Peyronie's Disease

Synonyms: Penile fibrosis, Induratio penis plastica

This a disorder of penile connective tissue, first brought to widespread medical attention by Francois Gigot de Peyronie in 1743.¹ Fibrous plaque formation occurs in the corpus cavernosum's tunica albuginea. There is inflammatory thickening with fibrin deposition, increased collagen production, decreased quantity of elastic fibres and subsequent fibrosis ± calcification. This leads to penile angulation or an hour-glass like deformity with distal flaccidity. It usually affects only the erect penis. Sexual intercourse can become painfully difficult or impossible. It is thought to occur (but nobody really knows) as a result of one-off or repeated penile vascular trauma causing leakage and immunological reaction in the relatively avascular tunica albuginea. Genetic susceptibility is thought to play a role.²

Exact figures for prevalence and incidence are hard to come by as many men may not seek help due to embarrassment. Best estimates suggest prevalence is about 0.39-3%. Although the condition mainly affects men aged 40-70 years, it has been reported in younger individuals.^3,4

Purportedly Dupuytren's contracture, phenytoin therapy, diabetes mellitus, and hypertension.^2,5,6

When Peyronie's first presents it tends to be with penile pain during erections, penile angulation (this can be seen in some cases in a flaccid penis), palpable fibrous plaque at the site of angulation, and erectile dysfunction. After 18-24 months the pain settles and plaque, angulation and calcification tend to predominate.

• Penile x-ray and ultrasound can demonstrate calcified and non-calcified plaques respectively. In specialist hands corpus cavernosography can help to demonstrate cavernosus deformity and vascular blockage.⁷
• MRI is used but adds little to clinical diagnosis in most cases.
• Penile scintigraphy with technetium Tc 99m human immunoglobulin G has been used to help distinguish unstable PD, which is best treated medically, from stable PD, which may require surgical intervention.⁸

Spontaneous remission makes controlled trials difficult to interpret. Before embarking on any surgical therapy, sufficient time should be allowed to pass (12 months at least) to allow resolution to occur. Most practitioners start with oral therapies before trying intra-lesional or surgical approaches. Psychosexual difficulties are an unsurprising byproduct of the condition and referral to a psychologist/counsellor/psychiatrist skilled in this area may significantly reduce the burden of the disease on the patient.

Drugs

• Oral Drugs which have been tried for this condition include para-aminobenzoate, tocopherol (vitamin E), colchicine, tamoxifen, propoleum and acetyl-L-carnitine. None of these have shown any consistent effect in placebo-controlled trials other than para-aminobenzoate, which may decrease plaque size and curvature, and acetyl-L-carnitine, which may reduce erectile pain and inhibit disease progression.⁹
• Intralesional The current standard of care involves injection with interferon-alpha-2a or -2b, verapamil or collagenase over 2-week intervals for a period of 5-6 months. Of these, interferon has the largest evidence-base but is also the most likely to produce adverse effects (fever and other flu-like symptoms).⁹
• Iontophoresis (electromotive drug administration, EMDA) A variety of researchers have used electrical current (up to 5mA) to deliver charged drug molecules to the affected area, usually a combination of dexamethasone, verapamil and/or orgotein and lidocaine. Some well-designed trials have shown significant benefits in subjective and objective criteria, particularly in men suffering the early phase of the disease. There appear to be no significant adverse effects apart from mild, local erythema. Further randomised controlled trials in this area may prove EMDA to be a useful first-line therapy for the early phase of Peyronie's.^10,11

Surgical

• Extracorporeal shock wave therapy NICE has produced guidance for professionals and public on the use of this technique in this context. Essentially, whilst there are no significant safety concerns, they are not convinced of any proof of efficacy for the procedure; they advise it is used in carefully-controlled, well-audited programs or as part of a research trial, with detailed explanation given to patients during the consenting process.¹²
• 'Cold steel' surgery² Surgery should be reserved for patients with significant morbidity who fail to respond to medical therapy. It should be deferred until 12-18 months, after which time changes to plaques and angulation is unlikely. Options include:
  • The Nesbit tuck procedure: normal tunica albuginea is removed from the side of the penile shaft opposite the plaque to straighten and shorten the penis. Potency should be normal, and the penile curvature should be less than 60°.
  • Tunica plication procedure: this involved plication rather than excision of the unaffected tunica albuginea to straighten the penis. this technique also causes penile shortening.
  • Plaque excision and grafting: this is performed to preserve penile length when the curvature is greater than 60°.
  • Plaque excision and penile prosthesis insertion: this is useful when severe erectile dysfunction is also a problem.
  • Carbon dioxide laser: this has been used to good effect in some cases to thin the plaque.

In one large study, all patients who reported penile pain had improvement and 89% reported complete resolution at one-year followup. The majority of patients were reported to have a decrease in flaccid length (average 12.2cm decreasing to 11.4 cm). Of men with curvature 12% had improved, 40% remained stable and 48% had worsened at follow-up.⁶