Peyronie’s disease: stages, diagnosis and treatment

Peyronie’s disease manifests with an incurvation of the penis. Although the prevalence is estimated to be below 1% among males of all ages, there is a higher incidence between the ages of 40 and 59 years. Symptoms will depend on the stage of the disease and treatment will vary between pharmacological or surgical, depending on the degree and response to medications.

Peyronie’s disease: what is it?

Peyronie’s disease is the most common cause of penile incurvation (especially dorsal), followed by congenital incurvation. It is a disorder of the penile connective tissue that produces a fibrous, non-elastic scar of the tunica albuginea of the corpora cavernosa.
The lesion can be palpated during penile flaccidity and manifests itself by deforming the penis during erection.

Causes of Peyronie’s disease

The true cause of this inflammatory process is unknown, although microtrauma and a wound healing disorder, which develops a hypertrophic scar, is considered the most accepted mechanism. It shares certain common pathophysiological factors with other diseases, such as Dupuytren’s disease (retraction of palmar aponeuroses), Ledderhose disease (retraction of plantar aponeuroses) and Garrod’s nodes (knuckles of the fingers).

Symptoms and stages of Peyronie’s disease

The classic triad of Peyronie’s disease is penile induration, pain and curvature of the penis on erection. Secondarily, the patient may suffer erectile dysfunction and/or penile shortening.

It usually appears in outbreaks with three phases:
– Acute phase: strong inflammatory response. Pain and more or less palpable nodule.
– Subacute phase: replacement and substitution of healthy albuginea tissue by collagen fibers predominates. Curvature and deformity of the penis.
These two phases usually last from 6 to 18 months, and during them the curve is still in progression.
– Chronic phase: characterized by an acellular lesion with fibrous, inelastic tissue. Calcification and ossification phenomena may appear in the plaque. Pain usually disappears and the curvature stabilizes.

Diagnosis of Peyronie’s disease

During the manifestation of Peyronie’s disease it is advisable to evaluate, by the expert in Urology:
– The clinical manifestations, to orient the stage of the disease.
– The physical examination of the penis, locate the plaques and measure the length of the penis, which will influence the surgery.
– Erectile function and general sexual function.
– The Kelami test or self-photography with erect penis.

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Pharmacological treatment of Peyronie’s disease

Contrary to popular belief, Peyronie’s disease has low rates of spontaneous resolution, watchful waiting is rarely indicated and surgery will be necessary.
Medical or conservative treatment of Peyronie’s disease focuses on the early stage of the disease, when pain and progression of the curvature is present. Several options have been suggested including:
– oral pharmacotherapy (vitamin E, Potaba, carnitine, pentoxylifine, tamoxifen, colchicine, 5PDE inhibitors).
– iontophoresis
– intralesional injections (steroids, verapamil)
– other topical treatments (verapamil)
The results are contradictory and with a low level of evidence, making it difficult to provide recommendations in clinical practice. More recently, penile extenders and, in selected cases, intralesional collagenase injections have been used with good results, but at a very high cost and with no guarantee of success.

Surgical treatment of Peyronie’s disease

Surgery should be considered only when the disease has been stable for at least six months, if medical treatment has failed, and when the penis has a degree of incurvation or erectile dysfunction that prevents sexual intercourse.
It is divided into two broad categories: plasty or plication procedures and grafting procedures.
– Tunica albuginea plasty/plication: This is probably the standard surgical treatment. It is indicated in patients with curves less than 60° and with adequate penile length.
– Incision/plaque excision and grafting: Indicated in complex curves greater than 60° with hinge or hourglass effect and/or with a short penis.
– Penile prosthesis: With or without additional procedure (modeling, plication or grafting), it is recommended in patients with Peyronie’s disease and erectile dysfunction unresponsive to pharmacotherapy.