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Androgen deficiency

The most important androgen in men is testosterone. Androgens are the sex steroids or hormones that produce changes in body shape and sexual characteristics typical of men after puberty. Androgens play a major role in the reproductive and sexual function of the adult male. The equivalent sex steroid produced by women is oestrogen.

Androgen deficiency occurs when reduced levels of testosterone arise from a lack of hormonal drive from the brain or problems with the testes. Replacement of testosterone may be given to such men and this is usually continued for life. About 1 in 200 men under 60 years of age suffer from androgen deficiency. However as men age, testosterone levels begin to fall from the age of 40 years. It is believed that by the age of 65 years, 10% of men will have androgen deficiency and by the age of 70 this figure will have risen to over 20%. Men’s testosterone levels fall much more gradually and over a longer period of time, unlike women, whose oestrogen levels fall rapidly when they go through the menopause.

Men with low testosterone complain of a number of symptoms including easy fatigue, low energy levels, low mood, irritability, poor concentration and reduced libido. Low testosterone may also contribute to erectile problems though androgen deficiency is an uncommon cause of this. As men age, the amount of body fat increases and muscle mass and strength decreases. A fall in testosterone levels is likely to contribute to these conditions. Low testosterone levels are also a risk factor for the development of osteoporosis.

It is difficult to diagnose androgen deficiency in older men purely on the basis of symptoms. Medical research is still needed to develop ways to identify older men who may be at risk of having androgen deficiency. As men age any significant medical illness can cause a fall in the level of testosterone but these levels usually recover when the illness has been treated.

Replacing testosterone in older men who have a very low testosterone has been shown to have a number of benefits on body fat, muscle, cholesterol and bone density as well as an improvement in quality of life.

Acknowledgement: Andrology Australia.

Peyronie’s Disease

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 said to be more common 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. Use of PDE5i by increasing penile blood flow may help.

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 in some cases. Shock wave therapy was originally developed as a treatment of vasculogenic ED.

The intention of this handout is for educational purpose only and not to be used as a guide for self-management. Consult with your specialist or GP.

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