Peyronie’s Disease White Paper

Peyronie disease

Introduction

The reproductive system is the only system of the body that is not essential to the survival of being, but rather it is essential to the survival of species. Diseases of reproductive organs thus are not life-threatening, but take away the element of pleasure, reduce satisfaction, and severely impact relationships. Peyronie’s Disease is one of these diseases.

Peyronie’s disease (PD) is a connective tissue disorder and causes the shaft of the penis to deviate from either side. Although a small change in the angle of the shaft is unnoticeable and is of no significance, PD results in a remarkable deviation in the angle of the erected penis that not only interferes with intercourse but also causes pain on erection. It is characterized by nodular or poorly defined fibroblasts that are surrounded by dense collagen; hence compromising elasticity of the organ. 

Prevalence

According to recent research, the documented evidence suggests that almost 3-9% of men suffer from Peyronie’s disease worldwide; however, that’s just the tip of the iceberg. This ratio only indicates the percentage of men who went to physicians and got themselves tested, and later got diagnosed with this disease.

Research estimates that there are quite a large number of PD cases that don’t even reach the physician’s office.  PD, just like other sexual disorders, is least talked about and swept under the rug as most men tend to hide their condition and shy away from seeking medical help regarding their issue.

Peyronie’s disease is reported in all areas of the world but the demographics show a higher incidence rate in men of Caucasian descent.

 Almost 50% of men, who suffer from Peyronie’s disease, have seen to show signs of depression, out of which 22% were diagnosed with severe depression due to their condition. These statistics indicate the importance of managing this disease as it is affecting the quality of life of many individuals suffering from PD. 

Structure of the Penis

The penis is the male copulatory organ made up of shaft and glans. The shaft of the penis contains three chambers, a pair of corpus cavernosa and corpus spongiosum, surrounded by fascial layers containing nerves, lymphatics, and blood vessels. The corpora cavernosa contains erectile tissues that act as a reservoir of blood, surrounded by a sheath of connective tissue with relatively low elasticity.

The urethra, a tube-like structure that delivers the semen and urine, runs through corpus spongiosum that lies in the undersurface of corpora cavernosa as shown in figure

When the blood vessels in the penis receive signals from the brain, they dilate to open floodgates that cause a gush of blood to fill the corpora cavernosa. As the penile tissue starts filling up with each pulse, the veins that drain the penis get compressed, blocking the drainage. This makes the penis erect – and keeps it erect until the arteries keep supplying extra blood to penile tissues. Even the erection is intended to cease, the arteries constrict, decreasing the supply of blood to corpora cavernosa. This eases the pressure on compressed veins present in surrounding tissue, thereby increasing the venous drainage and outpouring the blood from the erect penis.

What Causes the Curvature?

Peyronie’s Disease is thought to be caused by the formation of scar tissue in the penis. Scar tissue is formed when a damaged body tissue fails to heal properly and is then replaced by irregularly placed fibrous tissue. The fibrous tissue has little to no elasticity and is thus incapable of expanding like the normal penile tissue. 

An intratunical bleed due to any reason results in the process of inflammation and scar formation; random orientation of the collagen fibers ends up restricting the expansion of the underlying corpora cavernosa, hence when the blood starts pouring into the corpora cavernosa, the part of the penis that is damaged or replaced by scar/fibrous tissue fails to expand. This causes local stricture that appears to “pull” the penis towards its side. Sometimes, the scar tissue is big enough to be seen or felt by the hands. These palpable masses are seen usually on the underside of the penis.

There may be flaccidity present away from the site of lesion and may present as an hour-glass deformity or rotation, which is nonetheless one of the more severe and serious forms of PD.

Risk factors

The cause of Peyronie’s Disease is yet to be discovered but it is thought to be multifactorial in nature. The following factors play an important role in the development of PD:

  1. Penile Injury – Minor injuries to the penile tissue cause no deformity of penis and scar formation. But when a large part of the penile tissue is damaged that cannot be repaired by the body, it is then replaced by scar tissue which lacks the ability to expand. But in some cases of microvascular trauma, which can be either during intercourse or otherwise can result in the formation of scar tissue, also known as ‘plagues’. These plagues are formed by the release of endogenous factors such as TGF-beta, which exacerbates the condition of PD.
  2. Age – Due to senile changes, the PD is more common in middle age or older men. 
  3. Genetic factors – Peyronie’s disease tends to have a familial predisposition i.e. it is more common in men whose blood relatives also have the same disease.
  4. Autoimmune disease – Men who suffer from autoimmune diseases such as Systemic Lupus Erythematosus (SLE), Sjogrens syndrome or Behcets disease, have higher chances of developing plagues due to their own body producing antibodies against the cells of the penis and resulting in scar formation.
  5. Connective tissue disorders – Connective tissue disorders are one of the most common causes of Peyronie’s disease. The defect in collagen synthesis and deposition leads to structural abnormalities. Thus PD is often associated with other disorders as well, such as Dupuytren’s contracture.

There are certain factors that do not independently cause Peyronie’s disease but are found to be more common in men with PD. These include:

  • Diabetes mellitus
  • Hypertension
  • Smoking
  • Alcohol intake
  • Surgical procedures such as transurethral prostatectomy, cystoscopy, etc. 
  • Beta-blocker (e.g. Propranolol) intake 
  • Deformities in sexual tract of the partner such as fibromatous lesions and history of surgical interventions. 

Signs and Symptoms 

Like all other diseases, Peyronie’s disease also presents with certain symptoms that can make its diagnosis clear. Other than pain with or without an erection, a person may or may not feel any other symptoms at all.  Asymptomatic diseases are more likely to go undiagnosed.. 

The signs and symptoms of Peyronie’s disease include: 

Curved Penis

A person with Peyronie’s disease will notice a curve in the penis that can occur spontaneously and has the ability to worsen over time. The shaft of the penis curves and deviates up, down or either side. Excessive changes in the penile structure might hinder sexual activities which are mostly unwanted. 

Changes in the shape of the penis, such as narrowing and shortening of the penis can also occur in PD. It can appear gradually or suddenly depending upon the severity of the disease. 

In some cases, the pain might evade off but the curvature of the penis persists. Although, problems related to erectile dysfunction or intercourse can take place in both situations. 

Hard lumps 

The penis can have hard, non-tender lumps on one or multiple sites. These lumps or nodules can be felt with hands and are thus confused with swelling by the person. Consult your physician if you’re feeling an irregular swelling on your penis to get a proper diagnosis..

Pain 

A person with Peyronie’s disease feels an unpleasant sensation during or after copulation. Pain can also be present during and after erection. This pain is usually associated as a result of the bend and curvature of the shaft. The pathophysiology of pain is a result of the fibrotic scar and plaque that has formed within the penis. 

Shortening of Penis 

In Peyronie Disease, The shaft of the penis might become shorter due to fibrosis.

Erectile dysfunction 

Erectile dysfunction is an inability to get an erection or maintain a harder erection required for penetration. The non-elastic fibrous tissue prevents the filling of corpora cavernosa and thus hampers the ability to maintain an erection. 

The above-mentioned signs and symptoms are classical features that when noticed and reported can help in the diagnosis and treatment of the disease before it progresses to a stage where it can no longer be cured. 

Diagnosis 

Early diagnosis is the key to every treatment.The first and foremost method to diagnose a disease is to look for the early signs and symptoms presented by the affected patient. 

History and examination

A detailed medical history is a must. A complete and detailed history can lead halfway to the diagnosis.. It involves asking the patient-relevant questions related to the symptoms he has been observing. 

The questions can include: 

  • Since when have you been experiencing pain in your genital area? 
  • When did you notice that it has swelled up? 
  • Do you experience any pain during erection and intercourse? 
  • Have you noticed any change in shape and structure lately? 
  • Are you taking any medications? Or have you started a new medicine recently? 
  • What made you show up to the physician? 

The examination includes visualizing the physical aspects of the genital. Your doctor would palpate (feel) the penis in a un-erected state to check the amount of scar tissue. Palpation is also done to feel the lumps, if any. It is one of the classical features to rule out the disease from others. Taking measurements also helps to see whether the penis has shortened overtime or not. 

Diagnosis of PD is formed based on a lot of things, since a lot of factors can contribute to a person developing PD. According to a latest research conducted by the Department of Urology in Turkey, it was seen that NLR (neutrophil-to-lymphocyte ratio) was a good biomarker to differentiate between acute and chronic cases of PD, this way it can aid in choosing a strategy to manage the disease in a more efficient way.

Investigations 

The second part of the diagnosis warrants the use of ideal tools for the investigation of the disease. This includes a series of tests such as ultrasound and X-rays. The latter  are not commonly involved in the detection of Peyronie’s disease, therefore, Ultrasound is more preferred. 

The defect in penile angle becomes more evident on erection and therefore the physician injects a cavernous injection into the penis to make it erect before the ultrasonic imaging. If the lump or plaque is hard and tender on percussion (painful to touch), it will be easily caught on the ultrasound. 

A blood flow test can be performed by a color Doppler ultrasound.

Course of disease

PD can either be acute or chronic in nature. Acute phases might last upto 2 weeks to almost a month however, almost 90% of acute conditions resolve on their own and don’t need any kind of medication. In chronic condition, a person suffering from PD for over 18 months may suffer from erectile dysfunction and may or may not feel pain during erection.

Treatment

In regards with the studies conducted by various researchers, it is evident that PD has both a heritable as well as environment-driven factor involved in its prevalence and progression, hence treating Peyronie’s Disease is a medical challenge. Medical advancement has been going on to completely cure the PD. Quite a lot of effective treatment options are available for PD. There are always two sides to a treatment: 

  1. Non-surgical 
  2. Surgical  

Non-surgical treatments

Based on a number of researches, the non-surgical treatments that have been proposed and tested out include; oral, topical, intralesional, extracorporeal shockwave therapy, and traction therapy. Each has shown varied rates of improvement in the condition of people suffering from PD. Non-surgical treatments outweigh in every manner as they decrease postoperative complications that most people face.

Oral Medications

Oral therapies are the easiest to administer with almost 100% compliance shown by patients. According to EUA guidelines, potassium para-aminobenzoate has seen to show a lot of improvement in decreasing pain as well as diminishing the deviation up to an extent. However there isn’t any other oral medication (vitamin E, pentoxifylline) that have tested to show marked changes in reversing the signs and symptoms of PD and are therefore not recommended according to the ICSM guidelines.

Topical Administration

Topical H-100 Gel, this is a mixture of organic and inorganic chemicals, it has anti-inflammatory effects and can inhibit the process of wound healing by decreasing the levels of those cytokines that initiate the process of inflammation. Through this way, it is expected to prove remarkable in decreasing the size of the plagues, and stop it from increasing and causing more damage.

Intralesional injections

There are a number of intralesional injections that have tested to be more therapeutic in the cases of PD, rather than the usage of oral medications or topical gels.

The proposed and tested intralesional infusions include, Collagenase Clostridium histolyticum (CCH), IFN α2b, verapamil as well as PRP+ Hyaluronic acid infusions which have shown considerable improvement in the correction of PD.

CCH

A bacteria C.histolyticum produces an enzyme Auxilium I and II, it has the potential to cleave collagen type I and III fibers. The plagues that sustain inside the shaft of the penis is abundant in these type of fibers and hence its infusion intralesionally helps somewhat dissolve these plagues. Those who underwent trials with CCH showed a significant improvement in their condition by a remarkable 34%. It is also FDA approved and its early usage in acute conditions can save the patient from worsening his penile deformity, with its adverse effects ranging from mild to moderate, hence it’s a relatively safer choice of treatment.

Interferon α2b

Interferon alpha 2b helps decrease extracellular matrix, by breaking down collagen. Studies have proved it to be a great method to improve curvature and also help in wound healing. Its infusion does not change the vascular parameters and markedly improves erectile function. It has really mild adverse effects, including having flu like symptoms, after the infusion.

Verapamil

Verapamil is ideally a calcium channel antagonist; it has seen to break down collagen and fibroblast fibers of the plagues present in the condition of PD. Research suggests that use of intralesional verapamil can help acute as well as in chronic conditions of PD. It has the potential to stabilize the plagues as well as reduce the curvature of the penis. The ICSM approves of the infusion of verapamil in order to manage the symptoms of PD, as it hardly has any adverse affects.

Plasma-rich platelets (PRP) + Hyaluronic Acid (HA)

Plasma rich proteins have been tested with affirmative results in increased angiogenesis, wound healing as well as improvement in cases of ED, PD as well as stress urinary incontinence. The way it gets prepared is by centrifuging blood and separating the plasma from it, which naturally becomes abundant in platelets. This resultant mixture is then mixed with hyaluronic acid and is then infused into the site of the lesion.

A recent trial was conducted using 90 people, they were carefully monitored for a whole month and there was a reduction in the angulations of almost 40% of individuals being affected by PD. Around 43% of them stated having better erections. Except for a very small number of people developing a few adverse affects, the trial suggested that the combination of PRP along with HA could be a major cost-effective treatment plan for the treatment and management of PD.

Extracorporeal shock wave therapy (ECSW)

ECSW therapy has been doing it rounds for the past decade or so, there have been a number of trials and researches to see the extent to which it can help diminish pain, decrease curvature and minimize plague sizes.

A research conducted in Korea in 2015, showed improvement in penile curvature in almost 30% of men, 60% of them had reduced plague hardness, with majority of the patients being satisfied with the therapy.

Another trial that was conducted in China in 2018, concluded that majority of the individuals experienced a decrease in penile pain, and that ECSW therapy definitely played a role in the management of penile pain, in patients of PD.

The most recent study conducted in Italy on 325 patients, concluded that extracorporeal shock wave therapy, helped decrease plague size, increase penile length in erection as well as decrease penile curvature to up to 5 degrees. Hence, this looks like a great non-invasive procedure to manage patients of PD, without any extreme adverse affects.

Mechanical Penile Therapy

Penile Traction Therapy (PTT)

As the name suggests, it’s a therapy to stop PD from worsening, this technique has showed improvement in the overall girth, length as well as the curvature. This can not only enhance sexual activity but also be a safer alternate to having surgery.

According to the statistics, about 40% of them who needed to get surgery done, had remarkable improvements from PTT which helped them overcome angulation by about 20 degrees. PTT has also shown decreased pain during erection and sonographic plagues disappeared in about 48% of them; hence it’s a safer and more effective method of managing PD.

Vacuum Erection Device (VED)

Cavernous sinuses get dilated by the use of VED, this helps increase the arterial flow. The increased flow brings up more enzymes that break down collagen. This device however, still lacks when compared to PTT, due to less trials and evidence, but combination of the two have shown to decrease the time it takes for the person to get recovered from PD.

Surgical Intervention 

When the disease has become chronic in nature and medical therapies have failed to show any response, that’s when surgical intervention takes over. Although surgical treatments are invasive and lengthy, they are worth considering for long-term benefits.

Components of the surgical therapy;

  • Plication techniques  
  • Graft-based technique 
  • Prosthesis technique 

Plication technique 

This technique aims to equalize both sides of the penis. Depending upon the size, either shortening or lengthening is required. The plication technique normally shortens the longer side. Plication technique is only indicated in the patient’s having reasonable erectile function, adequate penile length, and patients free of hourglass-type narrowing. 

Graft-based techniques

When patients present with a circumferential plaque that leads to hourglass-deformity they cannot be treated with plication techniques and hence they need to undergo a graft-based technique. Therefore, graft-based techniques are used in more complicated cases. The donor graft tissues for grafting are temporalis fascia, tunica vaginalis, penile skin, and saphenous vein. 

Studies have found the penile straightening for up to 96% after the use of grafts. Patients who undergo this surgery are reported to have remedied erectile dysfunction and can feel their organs again. 

Newer research has introduced the uses of porcine small intestine submucosa and human pericardium as new materials for the grafting technique. 

Prosthesis technique 

When both the medical and surgical therapy fail, prosthesis techniques are recommended. This intervention gives marvelous results and can be used with the modern inflatable prosthesis. The technique only requires intraoperative modeling without increasing the rate of revision. 

For severe cases where plaque retention is massive, grafting might be required during the prosthesis placement. 

The Demerits of using surgical and prosthetic options is that they are invasive procedures and require incision and tearing of the tissues. This increases the chances of postoperative infections and complications. Also, these procedures are expensive and require fine surgical skills.  

Conclusion 

A person experiencing sexual dysfunction is more likely to lose his self-esteem which can have a great impact on intimate relationships. Therefore, prompt diagnosis and early treatment of Peyronie’s disease is necessary to decrease morbidity and restore healthy and jovial lifestyles. Peyronie’s Disease is treatable, you just have to overcome the fear of expressing it. Book at appointment with our board certified urologist/sexologist/physician now <Sponsor link here>

References

BJEKIC, M. D., VLAJINAC, H. D., SIPETIC, S. B. and MARINKOVIC, J. M. (2006), Risk factors for Peyronie’s disease: a case‐control study. BJU International, 97: 570-574. doi:10.1111/j.1464-410X.2006.05969.x

Bilgutay, A. N., & Pastuszak, A. W. (2015). PEYRONIE’S DISEASE: A REVIEW OF ETIOLOGY, DIAGNOSIS, AND MANAGEMENT. Current sexual health reports, 7(2), 117–131. doi:10.1007/s11930-015-0045-y

Dell’Atti, L., & Galosi, A. B. (2018). Sonographic patterns of Peyronie’s disease in patients with absence of palpable plaques. International braz j urol : official journal of the Brazilian Society of Urology, 44(2), 362–369. doi:10.1590/S1677-5538.IBJU.2017.0298

Dell’Atti, L., & Galosi, A. B. (2018). Sonographic patterns of Peyronie’s disease in patients with absence of palpable plaques. International braz j urol : official journal of the Brazilian Society of Urology, 44(2), 362–369. doi:10.1590/S1677-5538.IBJU.2017.0298

Hussein, A. A., Alwaal, A., & Lue, T. F. (2015). All about Peyronie’s disease. Asian journal of urology, 2(2), 70–78. doi:10.1016/j.ajur.2015.04.019

Kayes, O., & Khadr, R. (2016). — —Recent advances in managing Peyronie’s disease. F1000Research, 5, F1000 Faculty Rev-2372. doi:10.12688/f1000research.9041.1

Kuehhas, F. E., Weibl, P., Georgi, T., Djakovic, N., & Herwig, R. (2011). Peyronie’s Disease: Nonsurgical Therapy Options. Reviews in urology, 13(3), 139–146.

Ostrowski, K. A., Gannon, J. R., & Walsh, T. J. (2016). A review of the epidemiology and treatment of Peyronie’s disease. Research and reports in urology, 8, 61–70. doi:10.2147/RRU.S65620

Paulis, G., Romano, G., Paulis, L., & Barletta, D. (2017). Recent Pathophysiological Aspects of Peyronie’s Disease: Role of Free Radicals, Rationale, and Therapeutic Implications for Antioxidant Treatment-Literature Review. Advances in urology, 2017, 4653512. doi:10.1155/2017/4653512

Randhawa, K., & Shukla, C. J. (2019). Non-invasive treatment in the management of Peyronie’s disease. Therapeutic advances in urology, 11, 1756287218823671. doi:10.1177/1756287218823671

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