Peyronie's disease: Plaque (inelastic scar, fibrosis) in tunica albuginea of corpora cavernosa

Etiology: unknown, possibly trauma

Presentation

• Penile pain with erection
• Deformity (curvature, indentation, narrowing ("waisting/hourglass" deformity), buckling ("hinge effect"))
• Erectile dysfunction (veno-occlusive dysfunction)
• Plaque may be asx

Natural history

• Acute phase (inflammation, pain)
• Lasts 6-18 mo, a/w plaque remodeling
• Chronic phase (remodeling stops)
• Pain resolves in 90% within 12 mo
• Curvature resolves in 15%, stabilizes in 40-50%, and progresses in 40-50%

Physical exam

• Note penile plaques (usually dorsal; may localize with US)
• Measure penile length on stretch
• Assess deformity during erection (photo or in-office erection with vacuum/injection)
• a/w Dupuytren's contracture (hand), Ledderhose's disease (plantar fascia)

Surveillance if not bothered/not interfering with sex. Manage pain during acute phase

PO medications - no benefit (includes PO vitamin E, Potaba, colchicine, tamoxifen, pentoxifylline (Trental))

Topical therapy - topical verapamil may help

Mechanical therapy - traction may reduce penile deformity and improve length. ESWL may reduce pain but does not affect plaque.

Intralesional plaque injections

• Verapamil (ILVT; intralesional verapamil treatment) (10 mg/10 cc, q2-4 wks x 12)
• Monitor blood pressure for 10 min after injection; avoid injecting into cavernosa (causes priapism)
• Collagenase (Xiaflex) 
• Indicated for palpable plaque and curvature at least 30°
• Up to 4 cycles spaced 6 wks apart
• **hide**Inject plaque at maximal concavity (localize when erect, inject while flaccid)
• **hide**2 injections spaced 1-3 d apart
• **hide**Follow up in another 1-3 d for in-office penile remodeling (bend flaccid penis opposite to curvature for 30s x 3)
• **hide**Patient performs self-modeling at home in between cycles
• Reduces penile curvature (by 35%), sustained for 9 mo. 75% report subjective improvement.
• Side effects: pain, bruising, swelling. Penile fracture in 1.5%.

Surgical

• Indicated if Peyronie's interferes with intercourse, deformity stable for > 3-6 mo, and no penile pain
• Shorten contralateral corpora/tunica albuginea
• Indicated if able to lose 1-1.5 cm penile length; adequate erections; curvature < 60°; no destabilizing deformity
• Corrects curvature in 80%, satisfaction in 70%
• Tunica-sparing (e.g. 16-dot plication)
• No excision of tunica/dissection of neurovascular bundle (located dorsally) decreases risk of loss of penile sensation/erectile dysfunction
• Non tunica-sparing - incise tunica albuginea to shorten (e.g. Nesbit, corporoplast)
• Plaque incision/excision with grafting
• Indicated for short penile length; adequate erections; curvature > 60°; destabilizing deformity present
• Preferred: plaque incision with non-synthetic graft
• Penile prosthesis
• Indicated if ED is present and not adequately treated
• Can further remodel intraoperatively if residual curvature > 60°