Peyronie's disease

Peyronie's Disease Overview

Peyronie's disease (PD) is an acquired, localized fibrotic disorder of the tunica albuginea resulting in deformity of penis, hardness, pain, and erectile dysfunction. It is a psychologically and physically disabling disorder, leading to a lower quality of life. Diagnosis is based on examination and ultrasound to confirm the fibrotic plaque. Since the introduction of PDE5i the incidence of Peyronies disease has increased by approximately 5% in men Treatment can be medical or surgical depending upon the severity of the disease. Surgical management is considered for patients who have penile deformity compromising sexual function and whose condition has persisted for more than 12 months, and is refractory to medical therapy.

PATHOGENESIS

The cause is multifactorial with interplay between genetic predisposition, trauma, and tissue ischemia. The basic issue is formation of fibrous plaque(s) which contain excessive collagen, fragmented elastic fibers, calcification and fibroblastic proliferation which change the anatomy of penis. These plaques cause focal loss of elasticity and affect erectile function which in turn is due to repeated minor, and usually unrecognized, blunt trauma to the penis during intercourse due to improper wound healing.

Risk factors

A family history of such diseases increases the chances of developing Peyronies disease, or with other associated diseases such as Dupuytren's contracture. Other causes maybe Genital and/or perineal injuries, radical prostatectomy, plantar fascial contracture, Paget disease and gout. Hypertension, smoking, hyperlipidemia, and diabetes have been proposed as risk factors, but they are more likely related to underlying erectile dysfunction The disease state is divided into an acute (or inflammatory) phase and a chronic phase. The active phase is characterized by changes in penile curvature or deformity, and pain, while stable disease is characterized by an absence of pain and non-progression of deformity.

CLINICAL MANIFESTATIONS

Common complains are of penile pain, nodule/plaque, indentation, curvature, deformity, or shortening during erection, as well as sexual dysfunction. Deformities are variable and may present as curvature, indentation, palpable plaque or nodule, hour glass narrowing, penile shortening (with or without curvature) or in combination. The condition is present more prominently during erection Decreased quality of life, erectile dysfunction, depression and in relationship issues are seen in such a disease.

DIAGNOSIS AND ASSESSMENT

A thorough clinical examination is mandated with a proper history of complains with duration Classic symptoms of the disease are - :

Penile nodules (plaques), curvature, and/or pain. It is important to define the psychological effect of PD on the patient and partner, as well as the extent of associated erectile dysfunction. Factors which determines the severity are:- Penile length Plaque size Penile curvature. An evaluation of the penis curvature on erection is important to determine Ultrasound has the highest sensitivity for plaques and duplex scan to assess the blood flow. Diagnosis may not always be straight forward and few key differential diagnoses should always be kept in mind.

TREATMENT FOR PEYRONIE's DISEASE

Treatment for Peyronie's disease are medical or surgical which depends upon the degree of the disease as well as the extent of the symptoms that the individual suffers. Critical review of scientific littérature identifies widespread use of inappropriate clinical endpoints, especially improvement in penile pain, as pain resolves spontaneously in the vast majority of patients. Improvement or resolution of penile deformity should be the benchmark at which the therapies should be measured I believe that intervention during the active phase is beneficial. Thus, early diagnosis and consideration of treatment is important. Few medical therapies which are beneficial are:- Intralesional injections Drugs like, Pentoxifylline, NSDID, Vit. E Anti - inflammatory Vitamin E Interferon alfa-2b

OTHER TREATMENTS: Like Penile traction, iontophoresis, extracorporeal shockwave therapy (ESWT), and radiation therapy are have not shown any conclusive results or benefits.

Surgical management

SURGICAL INDICATIONS Surgical management is indicated for patients where Peyronie's disease has persisted for more than 12 months and is associated with a penile deformity compromising sexual function. It is important to delay surgery until disease has been stable for at least three months because surgical results can be compromised by active disease Simultaneous implantation of a penile prosthesis is indicated in men with Peyronie's disease and erectile dysfunction (ED) unresponsive to oral agents or intracavernous injection therapy Choice of surgical approach — is always case specific and disease specific Factors to consider for the best surgical choice are the length of the penis, configuration (eg, hourglass, curved) and severity of the deformity, erectile capacity, and patient expectations.

Surgical options include:- Tunical shortening (e.g. plication) Tunical lengthening (e.g. grafting) Implantation of penile prostheses (with adjuvant procedures to allow for resolution)

Patient counseling — A thorough preoperative discussion is essential and should review preparation, complications, and realistic long-term outcomes associated with the planned surgery.

Patients are informed of the risks of temporary or permanent penile hypoesthesia or anesthesia, future plaque formation, recurrent curvature, and risk of de novo or worsened ED. Patients with ED or significant risk factors for future ED should be counseled regarding the placement of a penile prosthesis at the time of surgery.

Surgical Consideration - The tunica is typically the target in Peyronie’s disease surgery, with either plication of the side opposite the plaque, or incision/grafting the same side as the plaque.

TECHNIQUES

Complementary techniques employed in the surgical management of Peyronie's disease include plication, grafting, or placement of a penile prosthesis. Tailored approaches are often required to manage the variety of plaque-induced penile deformities associated with Peyronie's plaques. Each of the techniques can be performed with or without plaque incision, which facilitates tunica mobility.

The most common plication techniques are:

Grafting — Men with Peyronie's disease who have a short penis, extensive plaque, or severe (>60º) or complex deformities will require a grafting procedure.

Graft materials — include: Penile prosthesis Autologous tissue like saphenous vein, fascia lata, rectus fascia, tunica vaginalis, dermis, buccal mucosa. Allograft or xenograft materials Synthetic grafts CARE The patient may shower but should keep the dressing dry, which can be accomplished by applying a condom or a plastic bag. Resume activities as tolerated. To avoid heavy lifting and soaking of wound for four weeks. Return to work in a few days depending upon speed of recovery. Sexual activity — The patient is instructed not to engage in sexual intercourse or masturbation for four to eight weeks, depending on the surgery.

OUTCOMES With an appropriately chosen technique taking into consideration patient-specific characteristics, reconstruction for Peyronie's disease achieves satisfactory results in the majority of men. Long-term satisfaction with return to sexual activity is high While some degree of penile shortening occurs in all patients, few have difficulty with penetration Residual curvature rates vary from 7 to 21 percent and may be due to suture absorption, slippage, or breakage.