Peyronies Disease   Peyronie's disease is a localized connective tissue disorder resulting in fibrotic plaque formation in the tunica albuginea of the corpora cavernosa of the penis. Urologists should know about it because it affects the esteem and quality of life of the men who have it and also that of their sexual partners. In addition, Peyronie's disease complicates the evaluation of sexual dysfunction and its treatment is controversial. The clinical hallmarks of Peyronies disease include: 1. Curvature of the penis with erection 2. Painful erections (which are temporary) 3. Fibrotic, palpable plaques 4. Diminished rigidity of the penis. The erectile curvature is in the direction of the lesion. The average duration of symptoms is 6 to 15 months. Most reported cases have been white males in their forties and fifties. Natural History of Peyronies Disease The average plaque size is usually less than 2 cm. Plaque location is usually dorsal (72 percent) and mid or distal shaft. In established Peyronie's disease, there has been no reported case of malignant transformation. (Occasionally metastatic lesions are misdiagnosed as Peyronie's disease. However, metastatic lesions are usually not in the tunica albuginea but deeper inside.) Some information in the literature about spontaneous regression indicated that 35 percent of men with this disease experienced complete regression and one third showed significant improvement. However, Gelbard reported the results of a patient survey where only 13 percent of patients claimed resolution and most patients had no change or they experienced continued gradual progression with eventual calcification (Gelbard, 1990). Calcification within plaques is considered the end stage of the disease and was reported by 30 percent of patients. Etiology of Peyronies Disease Numerous theories about etiology of Peyronies disease have been proposed. Associations with vasoactive substance injection therapy, trauma, vitamin E deficiency, use of beta-blocking agents and autoimmune phenomena have been noted. In one theory, Peyronie's disease results from acute or repetitive trauma with tissue disruption and microvascular injury. This leads to fibrin deposition in the tissue space that accumulates after additional trauma. Collagen is also trapped and pathologic fibrosis follows. In addition, with age there is a decrease in the elasticity of collagen fibers. This theory makes sense because most lesions are dorsal, which is where the most stress occurs. Spontaneous regression is most probable in those patients who are in the following category: 1. are less than 50 years old. 2. have discrete plaques that are less than 2 cm long and are palpably soft and without calcification. 3. and have a shorter duration of symptoms (less than 6 months). Diagnosis To evaluate patients, follow these five steps: 1. take a detailed history and perform a physical examination (review any association with Dupeytren's disease, history of penile trauma or surgery, problem's duration, pain, curvature, narrowing of the shaft, potency; 2. perform color Doppler examination after intracavernous injection of 10 mcg of prostaglandin E1 and evaluate erectile function, penile anatomy, arterial collaterals. 3. record size and location of plaque by palpation and ultrasound examination and include drawings to estimate curvature. . Medical Management of Peyronies Disease Patients with few symptoms who have curvature but can achieve penetration should be monitored but not treated. This is also true for the man who is not sexually motivated or active and is without a partner. Oral Treatments, Injections, and Others Tamoxifen (20 mg b.i.d.) was studied in a 36-patient trial (not blinded) (Ralph, Brooks, Bottazzo & Pryor, 1992). Sixteen of 36 reported improvement in pain, one third reported less curvature, and of those with increased inflammation, improvements in inflammation, pain and curvature were reported. Cholchicine (1.2 mg b.i.d.) treatment improved the size of plaques and lessened pain and discomfort but there was little effect on penile curvature (Akkus, Carrier, Rehman, Breza, Kadioglu & Lue, 1994). Some physicians use intralesional injections of such drugs as steroids, parathyroid, and DMSO. Use of radiation therapy is not recommended because although it lessens the pain it can worsen the disease and induce fibrosis. Surgery for Peyronies Disease Surgery should not be offered as an option as long as the disease continues to evolve. Most authors recommend one year of conservative therapy before surgery unless the plaque is calcified. Surgical candidates with penile curvature may be divided into those with erectile dysfunction and those with rigid erections. Most surgeons would treat the erectile dysfunction group with a penile straightening procedure and prosthesis implantation. Surgical treatment of patients with Peyronie's disease who have rigid erections is controversial. Types of Procedures The surgeon should clearly communicate the goals and risks of surgery to the patient and his sexual partner. Options in surgical procedures include plication, incision and graft, and prosthesis implantation. A disadvantage to plication is that this procedure shortens the penis. An advantage is that plications can be done in small bits. The surgeon induces an erection during the beginning of the procedure to see exactly where the plaque is and then again at the end to ensure all the plaque has been removed. Most surgeons favor the use of dermal graft for an excision procedure. This is partly because they are relatively straightforward and have been used successfully for so long. The grafts are harvested in a hairless region near the inguinal crease and prepared by hand or machine. The surgeon excises the plaque and makes transverse cuts down corpora bodies which allows the upper surface of the tunica to be lengthened so that the graft can be placed there. Care should be taken not to cut too deeply into the cavernosal tissue because it is needed for producing erections. Grafts should be approximately 25 to 35 percent larger than the area excised to accommodate shrinkage. Excising ventral lesions is difficult because of the presence of the urethra. The corpora spongiosum must be dissected away from the corpora bodies. Start much more proximal than the extent of the plaque and move across the midline to what is more normal tissue. Once that plane is established, extend it distally down the shaft and then the plaque can be demarcated from the surrounding tissue easily. Dorsal lesions are also problematic. Go 2 cm proximal to the plaque and cross the midline to the opposite corpora body. Lift the neurovascular bundle up, travel through the plaque and separate the plaque from the corpora body. Numerous studies document up to 70 percent postoperative erectile dysfunction after plaque excision and dermal grafting (Wild, 1979). Other studies report more favorable outcomes. For instance, the largest series, with 110 patients, documented that 84 percent were able to resume sexual intercourse postoperatively (Jordan, 1993). Prosthesis Implantation Implantation of a penile prosthesis with or without incision or excision of the plaque may be sufficient to correct the curvature. This surgery is critical to ensure potency in any patient with erectile dysfunction. Other patients who have severely angulated penes, can achieve rigid erections, and have excellent arterial flows on color Doppler evaluation may need only excision of plaque and grafting. (If postoperative impotence occurs, a penile prosthesis can be implanted then). Several types of prostheses exist including semi rigid rod devices and 1-, 2-, and 3-piece inflatable devices. The patient and surgeon can select the most appropriate one for the patient's needs. Once the prosthesis is implanted, if mild angulation remains during erection, application or excision of the corpus opposite the point of maximal angulation can correct it. However, this does tend to shorten the penis. If the penile curvature is severe during erection, and the patient has a short phallus, the plaque should be incised or excised.