Straightening Out: The Facts on Peyronie’s Disease

Peyronie’s disease (PD) does not spell the end for men who suffer from this condition.

With a greater knowledge of its symptoms and range of treatment options available, primary care practitioners can all play a part to improve the sexual well-being of their patients.

About Peyronie’s Disease

Originally known as induration penis plastica, Peyronie’s disease (PD) was described and eponymously named after François Gigot de La Peyronie in 1743.

PD is characterised by the development of fibrous tunical plaque(s) and is usually associated with some degree of penile curvature. There is a significant psychological component in patients suffering from PD as approximately 48% of PD patients are affected by resulting clinical depression. The prevalence of PD is reported to range from 3% to 9% in the adult male population and PD frequently presents in men when they are 50 years old and above.

The main problems with PD are penile curvature interfering with sexual activity and penile shortening, which can be embarrassing symptoms for the affected men. Since PD affects the private parts of a patient’s body, it can be difficult for affected men to present themselves to doctors. As such, the reported prevalence of PD in literature may not be accurate.

When considering the natural history of PD one year postdiagnosis, it is found that about 40% of men with PD reported penile curvature that remained unchanged. Approximately 45% of them reported progressive penile curvature and less than 15% reported spontaneous resolution.

PD is often associated with prior penile trauma but this history is not universal. The uncertainty about the pathogenesis and natural history of PD adds to the difficulty of managing men who present this condition.

 

Causes of Peyronie’s Disease

Recently, PD has been categorised as a wound healing disorder. A common presentation is a fibrous and inelastic scar or plaque of the tunica albuginea that appears, following trauma to the penis. It is postulated that trauma causes increased transforming growth factor beta 1 (TGF-β1) levels, which results in an intense pro-inflammatory and pro-fibrotic cascade with subsequent deposition of collagen, resulting in the hallmark of the disease: plaque formation and penile curvature.

Studies have shown that inducible nitric oxide levels are quenched by reactive oxygen species (ROS), creating peroxynitrite, a highly toxic and pro-fibrotic compound. Although the pathophysiology of PD is still poorly understood, attempts at manipulating the levels of TGF-β1 and ROS could theoretically alter the natural history of PD, which form the basis of many of our current medical therapies.

As a general rule, the aim of medical management of PD is to alter the wound healing process and prevent plaque formation.

Diagnosing Peyronie’s Disease

Plaque formations along the penile shaft are commonly found upon examination of the stretched and non-erect penis. The most common location would be over the dorsal aspect of the penile shaft, since dorsal curvature is far more common than ventral ones.

Some men would present photos of their erect penis, showing the penile deformity that they are concerned about. The investigative method of choice is a penile Doppler ultrasound. Prior to the ultrasound, the patient would be administered with intracavernosal alprostadil, which is a Prostaglandin E1 (PGE1) analogue, to induce an artificial erection. The penile curvature could then be measured with a goniometer and documented as a baseline prior to the administration of any form of treatment. At the same time, the erectile function would be assessed with the ultrasound.

Treatments for Peyronie’s Disease

Medical therapy for PD (or minimally invasive management) can be sub-divided into oral, topical, iontophoretic, intralesional, radio therapeutic, shockwave therapy, penile traction or any combination of the above. There is also a recent interest in including stem cells for the treatment of PD. The current literature only supports the use of oral therapy as well as intralesional therapy.

  • Oral Therapy

    Oral therapy has been shown in randomised controlled trials to significantly improve penile curvature and plaque volume through the use of pentoxifylline (PTX) and Coenzyme Q10 (CoQ10).

    PTX is a non-selective phosphodiesterase inhibitor with anti-inflammatory properties. It is shown to inhibit fibroblast proliferation and attenuate both collagen fibre deposition as well as elastogenesis in vitro. PTX downregulates TGF-β and increases fibrinolytic activity.

    A retrospective cohort study showed that treatment with PTX appeared to stabilise or reduce calcium content in PD plaque. In a random trial, administering PTX sustainedrelease of 400mg twice daily for six months significantly improved penile curvature and plaque volumes, as compared to the placebo results. The authors also concluded that PTX is moderately effective in reducing penile curvature and plaque volume in patients with early chronic PD.

    Omega-3 is a polyunsaturated fatty acid that stimulates the production of collagenase. The only prospective, randomised, doubleblind, placebo-controlled study that evaluates the efficacy of Omega-3 fatty acids in PD was performed by Safarinejad. The study has shown no significant improvements in penile curvature, penile pain during erection, or erectile function with the use of Omega-3 fatty acids.

    CoQ10 is a very potent antioxidant. In a double-blinded, placebocontrolled study, early chronic PD patients taking 300mg of CoQ10 daily for 24 weeks demonstrated statistically significant reductions in plaque size as well as improvements in both penile curvature and erectile function.

     
  • Intralesional Therapy

    Men with PD should be referred to urologists with subspecialty interests in andrology and urological prosthetic surgery, should they fail to respond to oral medication. Intralesional therapy with or without penile traction therapy has been shown to be efficacious. The newest intralesional therapy that is approved by the Food and Drug Administration (FDA) in the United States, is the use of collagenase clostridium histolyticum (CCh). This drug has been shown to reduce contractures and improve the range of motion in joints affected by advanced Dupuytren’s contracture (a disease that is characterised by development of palmar fibrous plaque).

    Findings from IMPRESS I and II, which are two independent, double-blind, placebo-controlled studies, reveal the efficacy and tolerability of CCh in improving the co-primary outcomes of physical penile curvature and psychological bother domains. This intralesional drug is currently not available in Singapore, but has been shown to bring about meaningful change in the penile curvature of men stricken with PD.

     
  • Surgical Options

    Surgical therapy includes plication procedures, incision and grafting, as well as the insertion of inflatable penile prosthesis with manual modeling.

    Surgical procedures for correcting penile curvature in men with PD range from penile plication procedures to insertion of penile prosthesis. The type of surgical procedure is determined by the erectile function of the patient. Men with good erections can undergo simple procedures like penile plication, to correct the angle of curvature. The shortcoming of this procedure is penile shortening.

    In patients with more severe curvatures, incision and grafting on the plaque with pericardial grafts have shown success. This surgical procedure should only be carried out by urologists who are experienced in the surgical management of PD, as erectile function can be adversely affected by merely incising the tunica albuginea.

    The gold standard treatment for men who exhibit both PD and erectile dysfunction is the insertion of an inflatable penile prosthesis with manual modeling. Not only will the patient have no problems with erections after placement of the penile prosthesis, the problem of progressive penile shortening due to the natural history of PD would also be dealt with. It would seem that PD is rarely seen locally, but this could be due to a stigma in local culture regarding such treatment, and a lack of awareness on disease diagnosis and management among many physicians.

    While PD is a benign condition, the loss of penile length is distressing to most if not all men. The unwanted penile curvature may also create discomfort during sex. A greater awareness of PD could help straighten things out in the bedroom for these men and their partners, enabling them to have a healthier sex life.

 

Dr Tan Ban Wei, Ronny 

Dr Ronny Tan is a Consultant from the Department of Urology in Tan Tock Seng Hospital. He graduated with MBBS from National University of Singapore (NUS), was elected a Member of the Royal College of Surgeons (Edinburgh) and conferred a Masters of Medicine (Surgery) from NUS. He completed his Advanced Specialist Training (Urology), board-certified in 2012 and became a Fellow of the Academy of Medicine, Singapore. He received the National Healthcare Group- Health Manpower Development Programme award and undertook his clinical fellowship in andrology, sexual medicine and urology prosthetic surgery with Professor Wayne Hellstrom at Tulane University (USA). He is an executive committee member of the Society for Men’s Health Singapore and a member of the International Society for Sexual Medicine.

References 

  1. Ronny BW Tan, Premsant Sangkum, Gregory C Mitchell, Wayne JG Hellstrom. Update on medical management of Peyronie’s disease. Curr Urol Rep. 2014; 15 (6):415. doi: 10.1007/s11934-014-0415-4. 
  2. Eric J Shaw, Gregory C Mitchell, Ronny BW Tan, Premsant Sangkum, Wayne JG Hellstrom. The nonsurgical treatment of Peyronie’s Disease: 2013 update. World J Mens Health. 2013 Dec;31(3):183-92. doi: 10.5534/wjmh.2013.31.3.183. Epub 2013 Dec 24