Peyronie Disease diagnosis and management

1. By Dr Sumit Gupta
Moderator: Prof S.Rajendra Singh

2.  Peyronie disease (PD) was first known as induratio
penis plastica.
 It was subsequently named after Francois Gigot de la
Peyronie because he was the first to describe and offer
treatment for it in a paper published in 1743
 PD is currently recognized as a wound-healing
disorder of the tunica albuginea that results in the
formation of an exuberant scar, occurring presumably
after an injury to the penis activates an abnormal
wound-healing response

3.  The resulting scar or plaque is inelastic and therefore
results in penile deformity including curvature,
indentation, hinge effect, and shortening and is
frequently accompanied by erectile dysfunction (ED).
 One of the most important characteristics of this
particular wound-healing disorder is that once the scar
has occurred, it does not undergo normal remodeling
and therefore the scar and deformity persist

4. Misconceptions associated with PD
 Peyronie is a rare disorder.
 • It have high likelihood of spontaneous resolution.
 • It is a disease of only middle-aged men.
 • It is a disease of only Caucasian men.
 • Plaque calcification is an indication of mature,
chronic phase disease.
 the trauma to the penis must occur only when it is
erect; however trauma to the flaccid penis may also
trigger this process

5. EPIDEMIOLOGY
 The incidence of PD varies widely depending on the
population being screened current estimates are between
3% and 9%, and the peak age of onset of PD is the early 50s.
 A linear increase in prevalence can be seen from ages 30 to
49, with an exponential increase in prevalence at age 50.
 PDE5 inhibitors have not been suggested to directly
contribute to the development of PD; rather, their
associated use in those with medical conditions that
contribute to ED likely unmasks deformities that would
have otherwise gone unrecognized.
 The prevalence of PD among diabetics has been shown to
be 8.1% to 20.3% depending on the population screened,
which is higher than in the general population.

6.  The prevalence of ED in men with PD has been
reported to be 37% to 58%.
 PD is not only a physically deforming but also a
psychologically devastating disorder, with 48% of
patients showing signs of moderate to severe
depression
 There appears to be an increased incidence of PD in
men who have undergone radical prostatectomy.
 Although hypogonadism may be associated with PD,
there is no clear evidence that it is a risk factor.

7. Etiology
 The exact cause of PD has not yet been defined, although
some injurious stimulus is necessary to trigger the cascade
of events that leads to PD in the susceptible individual
 Trauma may be a single event experienced by the patient or
may take the form of repetitive microtrauma to the penis.
 The proposed mechanism is that in the erect state, the
pressures inside the penis can get quite high and it may get
higher when external forces are placed on the penis during
intercourse.
 These pressures may exceed the elasticity and strength of
the tunica tissues, resulting in a microfracture.

8.  Oxygen free radicals, oxidative stress, NO,
myofibroblasts, TGF-β1, and fibrotic gene expression
all play a key role in the development of PD and are
key avenues for future research to further elucidate the
exact mechanism behind the development of PD.

10. Symptoms
 The most frequent presenting symptoms of patients with
PD include penile pain, erect deformity, palpable plaque, as
well as ED
 Not all patients experience pain or are able to palpate a
plaque, but the shortening, hinge effect, distal softening,
and curvature, when present, are readily recognized.
 Pain, when present in the acute phase, can occur in the
flaccid condition with palpation of the plaque, with
erection, or during intercourse.
 Once the disease process is stable, most pain will resolve,
but in some men the pain persists with what has been
referred to as “torque” pain associated with a pulling
sensation on the plaque when a strong erection occurs

11.  Curvature is one of the most recognized and
distressing deformities associated with PD
 Still many men are capable of sexual activity with
curvature up to 60 degrees, particularly if the
curvature is dorsal and more gradual along the shaft.
 Men with ventral or lateral curvatures may have a
more difficult time with intercourse because of
discomfort.
 Classification by degree of curvature was introduced
by Kelami .

12.  In one study 39.5% of patients had 30 degrees (mild)
or less, 35% had 31 to 60 degrees (moderate), and
13.5% had more than 60 degrees of curvature (severe);
12% had no curvature but did experience an hourglass
deformity resulting in an unstable erection

13.  Plaque can manifest in a variety of configurations
including cords; simple nodules coin like, irregular
dumbbell shapes; or I-beam plaques
 The orientation of the plaque usually defines the
deformity.
 Therefore patients with a simple dorsal plaque have
dorsal curvature.
 If there is transverse or spiraling scarring, which can
be partial or circumferential, this could result in
varying degrees of indentation including an hourglass
deformity or a hinge effect.

14. EVALUATION OF THE PATIENT
 As with all medical conditions, a detailed history is a
critical part of the evaluation of the man with PD .
 The interview should focus on presenting signs and
symptoms such as pain, deformity, and palpable plaque.
 The assessment should also include whether onset was
gradual or sudden and the estimated time that symptoms
began.
 it should be determined whether there was any inciting
event that may have triggered the process, including direct
external penile trauma.
 Patient should be asked whether there is any personal or
family history of other fibrotic disorders including
Dupuytren Disease and Ledderhose disease.

15. Erectile capacity ?????
 Patients should be carefully queried as to their erectile capacity.
 Ultimately the question is whether the patient is capable of
intromission or incapable because of deformity and/or diminished
rigidity.
 A useful question that has been shown to be an effective predictor of
postoperative erectile function is “If your penis was straight with the
same quality of rigidity that you have now, do you think it would
be adequate for penetrative sexual activity?
 Clearly if the patient does not feel his erections would be satisfactory
with or without pharmacotherapy, this can help direct the patient to
treatment with a penile prosthesis and straightening maneuvers.
 Nonsurgical or other surgical approaches could result in improvement
of deformity, but if there is persistent ED, such treatment would likely
not give the patient a sexually functional erection.

16.  Further information to be obtained from the sexual
history will be whether there are any vascular risk
factors for ED, including a history of diabetes,
hypertension, elevated cholesterol, and smoking.

17. Physical examination
 The value of a photograph taken at home of the erect penis has
been controversial because of the inability to adequately
represent and measure a three-dimensional deformity
 The physical examination should include a general assessment of
the femoral pulses, appearance of the flaccid penis
 To assess the Peyronie plaque, the penis should be examined on
stretch, which allows easier identification of the plaque.
 The location of the plaque may be useful to record, but
measurement of the size of the plaque with any modality has
been found to be inaccurate because the plaque is rarely a
discrete lesion

18.  The stretched penile length (SPL) is also a critical
parameter to measure at the initial consultation.
 This is performed by placing the penis on stretch by
grasping the glans and pulling at a 90-degree angle
away from the body .
 Measurement is from the pubis to the corona dorsally,
as these are two fixed points and facilitate repeated
measurement during the course of treatment and
follow-up.

20.  The consistency of the plaque may be recorded.
 A “rock hard” plaque may be an indicator of
calcification but will need to be confirmed with some
form of imaging, preferably ultrasonography .
 A calcified plaque is readily identified on
ultrasonography because of the hyperdensity of the
plaque with shadowing behind it.
 Computed tomography and magnetic resonance
imaging have little value in the evaluation of the man
with PD

21. Calcification
 Only recently has it been recognized that calcification may occur
early after the onset of the scarring process, and therefore the
previously held notion that calcification is an indication of
chronic, severe, and/or mature disease appears untrue.
 Calcification is most likely the result of a different genetic
subtype of PD in which there is activation of genes involved in
osteoblastic activity
 That’s Why some plaques undergo mineralization and other
don’t
 The extent of mineralization may have a bearing on a successful
response to nonsurgical therapy; men with more extensive
calcification are less likely to benefit from nonsurgical
treatment.

22.  Several investigators have also indicated that intralesional
injection therapy with verapamil and interferon (IFN) is less
likely to be successful in men with significant calcification
 Investigators have also suggested that patients with extensive
calcification are more apt to proceed to placement of a penile
prosthesis .
 Recently a calcification grading system was published.
 The investigators found that patients with grade 3, or the most
extensive, calcification (>1.5 cm in any dimension or multiple
plaques ≥1.0 cm) were more likely to undergo surgery.
 This is in contradistinction to those who had less severe
calcification of grade 1 (<0.3 mm) or grade 2 (0.3 to 1.5 cm) or no
calcification ,has decreased likelihood of proceeding to surgery

23. Measurement of curvature with
goniometer

24.  In response to the proposed increased prevalence of
hypogonadism with PD, recommendation is to obtain
a morning serum total testosterone level during the
initial evaluation

25. Value of Penile Duplex Ultrasonography for
Peyronie Disease
 Identification and measurement of plaque
calcification
 Identification of corporeal fibrosis
 Observation of erectile response to vasoactive
intracavernosal injection
 Measurement of penile vascular parameters (peak
systolic
 velocity, end-diastolic velocity, and resistive index)
 Optimum objective measurement of erect penile
deformity(curvature, girth irregularities, hinge effect)

26. Non surgical treatment
 Usually advised in pts not willing for surgery , not fit
for surgery or with minimal symptoms with deformity
of less then 30deg.

30. Combination therapy
 Combination therapy, also known as a “three-armed
approach” using daily pentoxifylline and L-arginine,
biweekly verapamil injections, and daily traction likely
provides the best opportunity for deformity
improvement by creating a synergy between the
chemical effects of the oral and/or injectable agents
with the mechanical effects of external forces on the
penis.

31. Surgery
Indication
 Deformity precludes satisfactory sexual intercourse
 Causes pain to pt or their partner during sexual
relations
 distress as a result of the appearance of the erect
penis.
 Failed conservative treatment
 Desire for most rapid and reliable result

32. Surgery remains the gold standard treatment
 To most rapidly and reliably correct the deformity
associated with PD
 And for men who also have ED.

33. Preoperative consent
 Is critical because patients with PD are mostly
distressed and frequently emotionally devastated.
 It is important to have a frank discussion with the
patient so that he understands the limitations of the
operation, as well as to set appropriate expectations
regarding outcomes
 The patient should understand that there is a
possibility of persistent or recurrent curvature,
reduction of penile erect length, diminished rigidity,
and decreased sexual sensation

34.  The patient should understand that the goal is to make
the penis “functionally straight,” which is defined as a
residual deformity of 20 degrees or less
 Change in penile erect length is more likely with
plication than with grafting, although all surgical
correction procedures have been associated with some
length loss.
 This is extremely important for the patient to
understand preoperatively because 70% to 80% of
patients initially have loss of length as a result of the
fibrotic disease process.

35. Preoperative Consent
 Set expectations regarding outcome.
 Persistent or recurrent curvature: The goal is
“functionally straight” (curvature <20 degrees)
 Change in length: The result is more likely shorter with
plication than with grafting.
 Diminished rigidity
≥5% in all studies—grafting more than plication
≥30% if suboptimal preoperative rigidity—dependent on
preoperative erectile quality
 Decreased sexual sensation
Typically resolves in 1 to 6 months
Rarely compromises orgasm or ejaculation

36. Choice of
surgical approach
The primary determinants are based on two factors
 Quality of the preoperative erection hardness and
 Severity of deformity, including curvature and
indentation.

37.  In men who have rigidity that is adequate for coital activity
with or without pharmacotherapy, tunica plication
techniques and plaque incision or partial excision with
grafting may be used.
 Tunica plication techniques are recommended for those
who have a simple curvature of less than 70 degrees, those
with absence of an hourglass or hinge effect, and those in
whom the anticipated loss of length would be less than
20% of the total erect length
 Grafting procedures are recommended for those with more
complex curves of greater than 60 to 70 degrees and/or a
destabilizing hourglass resulting in a hinge effect.

38.  For the man who has PD and ED that is refractory to
medical therapy, published algorithms have indicated that
penile prosthesis placement is the procedure of choice
 This procedure allows for correction of the deformity while
also addressing the ED.
 If curvature is not satisfactorily corrected with the
prosthesis inflated during surgery, additional straightening
maneuvers may be performed like manual modeling .
 If there is residual curvature in excess of 30 degrees after
modeling, then a relaxing incision in the tunica albuginea
overlying the area of maximum curvature can be made.

39. Tunical Shortening Procedures
 Penile plication aims to shorten the longer (or
convex) side of the tunica albuginea to match the
length to the shorter side.
 Advantages to these approaches include shorter
surgical time, good cosmetic outcomes, minimal effect
on rigidity, simple and safe surgery, and effective
straightening

40. The Nesbit procedure and The
Yachia procedure

41. Drawback
 The drawbacks of any tunica plication procedure for
PD are that it does not correct shortening and it
potentially may enhance loss of penile shaft length.
 It does not address hinge or hourglass effect and may
exacerbate it, resulting in an unstable penis.
 The plaque is also left in situ.
 Penile narrowing or indentation has been reported in
up to 17% with these techniques.
 In addition, there can be pain associated with the
knots and suture granulomas.

42. Tunical Lengthening Procedures
 (Plaque Incision or Partial Excision and Grafting)
 Indications includes
 Greater complexity of disease with several (or /all) of
the following:
1. curvature greater than 60 to 70 degrees,
2. shaft narrowing, hinging, and extensive plaque
calcification
 Most important, for the patient to be a candidate for
incision or PEG, he must have strong preoperative
erections .

43.  There was a linear association between preoperative
and postoperative ED .
 Expert opinion has been consistent that patients with
ventral deformity do not do well with grafting
procedures.
 Historically, total excision of the plaque was practiced
to “cut out the disease,” with large onlay grafts, which
has an unacceptably high rate of ED.

44. Graft Materials
The ideal graft should approximate the strength and
elastic characteristics of normal tunica albuginea;
should have minimal morbidity and tissue reaction;
should be readily available, not too thick, pliable, easy
to size and suture inexpensive, and resistant to
infection; and should preserve erectile capacity.

45.  The two most common grafts currently used are
Tutoplast (Coloplast US, Minneapolis, MN), processed
human and bovine pericardium, and porcine small
intestinal submucosa (SIS) grafts (Surgisis ES, Cook
Urological, Spencer, IN)
 These packaged processed grafts are being used with
increased frequency because of their ease of use and
reduction in operating times.
 The pericardial grafts are thin, are strong, do not
contract, and have no reports of infection or rejection.

46. Postoperative Management
 The postoperative rehabilitation period is critical to
reduce the risk of postoperative ED and length loss as
well as to optimize straight healing.
 Typically a patient is seen 2 weeks after surgery, at
which point massage and stretch therapy are initiated.
 The patient is instructed to grasp the penis by the
glans and gently stretch it away from the body and
then with his other hand to massage the shaft of the
penis for 5 minutes twice per day for 2 to 4 weeks.

47.  Investigators have recommended the use of nocturnal
PDE5 inhibitors to enhance postoperative vasodilation,
which may help support graft take, reduce cicatrix
contraction, and theoretically preserve cavernosal
tissue, thereby reducing postoperative ED
 Finally, external penile traction devices have been
encouraged and have been recently shown to reduce
length loss postoperatively and can even enhanc
length gain after both grafting and plication
procedures

48. Penile Prosthesis for Men with
Peyronie Disease
Indications
 In men with PD and concurrent ED refractory to PDE5
inhibitors, penile prosthesis placement is the
procedure of choice
 Additional straightening maneuvers may be necessary,
including manual modeling and incising of the tunica
albuginea with or without grafting

49.  An inflatable penile prosthesis (IPP) appears to be the
preferred surgical implant, as the pressure within the
cylinders allows for superior correction of curvature
with manual modeling, as well as improved girth
enhancement.
 Malleable prostheses, when used for PD historically,
were associated with narrow, cold, and less than
natural erections.

50.  By far the most common postoperative complaint
heard from men who have undergone penile prosthesis
placement is length
 Postoperative prolonged cylinder inflation has been
recommended to maintain penile length and decrease
residual curvature

52. Conclusion
 Nonsurgical treatment include oral, injection, and/or
mechanical therapy which may stop progression and
possibly improve deformity and sexual function.
 When surgery is indicated, the goal is to correct the
deformity and prevent worsening of ED so that
penetrative sexual activity is possible.

53. Thank you