Management of Peyronie's Disease in the Aging Male

Rany Shamloul; Anthony J Bella

Disclosures

Aging Health. 2011;7(1):65-78. 

In This Article

Abstract and Introduction

Abstract

Peyronie's disease (PD) is an acquired inelastic scar of the tunica albuginea of the penis, resulting in penile pain, curvature and other deformities, and sexual dysfunction, as well as significant psychological morbidity and relationship/partner issues. Contemporary data suggest an incidence of one in 20 men, with peak occurrence between ages of 50–55 years. Initial diagnosis of PD is made by thorough medical history and examination of the external genitalia; early referal to an urologist experienced in PD management is recommended. Evidence for nonsurgical treatment options is limited; the most commonly used, vitamin E, has not been shown to have benefit over placebo. Recent double-blinded placebo-controlled evidence suggests a role for oral pentoxifylline as a first-line agent. Intralesional injection therapy with verapamil is a frequently utilized option, as first- or second-line treatment, or in combination with other modalities. IFN-β2b injections into the penile plaque have also shown benefit over placebo in decreasing penile curvature, plaque size, penile pain and plaque density. Penile traction is currently under investigation for a potential role in PD management. The gold standard treatment for clinically significant deformity after PD has stabilized remains surgery. Several surgical options are available, including minimally invasive plication procedures, incision of the plaque and grafting or a penile prosthesis (when concurrent treatment-resistant erectile dysfunction is present).

Introduction

Peyronie's disease (PD) is an acquired, localized fibrotic disorder of the tunica albuginea, resulting in penile deformity, pain and, in some men, erectile dysfunction (ED) (Figures 1 & 2).[1] PD can be a psychologically and physically disabling disorder, leading to a lower quality of life both for the patient and their partner. The natural history of PD is unpredictable, although less than 13% of men with PD will show spontaneous improvement. Initial diagnosis is generally straightforward, and is based on history and external genital examination. Penile ultrasound can also be used to confirm the presence of fibrotic plaques or calcifications.[1]

Figure 1.

Peyronie's disease deformities. Scarring of the tunica albuginea leads to formation of an inelastic plaque, resulting in penile pain, curvature, loss of length and loss of width. The changes are most pronounced, or occur exclusively, with erection.
Reproduced with permission from.83

Figure 2.

Severity of deformity. Objective measurement of the degree of penile curvature can be performed via direct observation of an in-office penile erection after injection of vasoactive agents (such as prostaglandin E-1) or performed on standardized photographs using two intersecting lines (A & B) through the center of the distal and proximal penile shaft. Deformity can be along one plane (up or down, left or right) or more complex, including corkscrews or angulations greater than 180 degrees.
Reproduced with permission from.84

Many clinicians, including urologists, have the misconception that PD is a rare condition, based on previous case reports documenting prevalence of no greater than 1%.[2,3] Current epidemiological estimates of the prevalence of PD range from 3.2%, as described in a 1999 questionnaire study involving 4432 respondents from Cologne, Germany,[4] to 8.9%, as reported in a 2004 study of 534 men who presented to American urologists for routine prostate screening.[5] Thus, a 5% overall prevalence is a reasonable figure to pass on to the patients. PD commonly occurs in older men (with a mean age of 53 years). A history of penile injury may be present; however, one study reports that the majority of men with PD in their series had no specific recollection of trauma, and 10% of patients experienced symptom onset before 40 years of age.[6] Owing to the nature of PD, many men may feel uncomfortable reporting it to their family physicians and, thus, the true prevalence of the disease may be undervalued – clinically, asking the question 'Are you able to have an erection and keep it until the end of sexual intercourse' and 'are there any new lumps, bumps or bends to the penis when it is erect?' serves as a useful case-finding approach to both ED and PD.

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