COMMENTARY

Cardiologists and Peyronie's Disease: Helping Mend These 'Broken Hearts'

Dr Melissa Walton-Shirley

Disclosures

July 15, 2013

Not until fictional Grey's Anatomy character Dr Mark Sloane suffered a "broken penis" in a 2009 episode did most of the world know this malady even existed. Peyronie's disease is a condition in which the erect penis is angulated or misshapen to the point that it makes intercourse uncomfortable or impossible. Rarely, it's heralded by an obvious injury, a "miscue" during sex, but more commonly nothing unusual has been noted in the days or weeks preceding presentation. Nine percent of males, mostly over the age of 55, develop the problem and tens of thousands are diagnosed annually.

Why cardiologists?

Although cardiovascular healthcare providers interface with this "at-risk" population daily, cardiologists rarely discuss it. What's worse, many of us are uninformed about the near-miraculous surgical fixes available.

Healthcare professionals should not only screen for this malady but also be ready with information that can save relationships and quality of life.

What's the pathology?

The development of a "plaque" occurs at the site of an injury or weak point in the shaft of the penis. When it heals, it's woven of a different fabric of plaque that is less pliable or distensible. When an erection occurs this new unforgiving fabric pulls the penis to one side or flexes it upward or downward.

I once made weekend rounds on a patient in his early 60s who for reasons unclear had never told his regular cardiologist of 20 years about his malady.

"It's difficult to maintain a relationship with my wife," he said, "because sex is impossible."

"What do you mean?" I inquired.

"Ever heard of Peyronie's disease?" he asked.

I answered truthfully that I'd heard of it but didn't know exactly what it was. He shrugged and said, "Life is miserable." I suggested he see a urologist and discharged him home, never knowing if he ever got the courage to bring it up again. The one time he was brave enough to mention his problem, the cardiologist who stood before him was an inadequate information resource. I sooth my conscience by thinking perhaps there really wasn't much help for him way back then.

Morning glory

Fast forward to just three years ago when a patient described in horror his awakening one morning to urinate. He called his wife to see the curiosity staring back at him as he stood over the toilet bowl. "It's shaped like a morning-glory vine," he lamented, a rather unusual description for a 90° upward angulation of his penis, but he got the point across. I recognized his description from my quick review many years before and referred him to the late great local urologist Dr Bo Marcol, who started him on verapamil injections. After weeks of no improvement, he was referred to Dr Douglas Milam, associate professor of urologic surgery at Vanderbilt University in Nashville, TN.

Dr Milam and his team completely restored the erectile function of the patient whose sex life had become nonexistent overnight. The couple no longer sits with furrowed brows from the frustration and denial of their favorite expression of mutual affection. The cause of their temporary stress is still a bit of a mystery. The patient recalled no episode of "rough sex" or injury prior to developing Peyronie's. He also denied any pain with erections. He was on cholesterol medication as his only cardiovascular drug but had noted decreased rigidity after he was placed on finasteride for hair loss. The patient fully blames this medication for his difficulties because the issue was temporally related.

Surgical options

When I inquired regarding surgical procedures available for repair of Peyronie's disease, Dr Milam replied, "We have found that the least invasive procedures involve a longitudinal incision and transverse closure, which works well in patients with up to 50° to 60° degrees of curvature. Patients who have more severe curvature, many of which are up to 90°, are usually better managed with a plaque incision and placement of a graft. Graft material can include small intestinal submucosa from a sheep, which is what I use. Others will use Tutoplast. Some previously used dermis donated from the patient himself," he explained.

Who's right for surgery?

"Other types of [erectile dysfunction] ED could be present," Dr Milam pointed out. "One must ascertain if the patient has adequate rigidity for intercourse. None of the Peyronie's procedures, other than an implant, improve rigidity at all. So up front if they don't have adequate rigidity, a surgical procedure is not helpful unless it's a penile implant. We have several questionnaires that tease out the history, and data support the use of these questionnaires" to guide surgical options.

Medications

Dr Milam listed a number of treatments that are largely viewed as failures by the urology community, including steroid injections, vitamins, verapamil injections, stretching devices, etc. There is, however, some hope for an up-and-coming medication called Xiaflex (collagenase clostridium histolyticum, Auxilium Pharmaceuticals/Pfizer), a collagenase enzyme that attacks the plaque. It was approved in 2010 for the treatment of Dupuytren's contracture, a disorder in which collagen buildup in the fingers causes them to flex permanently. "Treatment involves as many as eight injections of the drug into the penile plaque over a period of a few months," according to company press releases. "Physicians may also manipulate the penis manually to help break up the plaque." The company reported that the treatment yielded a 37.6% reduction in penile curvature in one trial and a 30.5% reduction in the second. "That's a pretty good result for patients with moderate curvature, but for patients with severe angulation, that is not an acceptable result," according to Dr Milam.

After an overnight stay in the hospital with six-week break from any attempts at intercourse, the surgical patient is placed on a daily dose of tadalafil (Cialis, Lilly) 5 mg postoperatively. This encourages nocturnal erections that in theory should provide adequate stretching of the graft to avoid shortening and improve function. "Even at that, nonrigorous sex is recommended for several months," said Dr Milam. "Woman on top and no bending backward is recommended. Adequate lubrication is a must. I've had a few gentlemen require two separate surgeries, and we never want to see that happen. I once had to give the partner of one of my patients a talking to," he said.

Fixing broken hearts

Thanks to the expertise of Dr Milam and his surgical team at Vanderbilt, the two-year long ordeal for my patient and his wife was finally over. This procedure is of course also available at other sites around the world, but it is perhaps "a best-kept secret" of the urologic world. Thanks to a quick referral, erectile dysfunction is no longer a topic for conversation for this couple. I am grateful I had the forethought to refer this patient to an excellent local urologist who knew where he could send his patient for definitive therapy.

As cardiologists, we must admit that a broken penis is really tantamount to not just one, but usually two, broken hearts. Thankfully, there is real help to mend them. As healthcare providers, we owe it our patients to take the time to find out where that help is. Just in case.

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