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Peyronie’s Disease is an acquired condition characterized by the formation of scars in the tunica of the penis. These scars can be easily palpated as a lump and tend to be tender 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 during erections.
Peyronie’s disease is frequently associated with other known cardiovascular risk factors, such as diabetes, high blood pressure, obesity and tobacco smoke. 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, certainly also the cardiovascular risk factors play a role by causing obstruction to the arteries feeding the penis.
Since Peyronie’s Disease can be associated with penile pain, shortening, deformity and worsening of the quality of the erection, it can be cause of severe distress in the patient and the partner.
At present, the actual mechanism causing Peyronie’s disease is still unknown. It is suspected that this condition occurs in the genetically predisposed patient following a trauma to the erect penis. Possibly patients with Peyronie’s Disease present an imbalance in the factors promoting the healing process after a trauma and this leads to excessive local tissue proliferation following a trauma.
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 around 3 to 9 months from the onset of the condition. At this stage the pain generally settles and the deformity stabilizes.
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 the adolescent 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 disease, patients presenting with this condition should always be actively screened for the known cardiovascular risk factors.
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, deformity and/or worsening of the quality of the erections.
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 of the penis during sexual intercourse. 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 erection. 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 curvature appear less pronounced.
Alternatively, an artificial pharmacological erection can be induced in the office. This will allow the surgeon to better assess the tridimensional extent of the curvature and better plan the treatment options.
As patients with Peyronie’s Disease frequently have cardiovascular disease, a thorough assessment of the penile blood supply should be carried out 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.
Patients should be also actively screened for cardiovascular risk factors.
There is very little evidence that medical treatment is effective during the acute phase of the disease. Traditionally patients have been offered with no proven success oral vitamin E, Tamoxifen, Pentoxyphilline, Potassium Paraaminobenzoate, Colchicine and Verapamil in the hope to slow the progression of Peyronie’s Disease.
There might be a rationale for stretching the penis during the acute phase of the disease in order to counter-effect the tunical shortening produced by the plaque. This can be achieved either by pharmacologically enhancing natural erections or mechanically, with the use of a vacuum or stretching device.
Spontaneous improvement of Peyronie’s Disease can occur in around 10% of patients. Peyronie’s Disease should be addressed during the chronic phase, when the deformity has stabilized. Treatment should be offered when the deformity and/or the quality of the erection render penetrative sexual intercourse difficult or impossible.
Surgery 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. Medical treatment consists in intraplaque injections of Collagenase Clostridium Histolyticum, which will be discussed in depth in a different section of this website, and in mechanically straightening the penis using a vacuum or stretching device.
The evidence of the effectiveness of the use of the vacuum pump or of the penile stretching device to mechanically straighten the penis is minimal. In the best-case scenario, the regular use of these devices may just slightly reduce penile curvature, which would be beneficial only in very selected patients.
The choice of the best surgical approach, apart from patients’ preference, should take in 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 induce further penile shortening, with an estimated loss of 1 cm for each 30 degrees of curvature corrected, and that the do not allow to correct hourglass deformities. Therefore these techniques are not indicated in patients with severe shortening, curvatures of more than 60 degrees, as the length loss would be more than 3 cm, 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. As it does not produce significant length loss, it is also indicated in these patients who have experienced a significant penile shortening and a curvature of less than 60 degrees if the loss of length expected with a plication type procedure would exceed 20% of the total penile length.
The main drawback of plaque incision and grafting is that up to 15% of patients may experience some worsening of the quality of the erection postoperatively. Patients with a pre-existent degree of erectile dysfunction should therefore be counselled 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 prosthesis 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 manoeuvres 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 needs to be adequately counselled 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.
Penile length restoration procedures involve the elongation of the corpora cavernosa with a circumferential graft simultaneously with the implantation of a penile prosthesis. These techniques are technically more challenging, time consuming and potentially associated with increased risk of complications, when compare with penile prosthesis implantation alone. These procedures should be therefore offered only to an extremely selected group of highly motivated patients who have experienced significant loss of length and who are prepared to take an increased risk of complications.
Mr Giulio Garaffa is a Consultant Urological Surgeon and Uroandrologist at Highgate Private Hospital who treats a wide range of urological conditions. Mr Garaffa is one of the biggest penile prosthesis implanter in Europe.
Mr Garaffa is available for patient appointments on Monday mornings every week at Highgate Private Hospital. To book an appointment with him please call 020 8341 4182 or email firstname.lastname@example.org
You can also see one of our Private GPs if you prefer, with whom appointments can be booked through the same team.
Copyright Mr Giulio Garaffa, 2016