Management of Peyronie's Disease in the Aging Male

Diagnosis & Assessment

Diagnosis is usually apparent from patient history and penile examination. Patients can be given a preliminary diagnosis of PD when they present with classic symptoms of the disease: penile nodules (plaques), curvature and/or pain. Possible associated disorders (e.g., Dupuytren's contractures or vascular disease), and inciting events (e.g., trauma or genitourinary instrumentation), should be evaluated. It is important to define the psychological effect of PD on the patient and partner, as well as to determine the extent of associated ED using a validated questionnaire (e.g., The International Index of Erectile Function-5 questionnaire [IIEF-5]).

Objectively, clinicians may measure penile length, plaque size and penile curvature (Figure 1). In classical PD, a well-defined plaque or induration is palpable on physical examination, even if the patient is unaware. Among men with PD affecting the dorsal side of the penis, two-thirds will have associated plaque.^[18] Lateral or ventral plaques are less common but, when present, can result in more coital difficulties. Plaques primarily located in the penile septum, or equally distributed on both the ventral and dorsal aspects of the penis, may cause penile shortening without angulation.^[19] Septal (or core) plaques may not be palpable; therefore, in a man with penile shortening and pain with erection, but no angulation deformity, PD cannot be ruled out, and ultrasound examination may be useful. Abnormal tissue may extend beyond the palpable lesion, or even into the corporal tissue or intercavernosal septum.^[20] The presence of multiple plaques located on opposite sides of the penis or septal plaques may cause penile shortening, with or without a penile deformity.^[21] Calcification may occur at initial presentation or develop over time. It is often helpful to have the patient take photographs of the erect penis at home to characterize the deformity, although if the erection is not of good quality, determination of deformity will be inaccurate. If the patient cannot, or will not do this, in-office pharmacoerection can be performed, which is also useful for definitive management (surgery) planning.

If the diagnosis of PD is uncertain after history and physical examination, imaging may be helpful. Various imaging modalities have been used to diagnose PD. Ultrasound has the highest sensitivity for plaques in the tunica albuguinea compared with other methods.^[1,22] Ultrasonography has additional advantages, owing to its easy availability, low risk and ability to image and quantify both calcified and soft-tissue elements of PD, as well as assess vascular status if a reconstructive procedure is being considered. However, ultrasound is operator dependent, and if inexperienced with PD, scant useful information may be obtained. Patients with PD and concomitant ED should undergo vascular assessment of their cavernosal arterial blood flow using duplex ultrasound.^[23] There is little evidence for plain radiography, computerized tomography or magnetic resonance for diagnosis and investigation of PD.^[1]

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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Management of Peyronie's Disease in the Aging Male

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