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Peyronie's disease

Case history

Adam is 48 and has been happily married for 25 years. He has two children. He presents to the surgery because he is experiencing problems having intercourse. His penis has always curved slightly to the left but the problem has worsened so much that over the last six months erection

is painful and intercourse is now physically impossible.

Dr Tanvir Jamil discusses.

Where is the anatomical defect that causes the penis to bend in Peyronie's disease?

The penis is composed of two columns of erectile tissue (corpora cavernosa), the corpus spongiosum which contains the urethra, and the sheath that surrounds the erectile tissue (tunica albuginea). In Peyronie's disease, dense, fibrous scar tissue (plaque) forms in the tunica albuginea.

How common is this problem?

Peyronie's disease occurs in about

1 per cent of men. It is most common between the ages of 45 and 60, but it also occurs in young and elderly men. Prevalence may be higher because of reluctance to seek medical attention.

What are the commonest causes of Peyronie's?

Cases that develop suddenly are often caused by trauma to the penis (for example injury or extremely vigorous sexual activity). Invasive penile procedures are also known to cause Peyronie's and these include urethral catheterisation, cystoscopy, and transurethral resection of the prostate.

Cases of Peyronie's that develop over time may be caused by an inherited abnormality of human leukocyte antigen B7 (HLA-B7), suggesting a genetic link. Also, Peyronie's occurs more frequently in men with family members who have the condition or a connective tissue disorder (such as systemic lupus erythematosus). About 30 per cent of patients also develop hardened tissue in other parts of the body (such as Dupuytren's contracture).

Microscopic examination of affected penile tissue is consistent with cases of vasculitis, suggesting the condition may have a vascular cause. Diabetes is also considered a risk factor. Very rarely the problem can be caused by propranolol. Peyronie's has also been associated with vitamin E deficiency.

Apart from a 'bent' penis what are the other signs/symptoms?

Peyronie's disease may be mild or severe, and may develop rapidly or over time. Symptoms include:

·hardened tissue (plaque) in the penis

·pain during erection

·curve in the penis during erection

·distortion of the penis (such as an hour-glass appearance)

·the penis may become rigid up to the area of the scar and remain flaccid past that point

·erectile dysfunction

·plaques can occur anywhere along the penis but most often develop on the top of the shaft, causing the penis to bend upward during erection; if plaque develops on the top and the bottom, indentations and shortening may occur.

What are the diagnostic pointers?

Diagnosis disease is usually made on history alone. Do remember to ask about any circumstances/surgery surrounding the onset of symptoms. The hardened tissue caused by the disorder is often palpable. Surgeons will often inject the penis so that it can be examined while erect.

In general practice you could ask the patient to bring a digital or Polaroid photograph of the deformity with him to the consulting room. A calcified plaque can also be identified using X-ray or ultrasound.

What can I tell Adam about the clinical course of his problem?

The clinical course of Peyronie's disease is variable. In up to 50 per cent cases there is spontaneous resolution of the disease process.

A review of 97 patients published in The Journal of Urology in 1990 (Vol 144) found that 40 per cent of patients felt the disease worsened over time and 15 per cent thought it improved. The disease process takes some 12 months to stabilise and it is during this period that it may resolve without treatment.

What are the treatment options?

Watchful waiting is certainly an option as half of all men may get better by themselves. A lot depends on pain and interference with intercourse. Adam has severe symptoms and will need referral to a urologist. The goal of treatment is to reduce pain and maintain sexual function.

Reconstructive surgery has proven to be the only therapy that corrects the curvature and eliminates the pain on a consistent basis. However, because Peyronie's may resolve on its own, it may be worth waiting at least six to 12 months before choosing this option.

Non-surgical treatment is implemented within six months of the onset of symptoms and before the plaque has calcified. Vitamin E supplementation and para-aminobenzoate tablets (B-complex substance) may be taken for several months. However, there is little efficacy and supporting evidence at present for either of these methods.

Intralesional injections of verapamil, collagenase, interferon and steroids may also be attempted. It is not yet clear which of these substances works best, although collagenase and verapamil appear the most promising at this time. Radiation and ultrasound treatments have been used in patients with significant amounts of pain.

While these treatments are successful in relieving the pain they do little to correct the curvature.

What does surgery involve?

Surgical treatment may be used in severe, persistent cases of Peyronie's that have not responded to non-surgical treatment.

Procedures involve excision of hardened tissue and skin graft, the removal or pinching (plication) of tissue opposite the plaque to reduce curvature (Nesbit procedure), a penile implant, or a combination of these.

In many of these procedures a circumcision is typically performed at the same time in uncircumcised men.

The removal of plaque requires a skin graft and may result in a partial loss of erectile function (such as less rigidity). The Nesbit procedure reduces the length of the erect penis.

Penile implants are inserted into the corpora cavernosa to increase rigidity. This procedure may be combined with incisions and skin grafts, or plication to effectively reduce curvature.

Most surgical procedures are done on an outpatient basis or as a short 23-hour hospital stay. Surgery can be performed with a general or regional anaesthetic.

Are there any special precautions to take after surgery?

During the recovery period, patients are prescribed medication that prevents them from having an erection and are advised to avoid sexual activity. Antibiotics are also prescribed to reduce the risk of infection.

Tanvir Jamil is a GP in Burnham, Buckinghamshire

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