Peyronie’s

 

Definition

“Wound healing disorder affecting the tunica albuginea”.

Acquired progressive condition resulting in fibrous plaque formation within the tunica albuginea.

Associated with penile deformity such as curvature, pain, shortening and difficulty with intercourse.

 

Epidemiology

Symptomatic incidence quoted at 1 % but estimated higher prevalence up to 9 % and significantly underreported.

Most commonly presents aged 50 – 60.

 

Risk factors / associations

• Age
• Diabetes, hypertension and smoking
• ED (?chicken/egg cause/effect)
• Dupuytren’s
• Pelvic surgery
• Radical prostatectomy
• Hypogonadism
• Congenital penile curvature
• Ledderhose (plantar fascia) contracture
• Tympanosclerosis

 

 

Pathogenesis

Tunica albuginea is a bilaminar structure with an inner circular and outer longitudinal layer.

The outer longitudinal layer is thinnest laterally and almost absent ventrally (think fracture locations), and thicker dorsally – hence most plaques and curvature are dorsal.

The exact pathophysiology is not clear but leading hypothesis is:

• Men are genetically pre-disposed
• Repetitive microtrauma or single trauma to tunica albuginea
• Abnormal wound healing and inflammatory cascade
• Leads to subsequent changes in the tunica collagen to type 3 collagen, and a fibrotic plaque which is inelastic during erection

 

Clinical features

Classically presents in 6^th decade but can occur in younger men.

May present complaining of any of:

• Curvature
• Pain
• Erectile dysfunction
• Loss of length
• Palpable plaque

Most commonly curve is dorsal, then lateral.

Acute (active or inflammatory) phase lasts between 6 and 18 months:

• Typically painful (although a third may have no pain)
• Pain can be erect or flaccid
• The curve may progress or change during the acute phase
  • Roughly 15 % improve, 40 % stable, 45 % progress

Chronic (stable) phase follows:

• Pain resolves, curvature and plaque stabilise

Significant psychological distress is not an uncommon feature.

 

Assessment

History:

• Duration of symptoms (is this acute or chronic phase?)
• Pain
• Perceived deformity or shortening (and is this changing)
• Ability to have intercourse
• Erections
• Medical and surgical history, medications, anaesthetic risks
• Associated conditions

Examination:

• General health and body habitus. Associated conditions (Dupuytren’s, plantar fascia)
• Palpable plaque
• Stretched penile length
• Circumcision
• Objective assessment of curvature and deformity
  • Photos (including different angles)
  • Artificial erection (in rooms or in theatre)
  • Complexity of curvature
    • ?Multi-axis or single axis
    • Hourglass or waisting deformity
    • Objective measurement with goniometer

No routine investigations are necessary or helpful.

 

Goals of treatment

During the acute phase – symptom management and pain control.

During the chronic phase – optimisation of sexual function – functionally straight penis with preservation of erectile function.

 

Non invasive / medical treatments:

In the acute phase – use NSAIDs for pain.

PDE5 inhibitors are useful for erectile dysfunction.

 

Various oral options have been trialled or used but there is a lack of evidence for any efficacy and they are not recommended in guidelines:

• Potassium para-aminobenzoate (potaba)
• Vitamin E
• Tamoxifen
• Colchicine
• Pentoxifylline
• Omega 3 fatty acids

 

Shockwave treatment – some evidence it may help with pain, but has not been shown to make any difference to curvature. Potential mechanisms include physical remodelling of the plaque, or hyperaemic response bringing inflammatory mediators which may help with plaque resorption.

 

 

Penile traction therapy – aims to non-surgically reduce curvature, enhance girth and recover lost length.

Studies have heterogenous methods – 30 mins – 8 hours per day

Inconvenient and cumbersome, but safe and seems tolerated by motivated patients.

Studies show moderate improvement in curvature and stretched penile length

 

Topical treatments – EAU guidelines recommend against topical treatments such as topical verapamil, H-100 gel, and steroids, with or without iontophoresis

No evidence of active compound penetrating tunica, and no evidence of efficacy.

 

Intralesional injections

Calcium channel antagonists verapamil and nicardipine have been used in the past – not recommended by EAU due to lack of efficacy.

Interferon α-2b has good in vitro efficacy and has been shown to improve penile curvature, plaque size and density, and pain compared to placebo.

Can be offered as a treatment as per EAU/AUA.

Intralesional steroids, hyaluronic acid and botox cannot be recommended on current evidence.

 

Collagenase (Xiaflex) has the best evidence of intralesional therapies.

• Collagenase toxin from clostridium histolyticum
• Purified bacterial enzyme which selectively attack and breaks down collagen
• IMPRESS trials
  • 2 x injections, separated by 1 – 3 days (0.58 mg / 0.25 mL)
  • Penile modelling 1 – 3 days after the second injection
  • At home modelling
  • Repeat that cycle up to 4 times at 6 week intervals

Indicated for

• Stable chronic disease
• 30 – 90 degrees
• Dorsal plaques
• Good erectile function

Average 34 % improvement in angulation (15 – 20°).

Risk of penile fracture, haematoma, pain. Advise no sex for 4 weeks following treatment to reduce risk of fracture.

No longer available in Australia and very expensive.

 

Surgery for Peyronie’s disease

Indications for surgery:

• Stable disease
• Compromised ability to have sex
• Strong patient preference with failure of conservative therapy

Consent is crucial

• Functionally straight penis is the goal
• Possibility of residual or persistent curvature, loss of length (real or perceived), diminished rigidity, change in sensation and ED related to either treatment or disease.
• “Penis will never be the same”.
• May require circumcision

If the patient is able to have sex, and minimal levels of bother, reassure and avoid operating.

Categories of procedures include:

1. Plication or tunical shortening procedures
2. Incision and grafting or tunical lengthening procedures
3. Penile prosthesis, with or without incision and grafting

 

Choice of procedures depends on:

• Degree and complexity of curvature
• Erectile function
• Patient preference

 

Penile plication

Indicated for milder “simple” curvatures, less than 60 – 70 degrees.

Risks – palpable knots, penile shortening (est. 1 cm for every 15°).

Options include:

1. Nesbit procedure – transverse elliptical excision of tunica on contralateral point to plaque/curvature, closed transversely with interrupted non-absorbable suture (2-0 prolene or ticron) with knots buried.
2. Yachia procedure – full thickness vertical incision of tunica on contralateral point to curvature, closed transversely without any excision of tunica
3. Lue dot plication – no incision, Lembert-type suture with 4 ‘dots’ per plication suture – 16 dots typically done with 2 sets on each ventral tunica for a dorsal curvature, modified for a lateral or ventral curve. 2-0 ticron (braided) or 2-0 prolene.

General technical points for plication procedures:

• Suture through glans for retraction
• Use saline or papaverine through a butterfly needle introduced to corpora for artificial erection testing
• Use Allis clamps on the corpora to assess degree of plication needed
• Can be done through circumferential degloving, or through longitudinal incision (especially if wanting to preserve foreskin).
• Can use skin hooks to elevate tunical defect during Nesbit

 

Incision and grafting techniques

Indicated for more complex curvatures with hinge defects, hourglass deformities, extensive calcification or > 60 – 70 degrees.

Higher risk of ED cf. plication (in excess of 25 %) – due to interruption of the dorsolateral neurovascular bundle.

Other risks include decreased distal rigidity (?venous leak), increased risk of sensory changes and risk of graft contracture.

H or Y relaxing incision in the tunica overlying the plaque/curvature.

Multiple options for graft tissue:

• Autologous – dermis, saphenous vein, temporalis fascia, tunica vaginalis, buccal mucosa
• Allografts – human cadaveric pericardium, dermis, fascia lata, dura
• Xenografts – bovine pericardium, porcina small bowel mucosa
• Synthetic – Tachosil, Dacron

 

Penile prosthesis +/- modelling +/- graft

Penile prosthesis is the recommended surgical treatment for Peyronie’s with therapy resistant ED.

In minor curvatures without significant defect (30° or less) – simply placement of IPP will be enough.

If after placement of IPP with partial inflation there is a bothersome curvature – can forcibly straighten the penis (often hearing a cracking sound) until straight enough with full inflation.

In known significant curvature, plication sutures (Dot technique) can be placed before putting in the implant to avoid needles after implant placed.

Alternatively, plaque can be incised with cut current after IPP placement, and graft placed over corporotomy to cover the implant.

Ensure expectations are managed pre-operatively regarding shortening and length. Peyronie’s patients with implants have lower satisfaction scores cf. normal IPP patients. IPP insertion is more difficult with high rates of corporal fibrosis (cf. normal IPP).

 

Post-op (incision-grafting)

Compression dressing 1 week.

Stretching crucial to prevent contracture and shortening.

Low dose tadalafil from 2 weeks, sex from 6 weeks.

 

Congenital penile curvature

Rare with reported incidence < 1 %.

Disproportionate development of tunica albuginea of the corporal bodies – not associated with urethral malformation / hypospadias and not acquired.

Usually ventral curvature more often than lateral or dorsal.

Definitive treatment is surgical and shares principles with Peyronie’s techniques. Can be delayed until after puberty (and can be managed conservatively if little bother / able to have sex).