Definition Peyronie’s Disease
Peyronie’s disease is a localised area of abnormal scar tissue or fibrosis that appears as a plaque or nodule in the penis. These plaques occur in about 1% of men over 50 years of age. A plaque is initially tender but when mature is painless and often associated with curvature of the erection. Most plaques occur on the top of the penis. Patients present with pain, a lump in the penis, a curvature of the erection or erectile dysfunction.
Physiology of Peyronie’s Disease
Peyronie’s disease has two distinct phases. The acute phase lasts 12-18 months and may be associated with pain during erection. Nodules form and a curvature may slowly develop. The chronic phase involves thickening of the scar tissue and the absence of pain. The curvature may improve, stay the same or deteriorate. The presence of calcification indicates a poorer outcome.
These plaques may arise without any known cause or may arise from mild trauma associated with mechanical strain of the erect penis during intercourse. This effect is commonly seen with the partner in the superior position. The exaggerated localised scarring response may be genetic (HLAB27) and associated with scarring in the hands, a condition known as Dupytren’s contracture. Penile injection therapy and men who have undergone radical prostatectomy may also predispose to this scarring.
Erection problems may occur in 20% of men with Peyronie’s disease. This may arise from a performance anxiety due to the pain and visible bend or due to a physical cause when penile blood vessels are affected by the plaque.
Treatment of Peyronie’s Disease
No treatment is required when there is minimal deformity, no pain and no discomfort. There is no consensus on the best treatments for the acute phase of Peyronie’s disease. Many treatments are anecdotal and not evidence based. However it is apparent that men experience a degree of depression where counselling is recommended.
Oral medication: When the plaque presents as a painful lump, the pain may be improved by oral medication using colchicine tablets (an anti-inflammatory used for the treatment of gout). Vitamin E can be taken orally and also applied to the skin of the penis. Oral proteins
l-carnitine and l-arginine are also used. An oral prescription medication oxypentifylline (Trental™) has been trialled overseas with some apparent benefit. Topical applications have not been proven to be that effective.
Injection medication: Various chemicals have been injected into the plaque such as cortisone, verapamil and interferon. A new injectable collagenase injection Xiaflex™ is now available in Australia. Xiaflex™ has been shown to reduce the curvature. Penile traction devices may assist to improve the shortening and curvature that are often a component of Peyronie’s disease.
Surgical treatment: Four surgical procedures are available to straighten the penis if the bend in the erection interferes with penetrative intercourse. However, surgery will not improve the rigidity of the erection if there is already a pre-existing problem with the rigidity. Surgery is only considered if the Peyronie’s plaque is stable and not causing further penile curvature.
The first procedure is a plication operation (Nesbitt procedure). It involves bending the penis straight with sutures but will cause some shortening of the penis.
The second procedure involves incision of the plaque with or without grafting of autologous or synthetic material. This is more complex and has slower recovery but has the benefit of preserving penile length.
The third procedure is the insertion of a penile implant and bending the penis straight. Occasionally grafting may also be incorporated as part of this procedure. The most severe cases whereby the penis is severely bent require complete dismemberment of the penile structures and then reconstructing it with synthetic material over a penile prosthesis.
Low intensity extra corporeal acoustic shock wave therapy has a controversial role in the treatment of Peyronie’s Disease but has been shown to have some benefit in reducing curvature is some cases. Shock wave therapy’s main use is in the treatment of vasculogenic ED.