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Peyronie's Disease

BACKGROUND

 

Peyronie’s disease (PD) is a condition of the penis in which fibrous plaques accumulate, resulting in deformity of the penis, [1]. The prevalence of the disease varies according to different sources, but may be as high as 9%, [2].

 

It occurs most commonly in the 40-60 age group, but can occur in those as young as 18, [1]. It is more common in white males, [2].

 

Fig 1. Penile angulation in PD.

RELEVANT ANATOMY AND PHYSIOLOGY

 

The penis is made up of two corpora cavernosa, which are formed by erectile tissue, and the corpus spongiosum, which contains the urethra. Surrounding the corpora cavernosa is the tunica albuginea, a tough fibrous layer. This is the area where the plaque forms in Peyronie’s disease, [3].

 

The most likely cause of PD is repeated sexual trauma; this is highlighted by the finding that the plaques mainly affect the dorsum of the penis. Trauma to the corpus cavernosa leads to microvascular injury of the tunica albuginea. The tunica albuginea is hypovascular, and therefore fibrinolysis does not occur, leading to the build up of fibrous plaques, [2]. The plaques may or may not calcify depending on the severity of the disease. These plaques lead to reduced expansion of the corpora cavernosa, therefore producing curvature of the penis dependant on the location of the plaque, [2,4].

 

ASSOCIATIONS

 

PD is associated with a number of other conditions and it may be possible that repeated sexual trauma in the presence of one or more of these conditions may increase the chance of the disease occurring, [1]. These associations include:

 

* Type 1 Diabetes Mellitus

* Arteriopaths: 30% of PD patients have concomitant arterial disease

* Genetic predisposition to poor wound healing

* Duputryens contracture: occurring in 10% of PD patients

* Family history of PD: in 2%, [1]

* There is no association with previous penile fracture, [2]

 

PRESENTATION AND DIAGNOSIS

 

Important presenting features include:

 

  • Penile curvature
  • Penile lumpiness
  • Erectile dysfunction (ED)
  • Penile pain during erection
  • Penile shortening

 

    Diagnosis is usually possible from the history and examination. Important features include timing of the disease, its impact on sexual function, and the patients’ wishes for management. A full history can also help exclude differential diagnosis such as congenital curvature of the penis. On examination there is either a plaque that can be felt, mostly in the dorsal region, or a palpable area of induration, [1].

     

    Diagnosis can be confirmed further by photographs taken by the patient. For those with severe deformities an intracavernosal injection of a vasoactive agent such as caverject is useful in the clinical setting to better show the extent of the disease.

     

    Other imaging studies such as X-ray or penile ultrasound can be used to show calcification, which usually implies plaque maturation and therefore the endpoint of the disease, [3].

     

    PD can be split into two phases: acute and chronic. The acute phase lasts for the first 18 months causing inflammatory changes, some angulation and penile pain, whilst the chronic phase results in a stable plaque and more severe penile angulation. This distinction is important for management of the disease, [3].

     

    MANAGEMENT

     

    As the cause of PD is currently unknown, there are many treatment options available. They can broadly be classed as conservative, medical, physical and surgical treatments.

     

    CONSERVATIVE:

     

    Conservative measures such as simple reassurance is an effective measure. For patients presenting with a lump or curvature of the penis, reassurance that there is not an underlying cancer causing the symptoms may be all that is needed to allay their anxiety. Patients who develop psychosexual difficulties can be referred to a psychiatrist or councillor trained in this area, [5].

     

    MEDICAL:

     

    The role of medical treatment in PD is difficult as studies have not consistently shown a beneficial treatment. However as medical treatments are often cheaper and less invasive than surgical treatments, many patients initially opt for a medical option. Studies have also previously shown that some symptoms of PD can regress over time, and for this reason medications can appear to act as placebos. Therefore, when evaluating a treatment, this must be taken into account, [3]. Medications are often used to treat concomitant erectile dysfunction, but these will not be discussed here. There are many drugs used; some of which are mentioned below:

     

    Vitamin E has antioxidant properties which prevents fibrosis. Studies have failed to show a consistent benefit over placebo in PD patients, but because it is cheap and has few side effects it is still often used, [1,3].

     

    Colchicine is an anti-inflammatory medication. It decreases collagen formation and stimulates collagenase activity, [1,3]. In one study it was shown to decrease penile pain in 95% of patients, although a different randomised placebo-controlled trial showed no benefit over placebo, [1].

     

    POTABA (potassium aminobenzoate) is an oral agent that has anti-fibrotic actions. However large doses are needed (12g per day), and the GI upset of the drug can be severe, [4].

     

    Verapamil,a calcium channel blocker,can be injected directly into the plaque to increase collagenase activity, and therefore decrease plaque size, [3,5]. Other injectable drugs that have been tried include interferon-alpha and steroids.

    PHYSICAL:

     

    Extra-corporeal shockwave lithotripsy (ESWL) uses high-pressure, low-frequency sound waves directed at the plaque. Its mechanism of action is not completely understood. It has however been shown to decrease both penile pain and angulation in some trials, [3]. NICE have produced guidelines for its use, but states that as the efficacy is yet to be determined by larger trials, ESWL should be reserved for audit or research purposes, requiring explanation to the patient about its currently uncertain efficacy, [5].

    SURGICAL:

     

    In order for surgery to be considered 4 criteria must be met:

     

    1/ Severity. The disease should be severe enough to affect sexual intercourse.

    2/ Time. A period of time should have elapsed to see if spontaneous regression occurs.

    3/ Medications. Non-surgical options have been tried and failed to produce sufficient benefit.

    4/ Stability. The disease should be stable, not worsening, [3,4].

     

    The operations performed for PD include: the Nesbit procedure, plaque incision and grafting, Lue’s procedure (plication) and finally insertion of a penile prosthesis. 

     

    NESBIT PROCEDURE

     

    The most common operation is the Nesbit procedure. This procedure involves removing a portion of the tunica albuginea on the normal side of the penis in order to straighten it.

     

    Complications of this operation include penile shortening, which occurs proportionally to the degree of curvature present; those with more severe curvature will have more shortening, [1]. Erectile function is usually maintained after this operation, [1]. 

     

    This type of operation is therefore used more for patients with moderate disease, but may be unsuitable for those with a shorter penile length, [4].

     

    Figure 2 illustrates the basics of the Nesbit procedure:

     

    1) The curved penis as seen after an induced erection...

    2) The penis is degloved.

    3) Tissue on the side opposite the curvature is removed resulting in a straighter penis.

     

    Fig 2. Nesbit procedure.

    LUE'S PROCEDURE

     

    Lue’s procedure, also known as the 16-dot technique, is a plication procedure, involving placing 16 small incisional dots, in two rows, into the opposite side of curvature of the penis. These are then tightened to straighten the deformity.

     

    It is less invasive as it requires no incision or excision of tissue. Benefits include the ability to perform the procedure under local anaesthetic, and being able to make adjustments during the operation, [6]. However it is only suited to those with simpler curvatures, not those with complex deformities.

     

    Like the Nesbit procedure it is associated with penile shortening, but also erectile dysfunction can occur similar to plaque incision. Palpable knots from the incisions may also occur, [6].

     

    Fig 3. The 16-dot method to correct a) dorsal curvature b) ventral curvature of the penis.

       

    PLAQUE INCISION AND GRAFTING

     

    Patients with a more severe curvature or shorter penis unsuitable for Nesbit procedure may be better suited to plaque incision and grafting. This involves making an H-shaped incision in the plaque and inserting a vein graft into the incision. The graft can be taken from the long saphenous vein. 

     

    Erectile dysfunction occurs in 15% of patients, and numbness of the glans penis may also occur, [7]. Shortening of the penis, although less than in the Nesbit procedure can still occur, [1]. 

     

    This operation requires two incisions, the second being to harvest the vein; however trials using autologous grafts such as bovine pericardium have shown good results, which would eliminate the need for a second incision, therefore reducing morbidity, [1].

     

    Fig 4 & 5. The H-shaped incision into the plaque, and placement of the graft.Fig 4 & 5. The H-shaped incision into the plaque, and placement of the graft.

    PENILE PROSTHESIS

     

    Patients with both PD and ED unresponsive to treatment may opt for insertion of a penile prosthesis, [3]. Prostheses can be inflatable or semi rigid (malleable). The prosthesis is inserted into the corpora cavernosa in order to cause penile rigidity. However, the penile length is only equal to the stretched flaccid penis as these devices do not increase length, [3]. 

     

    The malleable prosthesis produces a worse cosmesis and as these cause permanent rigidity, patients may find concealing it difficult. Overall however they are an excellent method of producing satisfactory rigidity for intercourse, [4].

     

    Flow chart below summarises the clinical approach to patients with Peyronie's disease:

    Flow chart showing an approach to patients with Peyronie's disease

    REFERENCES

     

    1 Ralph DJ, Minhas S. The management of Peyronie’s disease. BJUI 2004;93(2);208-215

    2 http://emedicine.medscape.com/article/1061264-overview

    3 http://emedicine.medscape.com/article/456574-treatment

    4 http://www.peyronies.org/pages/treatment.htm

    5 http://www.patient.co.uk/doctor/Peyronie's-Disease.htm

    6 Tran VQ, Kim DH, Lesser TF, Aboseif SR, Review of the Surgical Approaches for Peyronie's Disease: Corporeal Plication and Plaque Incision with Grafting, Advances in Urology, vol. 2008, Article ID 263450, 4 pages, 2008. doi:10.1155/2008/263450

    7 Kalsi J, Minhas S, Christopher N, Ralph D. The results of plaque incision and venous grafting (Lue procedure) to correct the penile deformity of Peyronie's disease. BJUI 2005;95(7);1029-1033

     

    Picture 1 taken from http://malecare.org/peyronies-disease/

    Picture 2 taken from http://www.mayoclinic.com/health/medical/IM01275

    Picture 3 taken from Lue TF, Gholami SS. Correction of penile curvature using the 16-dot placation technique: a review of 132 patients. Journal of Urology. 2002:167: 2066-2069

    Pictures 4 and 5 taken from http://knol.google.com/k/peyronie-s-disease-acquired-deformity-of-the-penis#

     

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