Peyronie's Disease

History and Background:

  • The first description of Peyronie's disease is credited to Francois Gigot de la Peyronie in 1743.
  • No consensus exists with regard to the etiology, prevalence and treatment of the condition.  
  • Peyronie's disease is associated with Dupuytren disease. Dupuytren disease has a familial pattern known to be transmitted in an autosomal dominant pattern. 
  • Thirty percent to 40% of men with Peyronie's disease will also have Dupuytren disease.

Eitiology and Natual History:

  • Peyronie's disease presents as a variety of deformities of the penis. 
  • The symptomatic incidence has been estimated at 1%, but data indicates that the incidence is increasing and now can be estimated conservatively at 5% and some recent estimates are  8.9% to 13%.
  • Peyronie’s disease is defined by the presence of an inflammatory reaction and eventual fibrotic plaque development within the tunica albuginea or of the corpora cavernosa.
  • This plaque, which is palpable on physical examination in established cases, is associated with the common presenting symptoms of Peyronie’s disease, including pain with erection, curvature or deformity of the erect penis and erectile dysfunction (ED).
  • Plaque formation is thought to be the result of trauma, to the erect or semi-erect penis, which is propagated by aberrant would healing.
  • Reports of an association between Peyronie’s disease and Dupuytren’s contracture, plantar fascial contracture, tympanosclerosis, diabetes, urethral instrumentation, autoimmune disorders and as an inherited form of the disorder suggest that a multifactorial etiology is likely.
  • Disease development is described in two phases. 
    • The first phase is associated with painful erections and changing deformity of the penis. 
    • The second phase,is characterized by the disappearance of painful erections, if previously present, and a stability in the disease process.
  • Most patients do not require surgery. 
  • Patient's do require reassurance and education. 
  • Surgery for Peyronie's disease is considered palliation for the mechanical effects of the disease.
  • Peyronie's disease has been related to a number of conditions. The strongest relation is to Dupuytren disease.
  • The development of Peyronie's disease does seem to be related to the unique anatomy of the tunica albuginea and its relationship to the septal fibers.
  • Buckling trauma of the penis, usually occurring during intercourse, has been implicated in the development of Peyronie's disease. 
  • TGF-β has been found to be related to the disordered healing process that leads to the scarring of the Peyronie's plaque. 
  • Failure of downregulation of a number of “antifibrotic” factors has been implicated.

Symptoms:

  • The presenting symptoms of Peyronie's disease include, in many patients, penile pain with erection; penile deformity, both flaccid and erect; shortening with and without an erection; plaque or indurated areas in the penis; and, in many patients, erectile dysfunction. 
  • On physical examination, virtually all patients have either a well-defined plaque or an area of induration that is palpable. 
  • The plaque is usually on the dorsal surface of the penis, intimately associated with the insertion of the septal fibers.
  • Spontaneous improvement in pain virtually always occurs as the inflammation resolves.

Patient Evaluation:

  • Patients with Peyronie's disease present with a variety of deformities of the penis. 
  • Most have noted an indurated area in the penis that has been identified as the plaque. 
  • Many patients have noticed erectile dysfunction. 
  • All patients must be evaluated with a medical history, as well as a detailed psychosexual history. 
  • Approximately one third of the patients will develop dystrophic calcification in the plaque that can be demonstrated by ultrasonography or plain radiography. 
  • The place for MRI in the evaluation of Peyronie's plaque has not been defined, nor has the place for vascular testing been clearly defined. 
  • However, most urologists would agree that in patients who are to be operated on, vascular testing to stratify the vascular parameters of erectile function is a necessity. 
  • Once all of the data have been assembled, individualization with regard to the patient's requirements, findings, and assessment is imperative.

Medical Management:

  • The efficacy of medical management of Peyronie's disease is difficult to determine because there are few RCT. 
  • Vitamin E has been used historically, and while supplementation has been studied for decades, and some success has been reported in older trials, those results have not been reproducible in RCT.
  • A combination of Vitamin E and colchicine has shown some promise in delaying progression of the condition.
  • Potassium aminobenzoate, in a small study, was found to reduce plaque size, not curvature, and thus in that study was found “efficacious.” However, the side effects make it difficult to tolerate.
  • A number of intralesional protocols have been proposed. 
  • The use of verapamil as an intralesional agent has been studied. A prospective study did show decrease in curvature in about 80% of the patients. 
  • Injections to plaques (scar tissue formed by the inflammation) with Verapamil may be effective in some patients, but a recent placebo controlled trial failed to show a significant improvement. 
  • So there are conflicting outcomes reported.
  • Interferon-alpha-2b has been proposed in recent publications.
  • Radiation therapy should be avoided. 
  • The vacuum erection device has not been adequately studied.
  • Penile traction has not been adequately studied.
  • The place of extracorporeal shockwave therapy has likewise not been adequately determined.

The use of collagenase as an intralesional agent has been subjected to a number of double-blind placebo-controlled protocols, and, in all, efficacy was suggested. Collagenase is currently not available as an approved treatment and remains in development.  

Surgery:

  • The consensus committee on Peyronie's disease at the World Health Organization Second International Consultation on Sexual Dysfunctions stated that the penile prosthesis is a reliable option for the older man with vascular impairment, erectile dysfunction, and acquired deformity of the penis.
  • It is not the only treatment of Peyronie's disease but rather a prudent treatment for the patient with significant erectile dysfunction in association with Peyronie's disease. 
  • Hydraulic prostheses are preferred, and those prostheses that have true controlled expansion cylinders have been shown to provide better results.

References:

  • Brock G, Lue TF: Peyronie's disease, a modified treatment. Urology 1993; 42:300-304.
  • Brock G, Hsu GL, Nunes L, et al: The anatomy of the tunica albuginea in the normal penis and Peyronie's disease. J Urol 1997; 157:276-281.
  • Carson CC, Jordan GH, Gelbard MK: Peyronie's disease: new concepts in etiology, diagnosis and treatment. Contemp Urol 1999; 11:44-64.
  • Dibenedetti DB, Nguyen D, Zografos L, Ziemiecki R, Zhou X. Adva Urol 2011;282503.
  • Hellstrom WJ: History, epidemiology and clinical presentation of Peyronie's disease [review]. Int J Impot Res 2003; 15(Suppl.):S91-S92. S121-4.
  • Levine LA, Greenfield JM: Establishing a standardized evaluation of the man with Peyronie's disease [review]. Int J Impot Res 2003; 15(Suppl.):S103-S112.
  • Levine LA. Peyronie's disease and erectile dysfunction: Current understanding and future direction. Indian J Urol 2006;22:246-50.
  • Mulhull JP, Creech SD, Boorjian SA, et al: Subjective and objective analysis of the prevalence of peyronie's disease in a population of men presenting for prostate cancer screening. J Urol 2004; 171:2350 - 53.
  • Mynderse LA, Monga M (October 2002). "Oral therapy for Peyronie's disease". International Journal of Impotence Research 14 (5): 340–4.
  • Nyberg Jr LM, Bias WB, Hochbert MC, Walsh PC: Identification of an inherited form of Peyronie's disease with autosomal dominant inheritance and association with Dupuytren's contracture and histocompatibility B7 cross-reacting antigens. J Urol 1982; 128:48-51.
  • O’Brien K, Parker M, Guhring P, et al: Analysis of the natural history of Peyronie's disease [abstract 69]. J Sex Med 2004; 1(Suppl. 1):50.
  • Prieto Castro RM, Leva Vallejo ME, Regueiro Lopez JC, et al: Combined treatment with vitamin E and colchicine in the early stages of Peyronie's disease. BJU Int 2003; 91:522-524.
  • Riedl CR, Sternig P, Gallé G, et al. (October 2005). "Liposomal recombinant human superoxide dismutase for the treatment of Peyronie's disease: a randomized placebo-controlled double-blind prospective clinical study". European Urology 48 (4): 656–61.
  • Trost LW, Gur S, Hellstrom WJ (2007). "Pharmacological Management of Peyronie's Disease". Drugs 67 (4): 527–45.
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