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Peyronie’s disease: new paradigm for the treatment of a unique cause of erectile dysfunction
Culley Carson
ABSTRACT
Peyronie’s Disease is an incurable condition of the tunica albuginea of the penis associated with scarring, plaque formation, and penile deformity on erection. It is often associated with erectile dysfunction. Recent data have supported a familial and genetic predisposition to this chronic condition. The etiology of Peyronie’s Disease is unknown but is likely associated with multiple micro-traumas to the erect penis in men who are susceptible to the scarring typical of Peyronie’s Disease. The treatment of Peyronie’s Disease has improved over the past decade as a result of animal studies and the approval of new medications. In the acute phase of the condition, phosphodiesterase type 5 inhibitors have been shown to have some benefit and are supported by animal studies demonstrating reduced fibrosis of the penis in animal models of Peyronie’s Disease. In the stable phase of the disease, newer injectable agents have shown great promise. Collagenase clostridium histolyticum is approved for the treatment of Peyronie’s plaques by direct injection into the scarred tissue with data showing satisfactory safety and efficacy. Surgical procedures for penile straightening have been refined with improved outcomes in the past decade. For those men with erectile dysfunction and Peyronie’s Disease, penile implants can restore erectile function and form. As a result of the new understanding of the risk factors for Peyronie’s Disease and recent advances in treatment options, the algorithm for the treatment of Peyronie’s Disease has improved outcomes for patients and their partners.
Introduction
Peyronie’s Disease (PD) is an often debilitating condition caused by fibrosis of the tunica albuginea (TA) of the penis resulting in difficulty with coitus in many patients. Over the past decade, the knowledge of the etiology, genetics, and treatment of PD has changed the approach to this condition that causes angst, depression, and disability in many men affected. Peyronie’s Disease was first reported by Fallopius and Vesalius in correspondence in 1561 [1]. Earlier reports exist, but the first series of patients was reported by Francois Gigot de la Peyronie in 1743. Peyronie often referred to as the father of French surgery was the first surgeon to be a physician to the royal court of France. He reported a series of five men with what he termed induratio penis plastica that consisted of ‘rosary beads’ in the penile shaft caused by irritation of the penis and best treated by bathing in the baths of Berege in Southern France. Little was known of the optimal treatment paradigm over the centuries and most men were told that there was no solution to their problem.
PD presents as fibrotic plaques of the TA causing penile deformities on erection. Plaques are usually unifocal (78–84%) and located on the dorsum of the penile shaft (46–62%) [2]. The plaques may occur ventrally or laterally. These dense scar tissue plaques cause deformities during erection including curvature, ‘hourglass deformity’, and multiple complex deformities. Curvature, usually, is directed to the side of the plaque and varies from minimal to more than 120 degrees. Patients also report penile shortening, often as much as one third to one half of pre-PD erectile length [3]. While the onset of the deformities is usually insidious, many patients report the acute appearance of curvature and deformity. In the early stages of PD, patients may experience pain in the penis, usually on erection and in the location of the plaque. This discomfort with erection resolves once the PD has become stable. While erectile dysfunction (ED) can occur with PD, erectile function is normal in the majority of patients.
The extent of curvature can make sexual intercourse difficult causing discomfort for patients and partners. Angles of curvature can be more than 90°; in one cohort approximately 20% of patients had curvature greater than 60° [3]. Erectile pain is likely due to inflammation associated with abnormal healing. A study of biopsies of 12 painful Peyronie’s plaques showed inflammatory collections surrounding the plaques in more than two-thirds of cases [4]. Pain associated with the plaques generally resolves within several months of onset and resolution of tenderness is a sign of stabilization. The acute phase of the condition usually lasts between 6 and 18 months. Once the acute phase has stabilized, a chronic phase characterized by little pain, stable penile deformity, and stable plaque size signals the best opportunity for treatment. 20–40% of PD patients report ED with a lack of tumescence or flaccidity distal to the plaque.
PD also affects the quality of life, with 77% of afflicted men reporting psychological complaints and two-thirds of those reporting frequent concern over the condition [5]. PD can cause a negative impact on self-image, a reduction in sexual satisfaction, relationship problems, anxiety, stress, and depression. Spontaneous disease regression has been noted in 5–40% of cases, with one large series reporting 13% resolution. The pain will generally resolve over time. Curvature is less likely to improve without treatment. Reports of low testosterone in PD patients suggest that evaluation should include a morning total testosterone level to screen for hypogonadism [6].
PD is most common in middle-aged and older men. The prevalence of PD has been reported from 0.38% to 3.7% of 40- to 70-year-old men [7]. However, the age at onset has been reported from 18 to 80 years of age. The prevalence of PD noted in contemporary prostate cancer screening populations has been 3.7% to 8.9% [8]. Approximately 10% of men with ED have PD [2].
Summary
PD is an incurable, sexually debilitating disease that results in penile deformity, coital difficulties, and significant psychological stress for patients and their partners. PD is more prevalent than previously thought, and its prevalence is likely to increase as populations age, and more men seek treatment for ED. The condition remains enigmatic with only limited evidence and speculation as to its pathogenesis. Treatment of PD should be individualized and tailored to the patient’s needs, goals and expectations, disease history, physical examination, and coital function [2]. While there are medical treatments, there are few with evidence-based data to support their safety and effectiveness. Randomized placebo-controlled trials support more recent advances in injectable therapies, especially CCH [15,16]. After PD has stabilized and less invasive options have failed, a surgical correction is an option for motivated patients with stable PD and functional erectile impairment. A surgical reconstruction is a good option when proper treatment decisions are made, with the goal of return to sexual function following PD treatment. While there have been many advances in the understanding of the etiology of PD and newer treatment alternatives, there remains much work to do in the understanding and treatment of PD. Recent progress in injectable agents and improved options for surgical reconstruction support that men should be encouraged to seek treatment for this physically and psychologically debilitating condition.
A practical treatment plan is the management of the patient initially and during the acute phase of PD expectantly [2]. If the patient is relatively asymptomatic, reassurance and clinical follow-up may be all that is necessary. Because of the associated hypogonadism with PD, it is important to do a screening morning total testosterone level on PD patients. If the patient has progressive or symptomatic PD, more aggressive treatment is indicated. Choosing between the different treatment options will depend on the physician’s clinical experience, interpretation of the available data, and on the patient’s comfort with different forms of therapy. Initial treatment in the active stage of PD can be with a daily PDE-5 inhibitor such as tadalafil. Treatment of stable curvature of fewer than 90 degrees is best with a course of CCH injections and home modeling. Treatment of concomitant ED can be with either oral or injectable erection-promoting agents or a vacuum erection device. Surgical intervention for penile straightening should be reserved for those with a severe penile deformity that alters the erectile function and who have failed less invasive options. Penile prosthesis implantation is used in patients with ED and PD who fail less invasive therapy and desire to resume sexual intercourse. Surgical intervention should be considered only after PD has stabilized for 6–12 months. With any treatment option, goals and expectations of treatment and adverse events should be discussed in detail with patients and partners.
Culley Carson
ABSTRACT
Peyronie’s Disease is an incurable condition of the tunica albuginea of the penis associated with scarring, plaque formation, and penile deformity on erection. It is often associated with erectile dysfunction. Recent data have supported a familial and genetic predisposition to this chronic condition. The etiology of Peyronie’s Disease is unknown but is likely associated with multiple micro-traumas to the erect penis in men who are susceptible to the scarring typical of Peyronie’s Disease. The treatment of Peyronie’s Disease has improved over the past decade as a result of animal studies and the approval of new medications. In the acute phase of the condition, phosphodiesterase type 5 inhibitors have been shown to have some benefit and are supported by animal studies demonstrating reduced fibrosis of the penis in animal models of Peyronie’s Disease. In the stable phase of the disease, newer injectable agents have shown great promise. Collagenase clostridium histolyticum is approved for the treatment of Peyronie’s plaques by direct injection into the scarred tissue with data showing satisfactory safety and efficacy. Surgical procedures for penile straightening have been refined with improved outcomes in the past decade. For those men with erectile dysfunction and Peyronie’s Disease, penile implants can restore erectile function and form. As a result of the new understanding of the risk factors for Peyronie’s Disease and recent advances in treatment options, the algorithm for the treatment of Peyronie’s Disease has improved outcomes for patients and their partners.
Introduction
Peyronie’s Disease (PD) is an often debilitating condition caused by fibrosis of the tunica albuginea (TA) of the penis resulting in difficulty with coitus in many patients. Over the past decade, the knowledge of the etiology, genetics, and treatment of PD has changed the approach to this condition that causes angst, depression, and disability in many men affected. Peyronie’s Disease was first reported by Fallopius and Vesalius in correspondence in 1561 [1]. Earlier reports exist, but the first series of patients was reported by Francois Gigot de la Peyronie in 1743. Peyronie often referred to as the father of French surgery was the first surgeon to be a physician to the royal court of France. He reported a series of five men with what he termed induratio penis plastica that consisted of ‘rosary beads’ in the penile shaft caused by irritation of the penis and best treated by bathing in the baths of Berege in Southern France. Little was known of the optimal treatment paradigm over the centuries and most men were told that there was no solution to their problem.
PD presents as fibrotic plaques of the TA causing penile deformities on erection. Plaques are usually unifocal (78–84%) and located on the dorsum of the penile shaft (46–62%) [2]. The plaques may occur ventrally or laterally. These dense scar tissue plaques cause deformities during erection including curvature, ‘hourglass deformity’, and multiple complex deformities. Curvature, usually, is directed to the side of the plaque and varies from minimal to more than 120 degrees. Patients also report penile shortening, often as much as one third to one half of pre-PD erectile length [3]. While the onset of the deformities is usually insidious, many patients report the acute appearance of curvature and deformity. In the early stages of PD, patients may experience pain in the penis, usually on erection and in the location of the plaque. This discomfort with erection resolves once the PD has become stable. While erectile dysfunction (ED) can occur with PD, erectile function is normal in the majority of patients.
The extent of curvature can make sexual intercourse difficult causing discomfort for patients and partners. Angles of curvature can be more than 90°; in one cohort approximately 20% of patients had curvature greater than 60° [3]. Erectile pain is likely due to inflammation associated with abnormal healing. A study of biopsies of 12 painful Peyronie’s plaques showed inflammatory collections surrounding the plaques in more than two-thirds of cases [4]. Pain associated with the plaques generally resolves within several months of onset and resolution of tenderness is a sign of stabilization. The acute phase of the condition usually lasts between 6 and 18 months. Once the acute phase has stabilized, a chronic phase characterized by little pain, stable penile deformity, and stable plaque size signals the best opportunity for treatment. 20–40% of PD patients report ED with a lack of tumescence or flaccidity distal to the plaque.
PD also affects the quality of life, with 77% of afflicted men reporting psychological complaints and two-thirds of those reporting frequent concern over the condition [5]. PD can cause a negative impact on self-image, a reduction in sexual satisfaction, relationship problems, anxiety, stress, and depression. Spontaneous disease regression has been noted in 5–40% of cases, with one large series reporting 13% resolution. The pain will generally resolve over time. Curvature is less likely to improve without treatment. Reports of low testosterone in PD patients suggest that evaluation should include a morning total testosterone level to screen for hypogonadism [6].
PD is most common in middle-aged and older men. The prevalence of PD has been reported from 0.38% to 3.7% of 40- to 70-year-old men [7]. However, the age at onset has been reported from 18 to 80 years of age. The prevalence of PD noted in contemporary prostate cancer screening populations has been 3.7% to 8.9% [8]. Approximately 10% of men with ED have PD [2].
Summary
PD is an incurable, sexually debilitating disease that results in penile deformity, coital difficulties, and significant psychological stress for patients and their partners. PD is more prevalent than previously thought, and its prevalence is likely to increase as populations age, and more men seek treatment for ED. The condition remains enigmatic with only limited evidence and speculation as to its pathogenesis. Treatment of PD should be individualized and tailored to the patient’s needs, goals and expectations, disease history, physical examination, and coital function [2]. While there are medical treatments, there are few with evidence-based data to support their safety and effectiveness. Randomized placebo-controlled trials support more recent advances in injectable therapies, especially CCH [15,16]. After PD has stabilized and less invasive options have failed, a surgical correction is an option for motivated patients with stable PD and functional erectile impairment. A surgical reconstruction is a good option when proper treatment decisions are made, with the goal of return to sexual function following PD treatment. While there have been many advances in the understanding of the etiology of PD and newer treatment alternatives, there remains much work to do in the understanding and treatment of PD. Recent progress in injectable agents and improved options for surgical reconstruction support that men should be encouraged to seek treatment for this physically and psychologically debilitating condition.
A practical treatment plan is the management of the patient initially and during the acute phase of PD expectantly [2]. If the patient is relatively asymptomatic, reassurance and clinical follow-up may be all that is necessary. Because of the associated hypogonadism with PD, it is important to do a screening morning total testosterone level on PD patients. If the patient has progressive or symptomatic PD, more aggressive treatment is indicated. Choosing between the different treatment options will depend on the physician’s clinical experience, interpretation of the available data, and on the patient’s comfort with different forms of therapy. Initial treatment in the active stage of PD can be with a daily PDE-5 inhibitor such as tadalafil. Treatment of stable curvature of fewer than 90 degrees is best with a course of CCH injections and home modeling. Treatment of concomitant ED can be with either oral or injectable erection-promoting agents or a vacuum erection device. Surgical intervention for penile straightening should be reserved for those with a severe penile deformity that alters the erectile function and who have failed less invasive options. Penile prosthesis implantation is used in patients with ED and PD who fail less invasive therapy and desire to resume sexual intercourse. Surgical intervention should be considered only after PD has stabilized for 6–12 months. With any treatment option, goals and expectations of treatment and adverse events should be discussed in detail with patients and partners.
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