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Peyronie's disease

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Peyronie's disease
Other namesPeyronie disease, induratio penis plastica (IPP),[1] chronic inflammation of the tunica albuginea (CITA)
Man showing abnormal curvature of the penis associated with Peyronie's disease
Pronunciation
SpecialtyUrology
CausesUnknown[2]
Frequency~10% of men[2]
Named afterFrançois Gigot de la Peyronie

Peyronie's disease (PD) is a benign, acquired penile connective tissue disease characterized by the occurrence of fibrotic plaques within the tunica albuginea — the dense elastic covering of the corpora cavernosa. The plaques cause abnormal curvature, pain, penile deformities (e.g., narrowing or indentation), and usually erectile dysfunction, particularly during erection. The condition typically leads to significant sexual and psychological effects, including difficulty with penetration and lowered self-esteem or evasiveness. Peyronie's disease is most often seen in middle-aged and older men with a mean age of onset between 55 and 60 years, although it has also been noted in younger individuals and adolescents.

While the etiology of PD is still a mystery, the leading hypothesis is that it arises from dysregulated wound healing in response to chronic microtrauma of the erect penis. This triggers a cascade of profibrotic molecular pathways — most notably overexpression of transforming growth factor-beta 1 (TGF-β1) — that end in fibroblast proliferation, myofibroblast differentiation, and overproduction of type I collagen. Genetic predisposition is supported by family clustering and linkage with systemic fibrosing disorders such as Dupuytren's contracture. Risk includes age, penile injury, diabetes mellitus, and cigarette smoking.

The prevalence of PD has been projected at 3% to 9% among the general population of men increasing with age and comorbidities such as erectile dysfunction or connective tissue disease. While PD is neither infectious nor malignant, it can have disastrous implications on sexual health and quality of life. It is diagnosed mainly on the clinical presentation supplemented by penile ultrasonography if necessary. Treatment depends on the phase and severity of the disease with conservative measures (e.g., oral therapy, traction, intralesional injection) in the milder and stable forms to surgical intervention for the advanced or stable ones. The condition is named for French surgeon François Gigot de la Peyronie, who in 1743 described the condition.[2][3]

It is estimated to affect 1–20% of men.[2] The condition becomes more common with age.[2]

Signs and symptoms

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Example of penis deformation from side

The most frequent sign of Peyronie's disease is penile curvature acquired on erection. The location and extent of curvature vary with the location and extent of the fibrous plaque of the tunica albuginea. Curvature is the most frequent complaint, but some men complain of penile shortening, penile narrowing (hourglass deformity), or indentations. Palpable plaques can be seen along the shaft, most commonly on the dorsum. Pain with erection is common during the initial, inflammatory phase but usually resolves during the chronic phase with resolution of swelling. Erectile dysfunction (ED) is estimated to affect 30–70% of men with PD, either due to decreased rigidity secondary to anatomic changes or psychogenic causes like distress and performance concern. PD can substantially impair sexual function and quality of life, leading to depression, relationship difficulties, and low self-esteem.[4][5][6]

Psychosocial

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Peyronie's disease can also have psychological effects. While most men will continue to be able to have sexual relations, they are likely to experience some degree of erectile dysfunction. It is not uncommon to exhibit depression or withdrawal from their sexual partners.[5]

Causes and Risk Factors

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The etiology of Peyronie's disease is multifactorial. The most widely held hypothesis is that recurrent microtrauma to the erect penis (e.g., during intercourse) leads to localized inflammation and abnormal wound healing in genetically predisposed men. This pathway initiates a cascade of pro-inflammatory and pro-fibrotic cytokines such as transforming growth factor beta 1 (TGF-β1), resulting in abnormal collagen deposition and plaque formation. Risk factors include advancing age, penile trauma, diabetes mellitus, Dupuytren's contracture, and tobacco smoking. Familial aggregation and linkage with other fibrosing disorders suggest a genetic basis. PD is seen most frequently in men over 40 years of age, with a prevalence in the general male population estimated at between 3% and 9%, and with higher prevalence in those with erectile dysfunction.[6][7][8][9]

Pathophysiology

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Peyronie's disease develops in two phases: the acute (inflammatory) and chronic (fibrotic) phase. During the acute phase, microtrauma induces damage to the endothelium, fibrin deposition, and immigration of immune cells into the tunica albuginea. Fibroblast proliferation and myofibroblast differentiation are promoted by cytokines like TGF-β1, PDGF (platelet-derived growth factor), and ROS (reactive oxygen species). Myofibroblasts overexpress type I collagen and extracellular matrix proteins, leading to plaque formation. In the chronic presentation, inflammation is reduced, but the fibrotic plaque is preserved, and partial calcification occurs in most cases. This causes structural deformity of the penile tissue and inelasticity that impedes normal growth during an erection. Intense calcification and fibrosis impair normal hemodynamics and penile elasticity of the penis, which usually causes venous leakage and erectile failure.[10][11]

Diagnosis

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This ultrasound depicts cross sections of the penis at different locations in a patient with Peyronie's disease. The top image shows normal anatomy whereas the bottom image shows scar tissue on the tunica albuginea (penis). The scar tissue is localized and responsible for the hallmark deformities of Peyronie's disease (curvature and narrowing).

Peyronie's disease diagnosis is mostly clinical. Patient history and physical examination are crucial. The most prominent features are acquired penile curvature, palpable plaques, erectile dysfunction, and pain during erections. Penile ultrasonography is the imaging method of choice for plaque location, measurement, and confirmation of calcification. Doppler ultrasound can be utilized to assess vascular function, which is useful in the evaluation of associated erectile dysfunction. Imaging also helps to differentiate PD from congenital penile curvature, penile fracture, or neoplastic disease. MRI can be employed in severe ones, although it is generally not required.[12]

Bent penis due Peyronie's disease

Ultrasonography

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On penile ultrasonography, the typical appearance is hyperechoic focal thickening of the tunica albuginea. Due to associated calcifications, the imaging of patients with Peyronie's disease shows acoustic shadowing, as illustrated in figures below. Less common findings, attributed to earlier stages of the disease (still mild fibrosis), are hypoechoic lesions with focal thickening of the paracavernous tissues, echoic focal thickening of the tunica without posterior acoustic shadowing, retractile isoechoic lesions with posterior attenuation of the beam, and focal loss of the continuity of the tunica albuginea.

In the Doppler study, increased flow around the plaques can suggest inflammatory activity and the absence of flow can suggest disease stability. Ultrasound is useful for the identification of lesions and to determine their relationship with the neurovascular bundle. Individuals with Peyronie's disease can present with erectile dysfunction, often related to venous leakage, due to insufficient drainage at the site of the plaque. Although plaques are more common on the dorsum of the penis, they can also be seen on the ventral face, lateral face, or septum.[13]

  • Transverse ultrasound of the penis, in a ventral view, in the middle portion of the penis. Note the echoic image with posterior acoustic shadowing, corresponding to calcification (arrow), in the left corpus cavernosum.[13]
    Transverse ultrasound of the penis, in a ventral view, in the middle portion of the penis. Note the echoic image with posterior acoustic shadowing, corresponding to calcification (arrow), in the left corpus cavernosum.[13]

Management and Treatment

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Peyronie's disease treatment is based on stage of disease, degree of curvature, loss of function, and patient choice. Conservative management[14] in the acute phase has the aim of reducing inflammation and disease extension. Treatment can be with tablets[15][16][17] such as pentoxifylline (an anti-fibrotic phosphodiesterase inhibitor), acetyl-L-carnitine, and vitamin E. Mechanical treatments in the form of penile traction therapy (PTT) and vacuum erection devices (VED) are used to correct the curvature due to plaque and preserve length.

Intralesional injection therapy[18][19] is the mainstay of non-surgical therapy, particularly for stable disease. Verapamil and interferon-α2b have intermediate efficacy. Collagenase Clostridium histolyticum (CCH)[20], an enzymatic drug approved by the US FDA, targets plaque collagen and repairs in moderate disease. It is administered in a series of treatment cycles with attendant penile modeling and elongation.

Surgical therapy[21][22] is reserved for fixed patients with severe curvature, or failed medical therapy. Operations include penile plication (shortening the concave portion of the penis), plaque incision or excision with grafting (lengthening the convex portion of the penis), and penile prosthesis implantation in concomitant erectile dysfunction. Reasonable levels of satisfaction after surgery are present, especially with appropriate preoperative counseling.

Epidemiology

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It is estimated to affect 1–20% of men.[2] The condition becomes more common with age.[2] The mean age at onset of disease is 55–60 years although many cases have been recorded in adolescence and early 20's.[6][23]

The overall prevalence of PD is about 1–20% in men. Rates range from 3.2 percent in a community-based survey of 4432 men (mean age of sample 57.4) to 16 percent among 488 men undergoing evaluation for erectile dysfunction (mean age 52.8).[24][25] The prevalence of PD among the 4432 men in the community based study who responded by self report positively for palpable plaque, newly occurring angulation or curvature and painful erection was 1.5 percent between the ages of 30 and 39, 3 percent between 40 and 49, 3 percent between 50 and 59, 4 percent between 60 and 69, and 6.5 percent over 70.

In 534 men undergoing routine prostate screening for cancer detection (without a specific urologic complaint), the prevalence of PD was 8.9 percent.[24] In this study, the mean age of those with PD was 68.2 years compared with 61.8 years of those without PD.

History

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The condition was first described in 1561 in correspondence between Andreas Vesalius and Gabriele Falloppio and separately by Gabriele Falloppio.[26][27] The condition is named after François Gigot de la Peyronie, who described it in 1743.[28]

References

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  1. ^ Freedberg, Irwin M.; Fitzpatrick, Thomas B. (2003). Fitzpatrick's dermatology in general medicine (6th ed.). New York: McGraw-Hill, Medical Pub. Division. p. 990. ISBN 978-0-07-138076-8.
  2. ^ a b c d e f g "Penile Curvature (Peyronie's Disease)". National Institute of Diabetes and Digestive and Kidney Diseases. July 2014. Retrieved 25 October 2017.
  3. ^ Levine, Laurence A (2010). "Peyronie's disease and erectile dysfunction: Current understanding and future direction". Indian Journal of Urology. 22 (3): 246–50. doi:10.4103/0970-1591.27633.
  4. ^ Smith, R. J.; Bryant, R. G. (1975-10-27). "Metal substitutions incarbonic anhydrase: a halide ion probe study". Biochemical and Biophysical Research Communications. 66 (4): 1281–1286. doi:10.1016/0006-291x(75)90498-2. ISSN 0006-291X. PMID 3.
  5. ^ a b Nelson CJ, Mulhall JP (March 2013). "Psychological impact of Peyronie's disease: a review". The Journal of Sexual Medicine. 10 (3): 653–60. doi:10.1111/j.1743-6109.2012.02999.x. PMID 23153101.
  6. ^ a b c Ralph, D. J.; Minhas, S. (January 2004). "The management of Peyronie's disease". British Journal of Urology International. 93 (2): 208–15. doi:10.1111/j.1464-410X.2004.04587.x. PMID 14690485. S2CID 38211880.
  7. ^ Tobias S. Köhler, Kevin T. McVary (2016). Contemporary Treatment of Erectile Dysfunction: A Clinical Guide. Springer. ISBN 9783319315874. Retrieved 2020-01-17.
  8. ^ Hatzimouratidisa, Konstantinos; Eardley, Ian; Giuliano, François; Hatzichristou, Dimitrios; Moncada, Ignacio; Salonia, Andrea; Vardi, Yoram; Wespes, Eric (2012). "EAU guidelines on penile curvature". European Urology. 62 (3): 543–552. doi:10.1016/j.eururo.2012.05.040. PMID 22658761. Retrieved 21 January 2020.
  9. ^ Abern, Michael R.; Levine, Laurence A. (2009). "Peyronie's disease: evaluation and review of nonsurgical therapy". The Scientific World Journal. 27 (9): 665–675. doi:10.1100/tsw.2009.92. PMC 5823162. PMID 19649505.
  10. ^ Di Maida, Fabrizio; Cito, Gianmartin; Lambertini, Luca; Valastro, Francesca; Morelli, Girolamo; Mari, Andrea; Carini, Marco; Minervini, Andrea; Cocci, Andrea (2021). "The Natural History of Peyronie's Disease". The World Journal of Men's Health. 39 (3): 399–405. doi:10.5534/wjmh.200065. ISSN 2287-4208. PMC 8255406. PMID 32648381.
  11. ^ Şahin, Mehmet Fatih; Doğan, Çağrı; Akgül, Murat; Yazıcı, Cenk Murat; Şeramet, Serkan; Dayısoylu, Hulusi Sıtkı (2024-05-17). "Bibliometric analysis of most cited Peyronie's disease and its management publications". Frontiers in Surgery. 11. doi:10.3389/fsurg.2024.1336391. ISSN 2296-875X. PMC 11140013. PMID 38826812.
  12. ^ Amin Z, Patel U, Friedman EP, Vale JA, Kirby R, Lees WR (May 1993). "Colour Doppler and duplex ultrasound assessment of Peyronie's disease in impotent men". The British Journal of Radiology. 66 (785): 398–402. doi:10.1259/0007-1285-66-785-398. PMID 8319059.
  13. ^ a b Originally copied from:
    Fernandes, Maitê Aline Vieira; Souza, Luis Ronan Marquez Ferreira de; Cartafina, Luciano Pousa (2018). "Ultrasound evaluation of the penis". Radiologia Brasileira. 51 (4): 257–261. doi:10.1590/0100-3984.2016.0152. ISSN 1678-7099. PMC 6124582. PMID 30202130.
    CC-BY license
  14. ^ Reddy, Amit G.; Dai, Michelle C.; Song, Jeffrey J.; Pierce, Hudson M.; Patel, Sagar R.; Lipshultz, Larry I. (2023-02-02). "Peyronie's Disease: An Outcomes-Based Guide to Non-Surgical and Novel Treatment Modalities". Research and Reports in Urology. 15: 55–67. doi:10.2147/RRU.S278796. PMC 9901485. PMID 36756281.
  15. ^ Abern, M. R., & Levine, L. A. (2009) (2009). "Peyronie's disease: evaluation and review of nonsurgical therapy". The Scientific World Journal. 9: 665–675. doi:10.1100/tsw.2009.92. PMID 19649505.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: numeric names: authors list (link)
  16. ^ Hauck, E. W., Diemer, T., Schmelz, H. U., & Weidner, W (2006). "A critical analysis of nonsurgical treatment of Peyronie's disease". European Urology. 49 (6): 987–997. doi:10.1016/j.eururo.2006.02.059.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  17. ^ Mynderse, L. A., & Monga, M. (2002). "Oral therapy for Peyronie's disease". International Journal of Impotence Research. 14 (5): 340–344. doi:10.1038/sj.ijir.3900869.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  18. ^ Khooblall, Prajit; Bole, Raevti; Lundy, Scott D.; Bajic, Petar (2023-06-21). "Expanded Utilization of Intralesional Therapies for Treatment of Peyronie's Disease". Research and Reports in Urology. 15: 205–216. doi:10.2147/RRU.S386340. PMC 10290860. PMID 37366388.
  19. ^ Trost, L. W., Gur, S., & Hellstrom, W. J. (2007). "Pharmacological management of Peyronie's disease". Drugs. 67 (4): 527–545. doi:10.2165/00003495-200767040-00004. PMID 17352513.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  20. ^ Phillips, Drew; Chan, Justin Y.H.; Flannigan, Ryan (May 2020). "Evaluating collagenase Clostridium histolyticum administration protocols in the treatment of Peyronie's disease". Current Opinion in Urology. 30 (3): 328–333. doi:10.1097/MOU.0000000000000760. ISSN 0963-0643.
  21. ^ Osmonov, Daniar; Ragheb, Ahmed; Ward, Sam; Blecher, Gideon; Falcone, Marco; Soave, Armin; Dahlem, Roland; van Renterghem, Koenraad; Christopher, Nim; Hatzichristodoulou, Georgios; Preto, Mirko; Garaffa, Giulio; Albersen, Maarten; Bettocchi, Carlo; Corona, Giovanni (2022-02-01). "ESSM Position Statement on Surgical Treatment of Peyronie's Disease". Sexual Medicine. 10 (1): 100459. doi:10.1016/j.esxm.2021.100459. ISSN 2050-1161. PMC 8847818. PMID 34823053.
  22. ^ Kadıoğlu, Ateş; Gürcan, Mehmet; Rakhmonovich, Abdurakhmonov Farkod; Dursun, Murat (2024-04-30). "Surgical management of complex curvature in Peyronie's disease". World Journal of Urology. 42 (1): 276. doi:10.1007/s00345-024-04936-z. ISSN 1433-8726. PMC 11061042. PMID 38689034.
  23. ^ Tal, Raanan; Hall, Matthew S.; Alex, Byron; Choi, Judy; Mulhall, John P. (2012-01-01). "Peyronie's Disease in Teenagers". The Journal of Sexual Medicine. 9 (1): 302–308. doi:10.1111/j.1743-6109.2011.02502.x. ISSN 1743-6095. PMID 21981606.
  24. ^ a b Mulhall, John P.; Creech, Steven D.; Boorjian, Stephen A.; Ghaly, SAM; Kim, Edward D.; Moty, Ayham; Davis, Rodney; Hellstrom, Wayne (2004). "Subjective and Objective Analysis of the Prevalence of Peyronie's Disease in a Population of Men Presenting for Prostate Cancer Screening". Journal of Urology. 171 (6 Part 1): 2350–2353. doi:10.1097/01.ju.0000127744.18878.f1. PMID 15126819.
  25. ^ Kadioglu, A.; Oktar, T.; Kandirali, E.; Kendirci, M.; Sanli, O.; Ozsoy, C. (2004). "Incidentally diagnosed Peyronie's disease in men presenting with erectile dysfuntion". International Journal of Impotence Research. 16 (6): 540–543. doi:10.1038/sj.ijir.3901247. PMID 15116064.
  26. ^ Dunsmuir WD, Kirby RS (October 1996). "Francois de LaPeyronie (1978-1747): the man and the disease he described". Br J Urol. 78 (4): 613–22. doi:10.1046/j.1464-410x.1996.14120.x. PMID 8944520.
  27. ^ Falloppio, Gabriele (1561). Gabrielis Falloppii medici Mutinensis Observationes anatomicae ad Petrum Mannam medicum Cremonensem. U.S. National Library of Medicine. Venetiis : Apud Marcum Antonium Vlmum.{{cite book}}: CS1 maint: publisher location (link)
  28. ^ Peyronie's disease at Whonamedit?
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