Introduction
Peyronie’s disease (PD) is a condition in which an inelastic scar (called a plaque) forms in an inner layer (tunica albuginea) of the penis. This causes curvature of the penis. It is most commonly seen in the fifth decade of life. PD is not a cancerous condition.
Causes of Peyronie’s Disease
Most cases do not have a known cause. One possible cause is trauma, which can happen during previous sexual intercourse. Men often do not recall such an event. PD has been associated with another condition called Dupuytren’s contracture (30% association), which is a shortening and thickening of the palm’s tissue that results in clawing of the fingers. The underlying process of scarring and contracture may be similar in both conditions. Men who do injection therapy for erectile dysfunction may get PD if they inject in the same spot repeatedly.
What are the symptoms?
Men with PD can present with:
- Penile pain – especially with erection in the early phases of the disease.
- Penile curvature or shortening – the deformity may be severe enough to prevent sexual penetration.
- Penile induration or plaque.
- Erectile dysfunction (ED) – it is unclear if Peyronie’s is the cause of ED or if it simply occurs with ED.
What happens if it is not treated?
During the initial phase of inflammation, there is often pain as well as penile curvature. The plaque is still remodelling and the disease may resolve spontaneously (14%), stabilize (46%) or become worse (40%) over time. It takes about a year for the plaque and deformity to stabilize. Therefore, surgical treatment should not be considered until at least one year has passed.
How is a patient with Peyronie’s Disease assessed?
A history of the duration, severity, pain, erectile dysfunction, and the ability to achieve sexual penetration should be obtained. During the examination, the plaque size and position are noted. An injection may be given to the penis to create an erection to assess the deformity. Otherwise, a drawing or a photo taken of the penile curvature in two views (top-down and side-on) can be helpful in determining the degree of angulation. An ultrasound of the penis can be useful to visualise the plaque.
What are the non-surgical treatments?
During the acute phase, treatment is aimed at relieving pain and preventing progression. Non-surgical treatments in general, show little benefit with respect to the deformity.
Oral treatments described in the literature include Vitamin E, colchicine, Potaba (potassium aminobenzoate), tamoxifen and PDE5 inhibitors. Combination therapy with Vitamin E and colchicine is often used because it is cheap, simple, and well-tolerated.
Topical verapamil has been used in combination with electric current therapy (iontophoresis) to show some benefit with deformity and plaque size in a study in 2004 (Di Stasis). However, the equipment is not widely available and more studies are needed.
Injection therapy into the plaque has also been studied. Of the agents used, verapamil may show some benefit. However, there are still no large-scale, placebo-controlled trials to support this.
Penile traction devices have been studied but the major limitation is that prolonged daily use is necessary, which is beyond what most men can or are willing to do.
What are the surgical options?
Surgery remains the only effective way of correcting the deformity. It should only be done after the disease has stabilised (> 1 year) to avoid the plaque progressing after surgery. Not all men need surgery; a good indication is if the deformity makes sexual penetration difficult or painful.
Plication surgery
The opposite side of the penis to the plaque is shortened by sutures to straighten the penis (the plaque is not removed). This is effective, causes less postoperative erectile dysfunction (ED) but always shortens the penis by about 1 – 2 cm.
Nesbit surgery
An elliptical piece of the inner layer of the penis (tunica albuginea) is excised from the unaffected side of the penis and the defect is closed in the transverse direction. This also shortens the penis but has a higher long-term success rate than plication and a lower rate of postoperative ED than grafting surgery. Hence, it is usually the procedure of choice in men with adequate erections and penile length, and a minor penile curvature without severe deformity.
Plaque excision or incision with grafting
The plaque is first removed and the defect is covered with a graft. This is more likely to cause postoperative ED but is less likely to cause penile shortening. This technique is best for men with adequate erectile function and severe penile deformity or shortening.
Penile prosthesis implantation surgery
Some men with PD may have severe erectile dysfunction that is not responsive to less invasive erection therapies. These men may benefit from the insertion of a penile prosthesis device.
What else do I need to know about the surgery?
Other than the risks of erectile dysfunction and penile shortening as described above, there are a few other points to know.
Men should not expect a 100% correction of the penile curvature after surgery. During the surgery, an artificial erection is created to enable as good a correction as possible. The most important outcome is that the penis is straight enough for sexual penetration.
If a man is uncircumcised, a circumcision (surgical removal of the foreskin) may be done during the surgery as well. This is because, to expose the inner layer of the penis (tunica albuginea), the outer loose layer of penile skin has to be pulled down after detaching it circumferentially from the base of the glans penis. When this outer skin is reattached at the end of the surgery, the foreskin’s blood supply may be compromised from the previous circumferential incision. To prevent ischaemia of the foreskin, a circumcision may be done.
The sutures used during plication surgery have to be strong and non-dissolvable. Therefore, men are always warned of the possibility that they may feel the suture on the shaft of the penis, especially during an erection.