Peyronie's Disease (Curved Penis)

This is the topic for which I am recognized as one of the world’s leading experts and for which I am invited to give lectures worldwide. My research team is also involved in most ongoing global trials studying new therapies.

For this topic, I suggest you also visit the websites:
www.malattiadilapeyronie.it and
www.collagenasi.it

Peyronie’s Disease (PD), also known as Induratio Penis Plastica (IPP), was first described by French surgeon François de La Peyronie (surgeon of King Louis XV’s army in 1743). It is an idiopathic connective tissue disease of the penis. It involves localized fibrosis of the tunica albuginea of the penis, which is the sheath that covers the corpora cavernosa.

Epidemiology

The actual incidence rate of Peyronie’s Disease is not known. A higher incidence rate is found in the age group between 50 and 59 years. In Italy, the prevalence is 7.1% in the 50-69 age range.

Pathophysiology and Etiopathogenesis

The currently most accepted hypothesis is that PD originates from an abnormal wound healing process in response to penile microtrauma, which typically occurs during sexual intercourse. According to Devine et al., an acute or repeated trauma to a fully or partially erect penis during sexual activity can cause a “delamination” between the layers of the tunica albuginea. Fibrous scar tissue forms.

This delamination generally occurs at the junction point between the septal fibers of the midline and the dorsal and ventral circular layers of the tunica albuginea. This leads to microvascular injury with hemorrhage within the intralaminar space. When the clot is resorbed, the remaining fibrin in the injured tissue releases response factors and activates fibroblasts, which cause cellular proliferation and an inflammatory reaction. Under these conditions of local hypoxia, reactive oxygen species (ROS) are also released, which consequently activate the Transforming Growth Factor (TGF-β1), capable of stimulating fibroblast proliferation and promoting the transformation of fibroblasts into myofibroblasts.

Fibroblasts and myofibroblasts are the cells that predominantly generate collagen in the body. In the penis, the collagen formed is type I and III. There is a genetic predisposition.

Clinical Presentation

The formation of the plaque on the tunica albuginea, in addition to the penile curvature, causes a penile deformity characterized also by narrowing and shortening, which are the classic signs that patients often report first. All this often leads to psychological alterations that make relationships with partners difficult. The disease is often characterized by a phase of pain during erection, which usually subsides in about 3 months. The pathology can cause erectile dysfunction.

Most plaques form on the dorsal (upper) side of the penis, causing the penis to curve upwards. Plaques that form on the ventral (lower) side of the penis cause the penis to curve downwards. Plaques that form on both sides of the penis cause it to shorten or other types of deformities known as “indentations” or “hourglass” deformities. Therefore, Peyronie’s Disease is a progressive and chronic disease for most patients, with a low probability of spontaneous resolution (13%).

Most men seek medical attention during the acute phase, which lasts up to a maximum of 18 months, but about 33% do not consult a doctor until the stable phase of the disease.

Penile curvature is classified using the Kelami system as mild (≤30°), moderate (31−60°), or severe (>60°).

Diagnosis

The diagnosis of PD is obtained from the patient’s clinical history and penile evaluation. The anamnesis must be thorough and include information about the onset of symptoms and the possible relationship with penile trauma during intercourse, the progression or stability of penile deformities, and whether these interfere with sexual intercourse. The presence of erectile dysfunction should also be investigated. Since this is a condition with a strong psycho-social impact, the patient’s mood and relational status should be explored, also in anticipation of a multidisciplinary therapeutic approach. For this purpose, a validated evaluation questionnaire is available, capable of measuring the psychosocial effects of the presence of PD and the response to treatment, the PDQ.

The penile examination includes:

1. Localization of the plaques and their consistency (soft or calcified);
2. Deformities (hourglass penis, hinge effect) and the angle of penile curvature, better assessed during erection, through intracavernosal injection of vasoactive substances or, alternatively, using photographic documentation provided by the patient;
3. Measurement of penile length, also in anticipation of surgical treatment, so that the patient understands that the loss of penile length depends on PD and not on the surgical act;
4. Evaluation of erectile dysfunction using the IIEF questionnaire;

If present, a penile echo-Doppler may be performed to assess vascular status. Penile ultrasound also allows for the exact localization of plaques, their size, and degree of calcification.

Other possible sites of fibrosis should also be evaluated during the physical examination: palms of the hands and soles of the feet.

Laboratory tests are not necessary for the diagnosis, except to confirm the presence of other risk factors for PD, such as diabetes and cardiovascular diseases.

Treatment

The treatment of PD is both medical and surgical; there are also other forms of non-surgical treatment (mechanical and radiation). Medical treatment includes oral, topical, and intralesional therapies. No treatment is approved by the FDA, and current studies are conflicting. Surgery is an option when the disease has been stable for 3 months after the acute phase. For curvatures under 60 degrees, techniques that act on the convex side of the penis (opposite the plaque) are used, resulting in shortening; for greater curvatures, plaque excision (concave part of the penis) and filling of the tunica with graft material are performed, with high risks to erectile capacity. In cases of disease with erectile dysfunction, prosthetic surgery is the gold standard.

Where I perform surgery

• • Villa Donatello (Firenze)

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