Peyronie Disease

Peyronie disease is an acquired fibrotic disorder of the tunica albuginea of the corpora cavernosa. It is characterised by the formation of a fibrous plaque, which leads to penile curvature, pain, deformity (indentation, hourglass narrowing, hinge effect), shortening and erectile dysfunction.

It is thought to result from repetitive micro trauma to the tunica during intercourse, with abnormal wound healing in genetically predisposed men. Features include transforming growth factor beta 1 overexpression, myofibroblast proliferation, collagen deposition, and elastin loss.

Prevalence is about 3 to 9 percent of men (more with screening), with a peak at 50 to 60 years.

Associated factors: Dupuytren contracture (about 20 to 30 percent), diabetes, hypertension, dyslipidaemia, smoking, erectile dysfunction, radical prostatectomy and pelvic radiation, and a family history.

Natural history:

• An acute (active) phase lasting 6 to 18 months, with painful erections, evolving curvature and plaque.
• Then a chronic (stable) phase with stable deformity. Pain resolves in most (about 90 percent) within 12 to 18 months.
• Curvature stabilises in 12 months, with spontaneous improvement in 10 to 15 percent, stability in about 40 to 50 percent, and worsening in 30 to 50 percent.

• Palpable penile plaque or nodule (often dorsal), penile curvature (dorsal in about 70 to 80 percent, lateral or ventral in others), indentation or hourglass deformity, and penile shortening.
• Painful erections (in the acute phase), and pain that resolves over months.
• Erectile dysfunction (30 to 60 percent) caused by veno occlusive dysfunction, or by pain, anxiety and mechanical difficulty.
• The penis may buckle (the flail or hinge effect, with soft erection distal to the plaque).
• Difficulty or inability to penetrate, and pain for the partner.
• Psychological distress, depression, loss of self-esteem and relationship difficulty (about 50 percent report distress).
• Penile fracture or trauma history in some.

• History: onset, duration, pain, change in curvature, trauma, medications, risk factors, erectile function, and distress; validated tools (Peyronie's Disease Questionnaire, International Index of Erectile Function).
• Examination: palpation of the stretched flaccid penis for plaque (size, location, and calcification), and measurement of the stretched penile length.
• Assess the curvature degree with a goniometer, from photographs of the erect penis taken by the patient (or after intracavernosal injection of alprostadil 10 to 20 micrograms or papaverine to induce a rigid erection).
• Penile Doppler ultrasound after intracavernosal injection: plaque size, calcification, and vascular status (arterial inflow and venous leak). It is indicated when considering surgery for erectile dysfunction, or in the setting of complex deformity.
• Laboratory evaluation: glucose or HbA1c, lipid profile, and testosterone, if clinically indicated.
• Stable disease is defined as stability of curvature for at least 3 to 6 months (usually at least 12 months from onset) with no pain.

• Reassurance and education: during the acute phase, observation is acceptable as 10 to 15 percent improve; treat concurrent erectile dysfunction.
• Oral therapy has limited or no proven benefit. Vitamin E, potassium para aminobenzoate (Potaba) 12 g daily (in divided doses; reduces plaque progression, not curvature), colchicine, L-carnitine, pentoxifylline 400 mg three times daily (mild evidence), and tamoxifen are not recommended.
• Non-steroidal anti-inflammatory drugs (ibuprofen 400 mg three times a day, or naproxen 500 mg twice daily) help the pain in the acute phase.
• Intralesional injection therapy for the stable phase (curvature of 30 to 90 degrees, stable plaque, no calcification, and no hourglass deformity): collagenase clostridium histolyticum 0.58 mg injected into the plaque at the point of maximum curvature, on day 1.
• Penile modelling follows 1 to 3 days later (manual bending in the opposite direction for 30 seconds, three times), plus at home stretching and modelling for 6 weeks. Give up to four cycles at intervals of 6 weeks. It reduces curvature by an average of 17 degrees (about 34 percent).
• Adverse effects of collagenase: penile haematoma or ecchymosis (over 50 percent), swelling, pain and rare corporal rupture (penile fracture, in 0.5 to 1 percent). Avoid intercourse for 2 weeks after each cycle.
• Verapamil 10 mg (in 10 mL saline), injected into the plaque every 2 weeks for 12 sessions, and interferon alpha-2b 5 million units every 2 weeks for 12 weeks are other injection options with modest evidence.
• Traction therapy: penile traction device used for 3 to 8 hours daily for 3 to 6 months, for penile length and curvature (the effect is modest, about 15 to 20 degrees, and about 1 to 2 cm in length gain). It can be used with injection therapy or after surgery.
• Vacuum devices and extender therapies have a minor role.
• Shock wave therapy is of limited benefit for pain and no effect on curvature; not recommended.
• Surgery for stable disease (at least 12 months after onset, curvature stable for at least 3 to 6 months, or in patients with a deformity preventing intercourse):
  • Plication or tunical shortening (Nesbit, Yachia, or 16-dot plication) on the convex side of the penis, for men with adequate rigidity and curvature below 60 degrees, with no hourglass or hinge deformity. Success is 80 to 90 percent for straightening. Shortening of 1 to 2 cm, and numbness, recurrence and erectile dysfunction are potential issues.
  • Plaque incision or excision with grafting (autologous vein, tunica vaginalis, pericardium or synthetic material) for severe curvature (above 60 degrees), complex deformity (hourglass, hinge) and adequate erectile function. Success is 70 to 90 percent. Risks include erectile dysfunction (10 to 25 percent), glans hypoesthesia, penile shortening and recurrence. Patients with preoperative erectile dysfunction are not good candidates.
  • Penile prosthesis (inflatable, three piece) with or without straightening manoeuvres (manual modelling, 'penile modelling' or incision of the plaque with or without graft) for men with severe erectile dysfunction not responsive to drugs, and with Peyronie disease. It is the best treatment for them, and satisfaction rates are above 80 to 90 percent.
• Treat erectile dysfunction with phosphodiesterase inhibitors: sildenafil 50 to 100 mg, tadalafil 5 mg daily or 20 mg on demand, as required.
• Psychological and sexual counselling, partner involvement.
• Follow up: every 3 to 6 months initially with penile measurement and curvature assessment; reassurance regarding the natural history; and surveillance for recurrence after surgery.