Peyronies disease

Peyronie’s Disease

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.

Presentation:
Cases of Peyronie’s disease range from mild to severe. Symptoms may develop slowly or appear overnight. In severe cases, the hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection. In many cases, the pain decreases over time, but the chordee may remain a problem, making sexual intercourse difficult. The sexual problems that result can disrupt a couple’s physical and emotional relationship and can lower a man’s self-esteem. Natural history of the disease goes through an active phase of painful erection and changing plaque configuration followed by a secondary phase of painless deformity and progressive calcification. The disease is progressive in 30-40% cases and stable in 40-50% but the spontaneous resolution is rare.



About 30 percent of men with Peyronie’s disease develop other fibrotic disorders as Dupuytren’s contracture of the hand. Familial association,diabetes and urethral instrumentation are other causes for Peyronies disease.

Pathophysiology:

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.



Diagnosis:
Doctors can usually diagnose Peyronie’s disease based on a physical examination. The plaque can be felt when the penis is limp. The erection may be induced by injecting intracavernosal papavarine or bimix and an Doppler ultrasound scan of the penis to pinpoint the location and calcification of the plaque and concomitant venous leak may be done. A photograph may be taken to document the angle of chordee prior to surgical treatment.

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 trioals have not shown efficacy of the medications but colchicines there are no placebo studies. It seems to be effective.

Researchers have also tried injecting chemical agents such as verapamil, collagenase, steroids, and interferon alpha-2b directly into the plaques. Verapamil and interferon alpha-2b seem to diminish curvature of the penis. The other injectable agent, collagenase, is undergoing clinical trial and results are not yet available. Steroids like triamcilone have caused loss and atrophy of the local tissues and weakening of the tunica. The surgical planes also become difficult after steroid injection.
The intralesional injections are given with 24 G needle making multiple passes through the plaque.There is a possibility that the multiple passes make the plaque weak by mechanical disruption.
Surgery
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.