Medical Management And Surgical Management Of Peyronie's Disease

Main Category: Urology / Nephrology
Also Included In: Erectile Dysfunction / Premature Ejaculation
Article Date: 10 Aug 2008 - 0:00 PDT

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UroToday.com Peyronie's disease is a scarring phenomenon affecting the tunica albuginea of the penis. Scar tissue forms "plaques" that can result in pain with erection, penile deviation, penile shortening, indentation, and/or erectile dysfunction. It is associated with difficulty with sexual intercourse and as such it is associated with loss of self-esteem and depression on the part of the patient and often on the part of the patient's partner. There are no approved medical therapies for the treatment of Peyronie's disease. Surgical treatment of Peyronie's disease must be highly individualized, and various surgeons all have their "best way" of dealing with the problem.

Peyronie's disease was described by Francois de la Peyronie in 1743. Fallopius in 1561 probably described the entity that bares Peyronie's name. Peyronie's disease is incurable, patients require reassurance, they may benefit from medical therapy, and fortunately few require surgery. As mentioned, the scar tissue impedes the expansion of the corpora cavernosa.

Peyronie's disease has been associated with some medications. Beta blockers have been implicated, however, subsequent studies have not verified that relationship, and if there is a relationship to beta blockers, it is probably via erectile dysfunction, and not cause and effect of the beta blocker itself. The association with phenytoin has never been founded and is probably not real. A very nice study by Lyles from the University of North Carolina has associated Peyronie's disease with patients who have Padgett's disease of the bone. Diabetes mellitus has been implicated, and it is probably again via erectile dysfunction. About 40% of patients with Peyronie's disease will show evidence of Dupuytren's disease, albeit many will be non-contractile. A lesser percentage will show evidence of Ledderhose's disease, and a very small number will have tympanosclerosis.

Peyronie's disease is a disease of patients between 45 and 65 years with a mean onset of 53 years old. The asymptomatic prevalence has been estimated to be as high as 20-25%. The years of peak incidence of Peyronie's disease as it turns out are also the years during which the body begins to age, tissues lose elasticity, and men note the onset of erectile dysfunction.

The current theory with regards to the etiology of Peyronie's disease involves trauma to the insertion of the septal fibers. The dorsum appears to be particularly vulnerable. To this date, there is no firm association to HLA subtypes, autoimmune disease, but Peyronie's disease is certainly a disease of hyperactive wound healing.

The scar tissue is composed of dense collagen with decreased elastin. Patients can demonstrate dystrophic calcification and in some cases cartilaginous metaplasia. TGFß1 has been implicated as a part of the process involving the etiology of Peyronie's disease. Other gross factors are also expressed, those being platelet derived growth factors A and B. TGFb1 has been implicated with other soft tissue fibrosis. It is implicated in ED. TGFß1 increases the synthesis of fibroblasts; and in short, it causes increased connective tissue as it governs the scarring process. It inhibits collagenase, and because of the unique anatomy of the insertion of the septal fibers, may be involved in a process of self-induction. All agree that Peyronie's disease is a disease of two phases, an active or immature phase and a mature or quiescent phase. What the practitioner does for Peyronie's disease is in many cases phase specific.

The physician seeing a patient with Peyronie's disease cannot underestimate the psychological impact on the patient and on his partner. With regards to medical management, the place of vitamin E, potaba, Colchicine, Tamoxifen, Carnitine, Pentoxifylline, and PDE5 inhibitors will be discussed. Where there are pertinent randomized controlled trials, those will be reviewed. It is clear that rigorous well-designed controlled studies have in the past not been uniformly done. They are needed, and we are in an era where that deficiency is being addressed. Intralesional injection will be addressed as will the randomized controlled trials associated with that. The place of topical therapy will be addressed, along with innovative delivery mechanisms such as iontophersis and electromotive therapy. The literature will be reviewed with regards to lithotripsy, and the place of combined medical therapy likewise reviewed.

A patient becomes a surgical candidate when he has stable and quiescent disease and that usually is a time that is greater than a year from onset of symptoms. The deformity should be stable for at least 3-6 months. The patient should be erectile pain free. These patients require detailed assessment of their erectile function, and it is imperative that a true informed consent be conducted with the patient. Surgical management options include the plication or corporoplasty techniques. I will review my techniques for these procedures. The place of excision or incision with grafting will be demonstrated and reviewed and the place of prosthetic placement likewise will be reviewed. As mentioned, surgery for Peyronie's disease must be highly individualized, and in most cases, lecturers focus on those procedures that they have had the best success with.

Presented by: Gerald H. Jordan, MD, FACS, FAAP, at the Masters in Urology Meeting - July 31, 2008 - August 2, 2008, Elbow Beach Resort, Bermuda

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