Treatments for Peyronie's Disease
What Is Peyronie’s Disease?
Peyronie’s disease is an acquired condition characterized by the formation of scars in the tunica albuginea of the penis. These scars can be easily palpated as a lump and tend to be tender for a few months during the initial phase of the disease.
Peyronie’s disease plaques cause loss of elasticity of the tunica of the penis, and this reduces the capacity of the penis to stretch during erections. Patients, therefore, frequently report penile shortening and deformity, such as curvature and narrowing of the shaft of the penis, which becomes visible during erections. In flaccidity, the lumps can still be palpated, but the deformity is not visible.
Peyronie’s disease is frequently associated with other known cardiovascular risk factors, such as diabetes, high blood pressure, high cholesterol levels, obesity, and tobacco smoke. It is now established that more than 60% of patients have at least one known cardiovascular risk factor.
Worsening of the quality of the erections is quite common in patients with Peyronie’s disease, although this can be potentially caused by the plaque itself, as it allows the blood to be rushed out of the tunica of the penis. Cardiovascular risk factors also play a role by causing obstruction to the arteries feeding the penis, thus, reducing the blood inflow into this organ.
Since Peyronie’s disease can be associated with penile pain, shortening, deformity, and worsening of the quality of the erection, it can cause severe distress in both the patient and the partner.
What Causes Peyronie’s Disease?
At present, the actual mechanism causing Peyronie’s disease is still not fully understood. It is suspected that Peyronie’s disease occurs in the genetically predisposed patient following trauma to the erect penis during sexual activity. It is believed that patients with Peyronie’s Disease present an imbalance in the factors that regulate the healing process following tissue damage, leading to excessive local tissue proliferation.
Typically, Peyronie’s disease presents an initial acute and a chronic phase. The acute phase is characterized by the formation of the plaque, which is tender at palpation as there is an active local inflammatory process. During this phase, stretching of the plaques, as physiologically occurs during erections, elicits vivid pain. Plaque size and type of deformity tend to change over time during this phase. The chronic phase starts when the inflammatory process eventually settles, usually within 6 to 12 months from the onset of the condition. At this stage, the pain generally settles, and the deformity does not change any more in time.
Who is More Likely to Get Peyronie’s Disease?
Peyronie’s disease is a quite common condition as it affects around 10% of men. Although it is typically a condition of the fifth and sixth decade of life, Peyronie’s disease can occur at any age. Usually in adolescents, the condition tends to be more aggressive in terms of size of the plaque and degree of deformity produced.
Potentially any male can develop Peyronie’s disease, although the condition is more likely to occur in the fifth and sixth decade of life and in patients with cardiovascular risk factors.
Due to the strong link between Peyronie’s disease and cardiovascular disease, patients presenting with this condition should always be actively screened for known cardiovascular risk factors such as high blood pressure, diabetes, and high cholesterol levels.
What are the Symptoms of Peyronie’s Disease?
The initial, acute phase of Peyronie’s disease is usually characterized by the formation of a tender nodule on the tunica of the penis. Erections at this stage tend to be painful, and patients usually notice a penile deformity, which, at this stage, still changes over time.
The inflammatory process progressively settles, and this leaves a non-tender nodule on the tunica of the penis. At this stage, erections are generally not painful, and patients usually complain of penile shortening and deformity, which become apparent during erections. Many patients also report a progressive worsening of the quality of their erections.
How is Peyronie’s Disease Diagnosed?
Peyronie’s disease diagnosis is based on history taking and on the examination of the patient. Frequently, patients report that the disease has started following a trauma to the penis during sexual activity. Examination of the penis will demonstrate the presence of a lump, which can be elastic or indurated in texture.
Deformity can be assessed only during erections, when the tunica albuginea of the penis is stretched to its maximum capacity. Self-photography of the erect penis can be a useful tool to identify the nature of the deformity. However, this can underestimate the exact tridimensional extent of the curvature, as the picture is, by definition, bi-planar. Also, an incomplete erection will make the deformity appear less pronounced.
Alternatively, an artificial erection can be induced in the office with the administration of a vasoactive medication. This allows the surgeon to assess more precisely the tridimensional extent of the curvature and better plan the treatment options.
As patients with Peyronie’s disease frequently have cardiovascular disease, which might have produced a degree of obstruction of the arteries feeding the penis, a thorough assessment of the penile blood supply should be carried out by performing an Eco Colour Doppler Ultrasound Scan. This investigation will provide the surgeon with extremely precious information that will also help to better decide which is the most appropriate treatment option for each specific patient.
What are the Options for the Treatment of Peyronie's Disease?
There is some evidence that medical treatment is effective during the acute phase of the disease to reduce the progression of the disease and limit the damage. Traditionally, patients have been offered, with no proven success, oral vitamin E, Tamoxifen, Pentoxyphilline, and Potassium Para aminobenzoate for the progression of Peyronie’s Disease.
The administration of low-intensity shockwave therapy in the acute phase may help to reduce the progression of the disease.
There might be a rationale for stretching the penis during the acute phase of the disease to counter-effect the tunicle shortening produced by the scarring process occurring at the level of the plaque. This can be achieved either by pharmacologically enhancing natural erections with the administration of Phosphodiesterase Type 5 Inhibitors such as Sildenafil, Tadalafil, Avanafil, and Vardenafil or mechanically with the use of a vacuum or stretching device.
Spontaneous improvement of Peyronie’s disease with progressive reduction of the degree of deformity can occur in less than 10% of patients.
The definitive treatment of Peyronie’s disease should be offered during the chronic phase when the deformity has stabilized.
Treatment should be offered when the deformity, penile shortening, and/or the quality of the erection render penetrative sexual intercourse difficult or impossible.
Although a combination of low-intensity shockwave therapy, intralesional injection therapy, and traction therapy may help to reduce the curvature, surgery still represents the gold standard treatment for Peyronie’s disease, and its aim is to guarantee a penis straight and hard enough to allow the patient to engage in penetrative sexual intercourse.
The choice of the best surgical approach, apart from patients’ preference, should take into consideration the quality of erection and the degree of deformity and shortening.
In patients with preserved erections, the curvature can be corrected either by shortening the longer side of the penis, which has not been affected by Peyronie’s Disease, or lengthening the shorter side, incising the plaque and interposing a graft. Both procedures can be performed as a day case.
Various techniques, such as the Nesbit and Yachia plication, the 16 and 24-dot technique, and the tunica albuginea plication (TAP) can be used to accomplish shortening of the longer side. These techniques are relatively simple and are not associated with any postoperative worsening of the quality of the erections. The main drawbacks are that they do not allow you to correct hourglass deformities. Therefore, these techniques are not indicated in patients with severe shortening or complex deformities with narrowing.
Although it is technically slightly a more challenging procedure than penile plications, plaque incision and grafting still represents a very reliable procedure that should be offered to patients with complex curvatures and narrowing of the shaft.
The main drawback of plaque incision and grafting is that up to 15% of patients may experience some worsening of the quality of the erections postoperatively. Patients with a pre-existent degree of erectile dysfunction should, therefore, be counseled against plaque incision and grafting.
Postoperative stretching of the graft, either by pharmacologically enhancing the natural erection or mechanically stretching the penis, is paramount to prevent graft contracture, recurrence of the curvature, and ultimately, penile shortening.
Patients with erectile dysfunction not responding to medical treatment or with a degree of erectile dysfunction and a complex deformity and/or severe shortening should be offered penile prosthesis implantation.
Both malleable and inflatable penile prostheses have been used in patients with Peyronie’s disease with excellent results, with up to 95% of patients and partners satisfied with the results of surgery. Apart from guaranteeing the axial rigidity necessary to engage in penetrative sexual intercourse, penile prosthesis implantation alone allows the correction of the curvature in almost all cases. Additional straightening maneuvers may be required to achieve adequate curvature correction in the remaining patients.
Plaque incision and grafting in combination with penile prosthesis implantation may be required in a very limited number of patients who present with very large, calcified plaques.
Patients undergoing penile prosthesis implantation need to be adequately counseled preoperatively that the aim of surgery is to guarantee a penis straight and hard enough for penetrative sexual intercourse and that the procedure will not restore the length lost because of Peyronie’s disease and the long-standing erectile dysfunction.
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