MULTIPLE TUNICA ALBUGINEA PLICATION FOR PEYRONIES DISEASE

A 50 year old gentleman presented to us with penile curvature.He was having problem with intercourse because of the penile deformity.His penograph( curvature recording on a simple paper by drawing the outline with pen on paper) showed curvature up to 60 degrees.

He was a diabetic.He had pain in penis which aggravated after the coitus.We started him on a combination of Colchicine 0.6 mg twice a day and tamoxifen .the pain gradually subsided but the curvature remained .

We finally gave him the option of penile curvature correction with the Tunica Albuginea Plication surgery.

The surgery was done under spinal anaesthesia.The penis was degloved.After the degloving the artificial erection was induced by injecting normal saline into one of the corporae.

The erection was maintained by a tourniquet at the base of the penis.We took multiple plicating sutures on the opposite side of the curvature till the curvature was corrected.

The whole surgery took around 45 minutes.The degloved skin was reapproximated.The patient was kept in the hospital for 2 days and then discharged.We kept an indwelling catheter for 24 hours.As a precaution we start all patients undergoing surgery on alfuzosin and ketoconazole 3 days prior to the surgery.The alfuzosin prevents any retention  and ketoconazole helps in preventing the vascular engorgement leading to hematoma.

Review of the literature:

Peyronie’s disease is characterized by a plaque, or hard lump, that forms within the penis. The plaque, a flat plate of scar tissue, develops in the tunica albuginea part of the penis, which is a covering of the erectile tissues. This condition was described by Fallopius in 1561 and popularized by Gigot de la peyronie in 1743.

The average age of onset of the disease is 53 years and its prevalence is 3.2% in sexually active men.

The trauma is believed to be central reason behind the Peyronies disease.The trauma to the penis causes buckling of the area of the attachment of the central septum with the tunica albugenia causing rupture of the blood vessesls. The hematoma is accompanied by the accumulation of the inflammatory mediators. The Peyronies disease goes through three stages:

Step 1: Inflammatory exudates between cavernosa and albuginea consisting of Lymphocytes macrophages, plasma cells which secrete Active cytokines TGF ß1 .The TGF ß1 increases collagen synthesis, proteoglycans, fibronectin

Step 2: Fibrous infiltration of the sub tunical layer

Step 3: Extensive localized fibrosis and ossification

The plaque causes chordee and venous leak which causes erectile dysfunction. iNOS deficiency is also supposed to be cause behind erectile dysfunction.

MEDICATIONS:

The goal of therapy :

1) To restore and maintain the ability to have intercourse.

2) To decrease the pain

3) To allay the fears in mind of the patient and re-educate him about the disease.

4) To restore cosmetic appearance

Experts usually recommend surgery only in long-term cases in which the disease is stabilized and the deformity prevents intercourse.

Medical Treatments

Various medications like Vit E 400 mgs three times a day for 3 months, Cochicine 0.5 mg 2 bd for 3 months or Tamoxifen 20 mg BD for 3 months.The placebo controlled trials have not shown efficacy of the medications but colchicines there are no placebo studies. It seems to be effective.

Three surgical procedures for Peyronie’s disease is done for curvature more than 45 degrees in angle making sexual intercourse difficult.Various procedures have been followed like placation(problem of further shortening penis),incision or excision and grafting(tunica vaginalis or saphenous vein graft) or implantation of penile prosthesis.

If the implant alone does not straighten the penis, implantation is combined with one of the other two surgical procedures.