The patient’s unmet needs (PUNs)
A 35-year-old man attends the surgery. A year or two ago he became aware of a tender lump in his penis that slowly resolved. Since then he has noticed a marked bend in his penis when he has an erection. As yet, this is not interfering with his sex life, but he’s concerned that it might if it deteriorates.
He has already, via Google, correctly self-diagnosed, and wants to know what might have caused the problem and whether it has any other implications for his health. He’s also keen to know about the merits of any treatment and whether surgery might be necessary.
The doctor’s educational needs (DENs)
What causes Peyronie’s disease? Does it have any association with other medical conditions?
Peyronie’s disease is a condition of unknown cause that most typically affects middle-aged men. The peak incidence is around the age of 50 years, although it is occasionally seen in men as young as 20. It is characterised by the development of fibrotic plaques within the tunica albuginea of the penis. Clinically there is a palpable lump associated with penile deformity, painful erections and occasionally erectile dysfunction (ED).
Although the aetiology is unknown, it may relate to minor trauma causing the development of a small haematoma under the tunica albuginea that initiates an exaggerated fibrotic reaction resulting in the development of the fibrotic plaque.
It is more common in men with vascular risk factors such as diabetes and hypertension. Men with Peyronie’s disease are also more likely to suffer from Dupuytren’s contractures.
What is the natural history?
Peyronie’s disease typically progresses over an 18- to 24-month period. From the initial appearance, the size of the plaque will increase and this is accompanied by progressive penile deformity. During this early ‘active’ phase erections are typically painful. Afterwards the condition typically becomes stable, with a diminution in the pain and stabilisation of the penile deformity.
The deformity is most usually a dorsal angulation of the penis that may reach 90° or more in severe cases. There may be ‘waisting’ of the penile shaft and there is typically some loss of penile length.
Does it lead to ED?
Peyronie’s disease is commonly associated with ED. There are many possible reasons for this. For example, ED may just be a reflection of the association of Peyronie’s disease with vascular disease.
However, ED can occur even in the absence of vascular disease and this is probably due to abnormal leakage of blood from the penis adjacent to the fibrous plaque. This classically results in a relatively weak erection distal to the fibrotic plaque such that the base of the penis is hard but the tip of the penis is less so. Additionally, Peyronie’s disease may cause ED because of the psychological effect of the deformity.
If ED does develop, how does the underlying Peyronie’s affect the management?
In the assessment of Peyronie’s disease it is important to ascertain the degree of ED. In particular, it is important to identify from the patient which issue is causing the greater problem. For some men restoration of rigid erections is the appropriate way forward if the deformity is relatively minor. If the erections are relatively firm but the deformity is significant then surgical treatment will be required. It is certainly not possible to assess the severity of a penile deformity without getting a fully rigid erection, so in men who present with Peyronie’s disease and ED it is usual to try to restore the quality of the erections in the first instance.
Is medical treatment of any value?
Medical therapy cannot currently be considered to be an effective treatment either in the early ‘active’ phase or in the later ‘stable’ phase. A whole range of pills, pastes and injections have been tried but none has been conclusively demonstrated to provide benefit. There are ongoing phase 3 trials to explore the potential for injections of collagenase into the fibrotic plaque and these may lead to the availability of a licensed medication in the future.
If ED is the predominant problem, then therapy with a PDE5 inhibitor is indicated. The BNF advises caution in relation to the use of PDE5 inhibitors in patients with Peyronie’s disease, but this simply reflects the fact that Peyronie’s patients were excluded from the registration trials for these drugs. There is extensive experience of their use in such patients and the side-effect profile is the same as in patients without Peyronie’s disease.
When should the GP consider asking for a surgical opinion?
Surgery is indicated in Peyronie’s disease when there is a deformity that prevents intercourse, or that makes it difficult. Typically the deformity is in the dorsal direction (towards the abdomen) and angles of deformity greater than 30-40° usually need surgery. Patients with deformities less severe than this are often able to maintain an active sex life without surgery.
What information should the patient be given prior to considering surgery?
The most important messages for the patient are that the condition should be stable before surgery is considered and that surgery should only be undertaken when the penile deformity prevents sexual intercourse, or makes it painful for either the patient or his partner. Using these criteria, only around 25-33% of men with Peyronie’s disease actually come to surgery.
The most common surgical procedure is a Nesbit’s procedure, which is a plication of the penis on the convex side of the deformity. This will inevitably produce some shortening of the penis. The greater the deformity, the greater the degree of penile shortening produced by the surgery. Since Peyronie’s disease is already associated with shrinkage in the size of the erect penis, the extra loss of length associated with surgery can make the penile size considerably less than the pre-morbid erection. Surgery for Peyronie’s disease can also exacerbate the ED and it is usual to quote a risk of around 5%.
An alternative procedure, which aims to maintain penile length, is the so-called Lue procedure, which involves grafting the concavity of the penis, either with saphenous vein harvested from the thigh, or with a biological mesh. Unfortunately, penile length is commonly not maintained, while the risk of ED is around 30-35%. Since the deformity is typically in the dorsal erection there is the added risk of damage to the dorsal neurovascular bundle with the associated risk of numbness of the penis. This complication is rare and only occurs in around 1-2% of cases.
• Peyronie’s disease is associated with vascular disease and with Dupuytren’s contracture
• The peak incidence is around 50 years of age, although cases can be seen in men as young as 20
• The characteristic clinical features are a lump within the penis, penile deformity, erectile dysfunction and pain upon erection
• The natural history of the condition is that the deformity progresses over 18 to 24 months before stabilising
• Peyronie’s disease is commonly associated with ED, partly because of its link with vascular disease, although ED can occur in the absence of vascular disease
• There is no treatment that has been shown in placebo-controlled randomised trials to be effective in the acute phase. It is important that the patient maintains sexual function if possible
• If in the acute phase there is co-existent ED, use of a PDE5 inhibitor is appropriate
• When the disease has stabilised, surgery is indicated if the deformity is severe enough to make sexual intercourse impossible or painful for either partner
• The commonest form of surgery is Nesbit’s procedure. The chief side-effects of this are penile shortening and rarely ED
Mr Ian Eardley is a consultant urologist at St James University Hospital, Leeds