Adam Luchey, MD
■ Stanley Zaslau, MD, MBA, FACS
■ Introduction
■ Named after François Gigot de la Peyronie in 1741, Peyronie’s disease (PD), a benign condition, is characterized by a palpable plaque and curvature of the penis when erect.
■ Lindsay et al. published the results of a 35-year study that showed a prevalence of 0.4% and the average age of onset at 53 years.1
■ However, when studied in autopsies, Smith noted the prevalence of plaques to be 22 of 100 men.
■ More recently, a review by Jalkut et al. stated that the increasing number of men presenting today with Peyronie’s disease can be attributed to the role of phosphodiesterase inhibitors in treatment for erectile dysfunction. Thus, an underlying ED may be responsible for the development of Peyronie’s disease.
■ Although no specific cause can be attributed to Peyronie’s disease, sexual trauma is strongly suspected.
• Trauma to the tunica albuginea allows release of transforming growth factor, activating reactive oxygen species, which allows collagen deposits and calcification of the plaque that causes the deformity.3
■ Physical Examination
■ Peyronie’s disease is divided into two phases, the acute and the chronic phase.
■ The acute phase is characterized by:
• Painful erections
• Nodule formation
• Change in curvature of erection (up to the first 18 months)
■ The chronic phase is characterized by:
• Stable nodule and deformity
• Relief of discomfort4,5
■ Peyronie’s disease can cause erectile dysfunction in up to 30—50% of cases and can prevent the patient from engaging in sexual intercourse.
■ Photographs of the erections are helpful, especially for following changes with treatment and planning any operative management.
■ The majority of the plaques are located on the dorsal or lateral sides of the penis.
■ When talking with patients, the practitioner should inquire about other risk factors that may cause erectile dysfunction, such as:
• Diabetes
• Smoking
• Hyperlipidemia
• Hypertension
• Coronary artery disease
■ Some believe there is an association between Peyronie’s disease and Dupuytren’s contractures, which should also be evaluated on physical exam.
■ Examining the penis in an outstretched position can help identify the extent of the plaques.
■ Ultrasound can help identify any calcification and can aid in tracking progression and/or response to treatment.
■ Medical Therapy Vitamin E
■ Vitamin E is an antioxidant, which means it inhibits oxidation by free radicals (Table 6.1).
■ However, it has a few side effects:
• Treatment can increase the likelihood of heart failure
• Has anticoagulative effects
■ Recent studies fail to show significant clinical benefit.8
■ This agent is given in divided doses of 800—1000 units per day. Typically Vitamin E is used for less than six months.
Table 6.1 Treatments for Peyronie's Disease
|
Pros |
C°ns і |
|
|
Vitamin E |
Antioxidant, scavenger of free radicals, few side effects |
Recent studies fail to show benefit.6-7 Treatment can potentiate heart failure and anticoagulative effects. |
|
Aminobenzoate Potassium |
Possibly decrease fibrinogenesis through altering serotonin levels4 |
Expensive, Gl upset. Other studies have shown no benefit of correcting deformity; not recommended.9-10-11 |
|
Colchicine |
Small, noncontrolled, unblinded shown benefit of improving curvature and decreasing plaque size12 |
Check periodic CBC (can lower blood cell counts), diarrhea |
|
Tamoxifen |
Regulated immune response through TGF-B decreasing fibrinogenesis13 |
Alopecia, no difference between tamoxifen and placebo15 |
|
Carnitine |
Showed promise when compared to tamoxifen |
Not recommended when compared to placebo16 |
|
Intralesional Verapamil |
Decrease in plaque volume and possible decrease in curvature deformity through inhibiting exocytosis of collagen, fibronectin, and glycosaminoglycans (increase collagenase activity)14 |
Only benefits acute phase. Topical verapamil not recommended.17 |
|
ESWT |
Elypothesize plaque lysis through inflammatory macrophages. |
No improvement in curvature, plaque size, or sexual function.18-19 |
Dosage
■ Vitamin E: Divided doses of 800—1000 units per day.
■ Aminobenzoate Potassium: 12 g/day in 4—6 divided doses6
■ Colchicine: 0.6 mg—1.2 mg daily for first week to 2.4 mg daily for three months in divided doses
■ Tamoxifen: 20 mg twice daily
■ Carnitine: 1 gram twice daily
■ Intralesional Verapamil: 12 injections (10 mg/ml) per day for two to four weeks
Abern and Levine studied intralesional steroids, which showed no objective benefit, and collagenase, which showed a possible benefit in plaque width and curvature; further studies are ongoing. The same researchers also showed promising results from taking combination intralesional verapamil with traction and oral pentoxifylline and L-arginine.11
■ Surgical Therapy
■ This procedure is not appropriate during the acute phase (< 1 years, painful erections) when the plaque is still changing and not mature. Three procedures are considered to be commonly performed depending on the degree and location of the plaque. These are:
1. Nesbitt procedure
2. Plaque excision and graft interposition
3. Penile prosthesis placement and orthoplasty
Nesbit Procedure
Nesbit procedure was first described in 1965 for correction of congenital curvature.20 When performing the Nesbit procedure, an elliptical incision is made into the tunica albuginea opposite that from the plaque in order to straighten the curvature.
■ Patients are told pre-operatively that they will experience penile shortening on average of 0.5 cm but values greater than this have been reported. In addition, details on loss of sensation, hematoma, and urethral injury have to be included.
■ Akkus et al., which published recommendations from 10 experts, stated that the Nesbit procedure was the treatment of choice with the least risk of postoperative erectile dysfunction for a stable deformity.21
■ Through modification of the procedure, Rolle et al. were able to achieve a statistical improvement in erectile dysfunction through a modified corporoplasty that enabled them to excise the fibrosed tunica albuginea only after the correct position was determined in real time without lengthening the operation. This was proven in both acquired and congenital penile curvature.22
Plaque Excision and Graft Interposition
■ In general, graft material (buccal, saphenous vein, tunica vaginalis, fascia lata, rectus fascia, cadaveric, and bovine pericardium) has less of a risk of penile shortening than other surgical procedure but the risk of erectile dysfunction is greater.
■ Buccal mucosa has been shown to have no shrinkage or change in elasticity and Liu et al. achieved complete straightening in 21 of 24 patients followed for 0.5—7 years with minimal loss of length.23
■ In a retrospective analysis of 11 patients undergoing dermal grafting, were encouraged to achieve erections after two weeks and sexual intercourse after six weeks.24
■ In a head to head comparison between cadaveric pericardium and dermal grafts, Chun and McGregor et al. showed that cadaveric pericardial grafts are equal to dermal grafts with the added benefit of commercial availability without the need for harvesting.25
Penile Prosthesis Placement with Orthoplasty
Prosthesis involvement for Peyronie’s is best suited for the elderly male with significant curvature as well as severe erectile dysfunction, and for this it is considered the firstline of treatment.26
■ Older prostheses did not allow modeling because their length did not achieve the rigidity needed to correct curvature. With advances in penile prostheses their applicability in Peyronie’s grew.
Ghanem et al. studied 20 men who had malleable penile prosthesis placed, all of which failed intracavernous injections. They reported straightening of the penile shaft in all cases and all but two were satisfied at one year post-op.27
■ Carson and colleagues studies 30 men, all with their duration of deformity greater than 12 months who were able to achieve penile straightening with a functional implant and modeling in 28 patients; the remaining required plaque incision.28 It has been known that modeling over an implant lends to an increase in intra-operative urethral injury compared to implantation of prosthesis by itself.29
■ There is no one perfect operation for chronic Peyronie’s disease. The physician must take into account the underlying erectile function, or lack thereof, and the risk of penile shortening when determining their approach. As always, surgeon experience is critical to patient outcome.
■ Conclusions
■ Although no specific cause of Peyronie’s disease is fully known, sexual trauma is strongly suspected.
■ Peyronie’s disease can cause ED and can prevent the patient from engaging in sexual intercourse.
■ Medical and surgical therapies are available to treat Peryonie’s disease. Treatment must be individualized to the patient’s degree of curvature, location of curvature, and presence of underlying ED.
■ Treatment is currently evolving and continued research in this area is ongoing.
■ References
1. Lindsay MB, Schain DM, Grambasch P. The incidence of Peyronie’s disease in Rochester, Minnesota, 1950 through 1984. J Urol. 1991;146:1007-1009.
2. Smith BH. Subclinical Peyronie’s disease. Am J Clin Pathol. 1969;52:385-390.
3. Jalkut M, Gonzalez-Cadavid N, Rajfer J. Peyronie’s disease: a review. Rev Urol. 2003 Summer;5(3):142-148.
4. Hellstrom WJ. Medical management of Peyronie’s disease. JAndrol. 2009;30:397-405.
5. Gelbard MK, Dorey F, James K. The natural history of Peyronie’s disease. J Urol. 1990;149:53-55.
6. Hasche-Klunder R. Treatment of Peyronie’s disease with para-aminobenzoacidic potassium (POTABA). Urologe A. 1978;17:224-227.
7. Pryor JP, Farrell CF. Controlled clinical trial of vitamin E in Peyronie’s disease. Prog Reprod Biol. 1983;9:41-45.
8. Broderick GA, Lue TF. Evaluation and nonsurgical management of erectile dysfunction and premature ejaculation. In: Wein AJ, Kavoussi LR, Novick AC, Partin AW, Peters CA, eds. Campbell-Walsh Urology. 9th ed. Philadelphia, PA: Saunders Elsevier Company; 2007:818-838.
9. Hasche-Klunder R. Treatment of Peyronie’s disease with para-aminobenzoacidic potassium (POTABA). Urologe A. 1978 Jul;17(4):224-227.
10. Weidner W, Hauch EW, Schnitker J. Peyronie’s disease study group of andrological group of german urologists. Potassium paraaminobenzoate (Potaba) in the treatment of Peyronie’s disease: a prospective, placebo-controlled, randomized study. Eur Urol. 2005;47:530-536.
11. Abern M, Levine L. Peyronie’s disease: evaluation and review of nonsurgical therapy. TSWJ. 2009 Jul 27;9:665-675.
12. Akkus E, Carrier S, Rehman J, et al. Is colchicine effective in Peyronie’s disease? A pilot study. Urology. 1994;44:291-295.
13. Colletta A, Wakefield L, Howell F, et al. Anti-oestrogens induce the secretion of transforming growth factor beta from human fetal fibroblasts. Br J Cancer. 1990;62:405-409.
14. Levine LA, Goldman K, Greenfield J. Experience with intraplaque injections of verapamil injection. J Urol. 1997;158:1395-1399.
15. Telojen C, Rhoden E, Grazziotin T, et al. Tamoxifen versus placebo in the treatment of Peyronie’s disease. J Urol. 1999;162:2003-2005.
16. Safarinejad M, Hosseini S, Kolahi A. Comparison of vitamin E and propionyl-L-carnitine, separately or in combination, in patients with early chronic Peyronie’s disease: a double-blind, placebo controlled, randomized study. J Urol. 2007;178:1398-1403.
17. Levine L. Comment on topical verapamil HCl, topical trifluoperazine, and topical magnesium sulfate for the treatment of Peyronie’s disease—a placebo-controlled pilot study. J Sex Med. 2007;4:1081-1082.
18. Hatzichristodoulou G, Mesiner C, Stenzl A, et al. (2006) Efficacy of extracorporeal shock wave therapy (ESWT) in patients with Peyronie's disease (PD)—first results of a prospective, randomized, placebo-controlled study. Paper presented at the AUA meeting.
19. Hatzichristodoulou G, Mesiner C, Stenzl A, et al. (2006) Efficacy of extracorporeal shock wave therapy (ESWT) in patients with Peyronie’s disease (PD)—first results of a prospective, randomized, placebo-controlled study. Paper presented at the AUA meeting.
20. Nesbit RM. Congenital curvature of the phallus report of three cases with description of corrective operation. J Urol. 1965;93:230.
21. Pryor J, Akkus E, Alter G, Jordan G, Lebret T, Levine L, et al. Peyronie’s disease. J Sex Med. 2004;1:110-115.
22. Rolle L, Tamagnone AT, Timpano M, et al. The Nesbit operation for penile curvature: an easy and effective technical modification. J Urol. 2005;173:171-174.
23. Liu B, Zhu XW, Zhong DC, Shen BH, Jiang H, Xie LP. Replacement of plaque by buccal mucosa in the treatment of Peyronie’s disease: a report of 27 cases. Zhonghua Nan Ke Xue. 2009;15:45-47.
24. Royal NK, Kumar A, Das SK, Pandey AK, Sharma GK, Trivedi S, Dwivedi US. Experience with plaque excision and dermal grafting in the surgical treatment of Peyronie’s disease. Singapore Med J. 2008;48:805-808.
25. Chun J, McGregor A, Krishnan R, Carson C. A comparison of dermal and cadaveric pericardial grafts in the modified Horton-Devine procedure for Peyronie’s disease. J Urol. 2001;166:185-188.
26. Levine LA, Lenting EL. A surgical algorithm for the treatment of Peyronie’s disease. J Urol. 1997;158:2149-2152.
27. Ghanem HM, Fahmy I, El-Meliegy A. Malleable penile implant without plauq surgery in the treatment of Peynoie’s disease. Int J Impotence Research. 1998;10:171-174.
28. Carson CC. Penile prosthesis implantation in the treatment of Peyronie’s Disease. Int J Impotence Research. 1998;10:125-1258.
29. Wilson S, Cleves M, Delk J. Long-term followup of treatment for Peyronie’s Disease: modeling the penis over an inflatable penile prosthesis. J Urol. 2001;165:825-829.