's disease, which is generally under-reported. In a questionnaire survey of 8,000 men aged 30-80 years in Cologne, 3.2 per cent reported a palpable penile plaque.1

A similar study in Italian men aged 50-69 years found a prevalence of 7.1 per cent.2 Prevalence in both studies increased with age, but presentation was highest in men in their early 50s, when they were more likely to be sexually active.

A major risk factor for Peyronie's disease is smoking. One study found that smokers were 4.6 times more likely to report the condition.2 A number of other vascular risk factors have also been identified (see box).3

Awareness of these associated conditions is important in managing patients with the disease. It is also important to be aware that half of Peyronie's disease patients also have a degree of erectile dysfunction.

Aetiology
The precise aetiology of Peyronie's disease remains uncertain, but a number of possible causes have been investigated (see diagram).

A popular theory is that Peyronie's disease occurs when microtrauma from the repeated stresses of sexual intercourse is combined with a failure of the wound healing processes. This leads to collagen alterations, failure of fibrin degradation and the upregulation of profibrotic cytokines.

Other possible factors being investigated include a genetic predisposition and infection.

Risk Factors for Peyronie's Disease
Incidence of co-morbidities in 307 patients with Peyronie's disease.3
Risk Factor Incidence
Hypercholesterolaemia 43%
Diabetes 33%
Hypertension 15%
Ischaemic heart disease 8%
Erectile dysfunction54%

Section 2: Assessment and Diagnosis
When taking the patient history, there are several indicators of Peyronie's disease that should be looked for (see box). These include a history of sexual trauma or penile fracture, and the presence of penile pain or curvature.

Examination
It is important to examine the genitalia to exclude other causes of penile lesions, particularly penile cancer. Given the incidence of vascular risk factors, it is also advisable to screen for hypertension and diabetes in primary care.

Once Peyronie's disease has been diagnosed, a more detailed examination of the problem is often carried out in the secondary care setting. This should include a record of the size and location of the Peyronie's plaque as well as any tenderness within it. It should also include a measurement of penile length and assessment of curvature.

Measurement
Peyronie's disease often causes penile shortening, so it is important to document penile length before and after treatment. Penile length is measured from the pubis to the tip, with the penis at full stretch. This correlates well with the length of the erect penis.

Assessing the penile curvature is best done in an outpatient clinic using an injection of an erectogenic agent. The angle and direction can then be assessed by a protractor and documented.

Investigations
Tests should be done to investigate any underlying risk factors or comorbidities.

Radiological investigation with doppler ultrasound or MRI with erectogenic agents may be required for surgical planning in complex cases. However, this is not necessary for the vast majority of patients.

PATIENT HISTORY

  • The presence of penile pain and/or curvature.
  • Duration of symptoms.
  • Rough estimate of angle and direction of curvature.
  • Ability to have intercourse.
  • Erectile capacity.
  • Any history of sexual trauma/penile fracture.
  • General medical and urological history

Dorsal deformity of Peyronie's Section 3: Non-Surgical Treatment
Patients diagnosed with an established plaque of Peyronie's disease but who are asymptomatic do not require any treatment. The natural history of Peyronie's disease is that the pain eventually subsides once the inflammatory phase of the condition is over. This initial phase may last up to a year.

In one study,4 the deformity or plaque worsened in 42 per cent of patients, remained the same in 45 per cent and improved in 13 per cent.

If the disease has been present for over a year, and stable for six months, surgery should be considered.

Drug treatments
Patients with the disease in its early inflammatory phase, or who have a progressing curvature, may benefit from a trial of medical treatment. It is important to note, however, that there have been no randomised, placebo-controlled trials of any drug treatments for Peyronie's disease.

Vitamin E, a relatively cheap and safe antioxidant, was compared to placebo in trial of 60 patients. In this study, 35 per cent of those taking 200mg vitamin E three times daily reported an improvement in pain, compared to only 7 per cent of those taking placebo.5

Potassium aminobenzoate, an antifibrotic agent that belongs to the vitamin B group family has also been tested. It was found to improve the pain of Peyronie's plaques, but it is costly and causes frequent GI side-effects.6 Smaller studies have shown some benefit with both tamoxifen and colchicine, but randomised trials failed to support these findings.

Non-invasive therapies
There is good evidence of benefit from intralesional injection of the calcium channel blocker verapamil7 and also from interferon.8 These have been shown to improve pain, curvature and sexual functioning. However, these therapies are not yet widely used.

The benefit of treatment with extracorporeal shock wave therapy (ESWT) has also been extensively studied, but a meta-analysis found no good evidence for its effectiveness.9 On the contrary, there is recent evidence that ESWT could worsen erectile function, possibly by causing penile fibrosis.

The use of vacuum devices in treating curvatures caused by Peyronie's disease is currently being evaluated.

Counselling
One of the important parts of the management of Peyronie's disease is counselling and managing patient's expectations. The psychological effects of an incurable penile deformity must not be underestimated.

It is important for patients to realise that the disease process cannot be reversed, and that despite our best therapeutic efforts, their penis will never return to normal.

Psychosexual counselling can be valuable.

A saphenous vein graft inserted into the dorsum of the penisSection 4: Surgical Therapy
Due to the lack of any effective medical treatment for established Peyronie's plaques and the resultant curvatures, surgery is the mainstay of treatment for Peyronie's disease.

The disease should have been present for a year and stable for three to six months prior to embarking on surgery, and the deformity should be causing difficulty with intercourse.

Patients can often manage intercourse with a dorsal curvature of around 20deg. The surgical threshold for a dorsal curvature should therefore be higher than that for ventral or lateral curvatures.

Nesbit procedure
The Nesbit procedure is by far the most commonly performed surgery for Peyronie's disease. Satisfaction and durability rates are high with one series reporting them as high as 82 per cent.10

The main problem with this procedure is that of penile shortening, although in 90 per cent of patients this was less than 1cm. Only in 1 per cent of patients did shortening affect intercourse.

Other complications include recurrent curvature and palpable knots, but the use of slowly dissolving sutures can help reduce this problem. The plication techniques are simpler, but have higher rates of recurrence and palpable knots.

Incision and grafting
In an attempt to reduce the incidence of penile shortening the Lue procedure has been developed. This technique involves incision and insertion of graft material into the defect (see figure).11

This is a more complex and lengthy operation, particularly as the most commonly used graft material is a de-tubularised saphenous vein taken from the patient at the time of operation. A variety of other autologous and synthetic graft materials have been used with varying results.

Satisfaction rates are high, and erectile dysfunction is the main complication, affecting 12 per cent of patients.12 Even with this procedure there is a risk of penile shortening. Despite this, incision and grafting is a popular procedure with patients anxious about their penile length.

Incision and grafting can also be used to treat waist deformities of the penis, where Peyronie's disease causes indentation on one side. The indented area can be incised longitudinally, and a graft inserted to expand the penis's circumference.

Penile prostheses
Peyronie's disease associated with erectile dysfunction presents more of a therapeutic problem. Where there is a mild degree of erectile dysfunction, it may be possible to carry out a Nesbit procedure and add oral pharmacotherapy with PDE5 inhibitors post-operatively.

In cases with significant erectile dysfunction, or who have risk factors pointing to this complication post-operatively, it is best to offer penile prosthesis insertion from the outset. This treats both the erectile dysfunction and the curvature.

One study has reported high success and satisfaction rates from this procedure, particularly when combined with the 'modelling procedure', where the penis is forcibly flexed in the opposite direction to the curvature.13

Surgical Options for Treatment

1. To shorten the long side:

  • Nesbit procedure - excision of an ellipse of tissue.
  • Yachia procedure - longitudinal incision with horizontal closure.
  • Plication - simple suture plication of tunical tissue.

2. To lengthen the short side:

  • Lue procedure - incision of the plaque and insertion of graft

3. Penile prostheses - for patients with significant erectile dysfunction or complex deformities/extensive penile fibrosis.

References

1. Sommer F, Schwarzer U, Wassmer G et al. Epidemiology of Peyronie's disease. Int J Impot Res 2002: 379-83.

2. La Pera G, Pescatori E, Calabrese M et al. Peyronie's disease: prevalence and association with cigarette smoking. A multicenter population-based study in men aged 50-69 years. Eur Urol 2001; 40: 525-30.

3. Kadioglu A, Tefekli A, Erol B et al. A retrospective review of 307 men with Peyronie's disease. J Urol 2002;168: 1,075-9.

4. Gelbard M, Dorey F, James K. The natural history of Peyronie's disease. J Urol 1990; 144: 1, 376-9.

5. Pryor J, Rarrel C. Controlled clinical trial of vitamin E in Peyronie's disease. Prog Reprod Biol Med 1983; 9: 41-5.

6. Shah P, Green N, Adib R et al. A muticentre double-blind controlled clinical trial of potassium paraminobenzoate (Potaba) in Peyronie's disease. Prog Reprod Biol Med 1983; 9: 61-7.

7. Levine L, Estrada C. Intralesional verapamil for the treatment of Peyronie's disease: a review. Int J Impot Res 2002; 14: 324-8.

8. Hellstrom W, Kendirci M, Matern R et al. Single-blind, multicenter, placebo controlled, parallel study to assess the safety and efficacy of intralesional interferon alpha-2B for minimally invasive treatment for Peyronie's disease. J Urol 2006; 176: 394-8.

9. Strebel R. Extracorporeal shock wave therapy for Peyronie's disease: exploratory meta-analysis of clinical trials. J Urol 2004 Nov; 172 (5 Pt 1): 2083.

10. Ralph D, al-Akraa M, Pryor J. The Nesbit operation for Peyronie's disease: 16-year experience. J Urol 1995; 154: 1,362-3.

11. Lue T, El-Sakka A. Venous patch graft for Peyronie's disease. Part I: technique. J Urol 1998; 160 (6 Pt 1): 2,047-9.

12. El-Sakka A, Rashwan H, Lue T. Venous patch graft for Peyronie's disease. Part II: outcome analysis. J Urol. 1998; 160 (6 Pt 1): 2,050-3.

13. Wilson S, Delk J 2nd. A new treatment for Peyronie's disease: modeling the penis over an inflatable penile prosthesis. J Urol 1994; 152(4): 1,121-3.

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