Management of Peyronie's Disease in the Aging Male

Pathogenesis

The underlying pathogenesis of PD is unknown, but is likely to be multifactorial, with an interplay between genetic predisposition, trauma and tissue ischemia. The underlying lesion of PD is a fibrous plaque(s) that contains excessive collagen, an altered framework of reduced and fragmented elastic fibers and fibroblastic proliferation, which alters penile anatomy. The fibrous plaque causes focal inelasticity and can compromise erectile function. Plaques may be fibrous, contain areas of calcification, or be completely ossified. Most authorities postulate that PD results from repeated minor blunt trauma to the penis during intercourse. PD is thought to be due to localized aberration of the wound healing process. For susceptible individuals, bleeding within the tunica albuginea, trapping of fibrin and inflammatory cells, and overexpression of matrix proteins, secondary to upregulation of cytokines and growth factors in the local environment, lead to plaque formation.^[7] Excess fibrin deposition in response to microvascular injury and upregulation of TGF-1, results in one or more areas of plaque formation.^[8]

Risk Factors

A family history of PD has been observed in 2% of patients.^[9] In total, 21% of patients with PD may also have Dupuytren's contracture.^[10] Patterns of gene expression in families with PD and Dupuytren's disease are similar, particularly in regard to collagen degradation, ossification and myofibroblast differentiation.^[11] Genital and/or perineal injuries, radical prostatectomy, plantar fascial contractures, tympanosclerosis, urethral instrumentation, Paget's disease, gout and lipomas have been associated, albeit weakly, with PD.^[12,13] Hypertension, smoking, hyperlipidemia and diabetes have been proposed to be risk factors, but they are more likely related to underlying ED, as current research does not show a relationship between these factors and severity of penile curvature.^[13] An association with vascular comorbidities is controversial,^[14] as is the role of overt trauma, such as penile fracture.^[15] It needs to be emphasized that a history of penile injury is not required for a man to develop PD.

Natural History

Following diagnosis, referral to an urologist with experience treating PD is recommended.^[16] Untreated PD resolves in only 12% of men, with 40–48% of men demonstrating worsening of curvature at 12 months, while curvature remains stable in the remaining patients.^[17] The mean change was 15° in those in whom curvature improved; therefore, from a clinical standpoint, this degree of improvement may not be meaningful in the context of deformities, which may be either greater than 90° or corkscrew shaped, for example. The disease state may often be divided into an acute (or inflammatory) phase and a chronic phase. During the former, there may be penile pain, even when flaccid, and there are often dynamic changes of penile malformation. During the latter, pain resolves and the deformities stabilize. Although pain resolves as part of the natural progression of PD, nonsurgical treatment may shorten this time period, as well as impacting the deformity; early initiation of therapy is recommended, and there is little or no role for observation unless the deformity is minimal and does not impact sexual function.

Cite this: Management of Peyronie's Disease in the Aging Male - Medscape - Feb 01, 2011.

Box Executive summary
Peyronie's disease (PD) involves the development of inelastic scar of the tunica albuginea of the penis, resulting in penile curvature, deformity and sexual dysfunction. The underlying pathogenesis of PD is unknown, and most likely represents a combination of factors, including chronic minor injury and genetic susceptibility. The presenting symptoms of PD are penile pain, induration, curvature and/or sexual dysfunction. Patient and partner quality of life are significantly impacted, as men with PD are at an increased risk of depression, relationship difficulties and body-image issues. Diagnosis is usually apparent from patient history and penile examination. On examination, clinicians may observe a penile plaque and penile curvature or deformity. When primary-care clinicians have limited experience in managing PD, they should refer the patient to an urologist once the diagnosis of PD is established, or in any patient with a penile deformity. For patients who do not have penile deformity compromising sexual function, and whose PD has persisted for less than 12 months, we suggest medical management rather than surgical management. For men with stable, mild curvature (≤30°), who have satisfactory erectile function, we suggest observation. If mild curvature worsens, or causes sexual dysfunction, we suggest medical and/or surgical management. Surgical management is indicated for patients whose PD has persisted for more than 12 months, and is associated with a penile deformity compromising sexual function. The length of the penis, nature (e.g., hourglass or curved), and severity of the deformity, erectile capacity and patient expectations, are important factors to consider when determining the surgical approach. Surgical techniques used for penile reconstruction in PD include plication, grafting or placement of a penile prosthesis. Plication shortens the convex side of the penis, whereas grafting techniques lengthen the concave side. Penile implants are used in patients with pre-existing erectile dysfunction (ED). Plaque incision is often combined with these techniques to improve the mobility of the plaque. Erectile dysfunction occurs in up 20% of patients following nonplication surgical reconstruction for PD, and can occur without a prior history of ED; however, ED is more likely to complicate procedures requiring dissection of the neurovascular bundle, or in patients with pre-existing ED.

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