Peyronie’s Disease is common fibrotic disorder of the penile erectile bodies that causes varying degrees of penile deformity and sexual dysfunction. Its exact causes are unknown, but probably the condition represents an abnormal response to injury in susceptible individuals. The structure injured is the tunica albuginea, the fibrous white coat that surrounds the erectile bodies of the penis. Most often, the precipitating trauma is a bending injury to the erect penis.; However, other causes such as urethral catheterization, blunt trauma to the flaccid penis, and medications have been reported. A Peyronie’s plaque is the thickened fibrous inflammatory nodule that is usually palpable along the shaft of the penis. Disordered collagen fibers and loss of elasticity prevent the expansion of the tunica albuginea during erection and this is directly responsible for the symptoms.
The three most common symptoms of Peyronie’s disease are a palpable penile plaque, painful erection, and penile curvature. The onset of these symptoms may be abrupt. The painful erection is not usually related to penetration, but to the pressure and turgidity of the penis, which is deformed by the presence of the non-expansile plaque. Thus, the plaque causes deviation of the penis. If the plaque is on the top of the penis, the curvature will usually point towards the ceiling. Conversely, if the plaque is on the under-surface of the penis, the erect penis will point towards the floor. Various combinations of curvature, as well as narrowing of the girth of the penis and penile shortening, all are possible. Erectile Dysfunction is another less common effect of Peyronie’s disease.
The diagnosis of Peyronie’s is based on history of a penile plaque or penile pain, and the physical examination finding of an induration or thickening of the tunica albuginea, namely the plaque. The penis is best examined with the shaft put on full-stretch so that the examiner can palpate the entire length of the penis. Self-photography can be useful to demonstrate the deformity of the penis during penile erection and may help the Urologist determine the severity of the curvature and the presence of other deformities.
A penile blood flow study using color duplex Doppler ultrasonography can serve several purposes. First of all, ultrasonography can image the plaques and determine their size, thickness, and degree of calcification. Heavily calcified plaques, that are like areas of bone formation, are very unlikely to respond to conservative therapy. The penile blood flow study can help determine the underlying integrity of the arteries and veins of the penis. This is important to plan surgical therapy for more severely affected individuals.
Treatment for Peyronie’s Disease is tailored to a specific individuals needs and can be divided into three therapeutic echelons:
1. oral pharmacotherapy
2. intralesional therapy
3. surgical reconstruction
We advocate treatment for all patients with Peyronie’s Disease, even with those with mild conditions.
For a man with mild curvature, moderate pain, less than 30-degree angulation with no hourglass narrowing or major shortening of the penis, we recommend oral therapy. Randomized controlled trials suggest that the medication Pentoxifylline may prevent disease progression and in some cases lead to clinical improvements in some men with Peyronie’s. Other choices of agents include colchicine, an anti-inflammatory agent commonly used for the treatment of gout, as well as Potaba. Small uncontrolled trials support the use of these medications.
For more significant curvature, when pain is a significant issue, or the rate of progression seems concerning, we use intralesional therapy. Intralesional verapamil, a calcium-channel blocker, has been shown to reduce pain, curvature, with limited side effects. After numbing the penis with local anesthesia, a very small needle is used to infiltrate the plaque with verapamil. Six treatments separated by two weeks each, comprise our usual protocol. Results in the literature are encouraging, suggesting a 60% response rate amongst patients.
Surgical therapy should be reserved for men with persistent sexual disability that is not responsive to more conservative therapies, or for men with severe deformity.
Penile Plication: Penile plication is a minimally invasive approach to correcting penile deformity that allows rapid recovery of sexual function with minimal risk to erectile hardness. The procedure involves a series of tensioning sutures placed on the side of the penis opposite the plaque. The penis has already been foreshortened by the plaque, and this plication equalizes the length of the two sides of the penis, creating a straight erection. Importantly, penile plication will not correct hourglass or other narrowing deformities, nor will is address severe loss of penile length. This is an outpatient procedure, which can be performed in less than an hour, has few side effects, and a high rate of patient satisfaction.
Penile reconstructive surgery with grafting: Plaque incision and grafting is reserved for patients with severe angulation, distinct narrowing of the girth of the penis, or profound shortening of penile length. This technique involves release of the scar either by incising or excising the plaque, and grafting in a substitute for the tunica albuginea to expand the length and girth of the penis. While penile length is improved modestly with this approach, over 90% of men can report a straight or nearly straight penis after surgery, and most can regain sexual activity. However, risks are associated with this approach including penile numbness (less than 10%), persistent angulation (less than 5%), and severe erectile dysfunction (less than 20%).