PEYRONIES DISEASE

Peyronie's disease - Definition
A benign penile condition characterized by curvature of the penile shaft secondary to the formation of fibrous tissue plaques within the tunica albuginea.

Epidemiology
Prevalence: ~1%, predominantly affecting men aged 40 - 60 years.

Pathophysiology
Dorsal penile plaques are most common (66%). The corpus cavernosus underlying the lesion cannot lengthen fully on erection, resulting in penile curvature. It may be associated with distal flaccidity or an unstable penis (due to cavernosal fibrosis). The disorder has 2 phases:
- Active phase (1 - 6 months): painful erections and changing penile deformity.
- Quiescent phase (9 - 12 months): disease burns out. Pain disappears with resolution of inflammation, and there is stabilization of the penile deformity.

Aetiology
The exact cause is unknown. It is likely that repeated minor trauma during intercourse causes microvascular injury and bleeding into the tunica, resulting in inflammation and fibrosis (exacerbated by transforming growth factor-beta, TGF-beta). Autoimmune disease processes have also been suggested, and there is a reported familial predisposition.

Presentation
Pain and curvature of the erect penis; hard area (plaque) on penis; erectile dysfunction (30 - 40%); penile shortening.

Associated disorders
Dupuytren's contractures (40%); plantar fascial contracture; tympanosclerosis; previous trauma; diabetes mellitus; arterial disease.

Evaluation
A full medical and sexual history are taken. Patient's photographs of the curvature are useful. Assess the location and size of the plaque (is it tender?). Colour Doppler USS is used to assess vascular abnormalities, whereas contrast-enhanced MRI is indicated for complex and extensive cavernosal fibrosis.

Management
Early disease with active inflammation (<3 months, penile pain, changing deformity) benefits most from medical therapy. Surgery is indicated for a stable, significant deformity (preventing intercourse). Non-mechanical components of erectile dysfunction can be treated conventionally (oral or intracavernosal medications; vacuum device; penile implant).
- Medical treatments Vitamin E (200mg TDS) for 3 months; tamoxifen 20mg BD for 3 months; colchicine (500mg TDS) for 6 weeks.
- Extracorporeal shock wave therapy (ESWL) treatment of the plaque.
- Nesbit's procedure The penis is degloved via a circumglandular incision. An artificial erection is induced by intracavernosal saline injection. On the opposite side of maximal deformity, an ellipse is excised (a width of 1mm is taken for every 10° of penile curvature), and then closed with sutures. Success rates are 88 - 94%. Warn the patient that penile shortening of 2 - 3cm frequently occurs.
- Plaque incision and grafting Incision of plaque with venous patch insertion to lengthen the affected side (and minimize penile shortening). Success rates 75 - 96%. Adverse effects: erectile dysfunction 5 - 12%