Management of Peyronie's Disease in the Aging Male

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.