Peyronie’s Disease - Penile Disease
Short summary
42-year-old male patient complained of penile pain. Physical examination and imaging studies were compatible with the diagnosis of Peyronie's disease. Cialis 20 mg was given in order to perform "vascular exercise" that should prepare him for ESWL treatment to break the plaques when the condition stabilizes.
Patient's questions
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Can you confirm the diagnosis?
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Suggested therapy?
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What is the prognosis?
Medical Background
Sex: M, Age: 42 years
The symptoms began approximately one and a half years ago with the onset of penile pain but no stranguria. The patient reports dysuria and pollakiuria (2 – 3 times a night). Symptoms of the lower urinary tract during the patient’s youth were treated with an alphalithic medication, which was beneficial. The patient had a specialist urology visit. During the medical examination, a fibrous thickening of the intercavernous septum at the root of the penis was found. This was described as a painful hard nodule - Induratio Penis Plastica (I.P.P.); Didymus and epididymis were normal; prostate 1.5 vv, fibroadenomatous, smooth, not painful.
PSA 0.7.
An ultrasound carried out and, confirmed the diagnosis of I.P.P., showing a sub-albugineal hyper-echogenic formation in the penis with a maximum diameter of 1 cm, which suggested an induratio plaque. Following an injection of 10 mg of Caverjet, a prompt increase in the flow in both cavernous arteries and all areas was observed. The patient’s hemodynamic status was normal.
During the patient’s last specialist urology visits, curving of the penis was observed due to Peyronie’s disease that had not been stabilized yet. An examination revealed the presence of a calcified plaque in the right corpus cavernosum (tunica albuginea had a slight shadow cone); slight erectile deficit. The patient was advised against any intervention until the disease had stabilized. Meanwhile, vascular exercise was suggested as being useful. Therefore, the patient was advised to continue with his sexual activities and to use Cialis 10 mg.
The patient will be due to have a further urology follow-up to assess the appropriateness of treatment with E.S.W.L. when the condition has stabilized.
The patient confirms having taken Cialis 20 mg for several months in order to perform the vascular exercises that should prepare him for treatment to break down the plaques in his penis when the condition stabilizes. Currently, from the patient’s point of view, the results of this therapeutic approach are as follows:
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From one plaque of approximately 2 cm, there are now two plaques. Sexual desire is progressively decreasing. The curving of the penis is becoming increasingly accentuated with a narrowing of the neck of the penis.
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Taking the Cialis causes significant tachycardia for the patient.
Given the above, the patient has currently stopped taking the Cialis.
Medical opinion
Diagnosis
The presenting symptoms of Peyronie's disease include, in many patients, penile pain with erection; penile deformity, flaccid and erect; shortening with and without an erection; plaque or indurated areas in the penis; and in many patients, erectile dysfunction. On physical examination, virtually all patients have either a well-defined plaque or an area of induration palpable. The plaque is usually on the dorsal surface of the penis, intimately associated with the insertion of the septal fibers. Demonstration of calcification is easily accomplished with ultrasound examination. The calcified plaque will be shown as shadowed areas. Plain radiography is also equally effective in demonstrating calcification within the plaque.
Natural history & prognosis
In most cases of Peyronie's disease, there are two phases. The first is an active phase, which not uncommonly is associated with painful erections and changing deformity of the penis. It is followed by a quiescent secondary phase, which is characterized by stabilization of the deformity, with disappearance of painful erections, if they were present, and, in general, stability of the process. Spontaneous improvement in pain virtually always occurs as the inflammation resolves. Up to a third of patients, however, present with what appears to be sudden development of painless deformity.
It is said that Peyronie's disease totally resolves in some patients. This is probably a misstatement. Clearly, there are some patients who traumatize their penises and then develop curvature secondary to the inflammatory process and its associated loss of compliance. In some, the inflammation resolves without seeming to enter into the phase of smoldering inflammation that ends in disordered healing and scar formation. Thus, the process is resolved. Semantically, however, these patients probably cannot be said to have resolved Peyronie's disease; rather, the trauma has resolved without the development of Peyronie's disease. In Mulhall's study of men diagnosed promptly after development of Peyronie's disease symptoms and findings who elected to avoid all therapy, few were found to show much improvement in curvature during a period of 12 months (O'Brien et al, 2004). Obviously this study could be faulted for not having observed the patients longer, but the point is made that "spontaneous resolution" of Peyronie's disease is an infrequent occurrence.
Treatment options
Vitamin E- should be given in divided doses of 800 to 1000 units a day. Treatment should be continued for no longer than 3 to 6 months, and patients must be cautioned about the possibility of anticoagulative side effects.
Colchicine- Patients were in the early phase of disease can receive Colchicine at a dose of 0.6 mg three times a day. Diminished plaque size and improved penile curvature were reported in approximately 50% of the patients which received this treatment.
ESWL- Extracorporeal shockwave therapy has been proposed as a treatment of Peyronie's disease since 1989 .There has been little standardization with regard to the treatment (varying dosages and machines). There are no controlled trials, but one case-controlled trial reported favorable results. No studies examining the efficacy of extracorporeal shockwave lithotripsy in the treatment of Peyronie's disease have been convened in the United States.
Surgery- For a patient to be a surgical candidate, he must have stable and mature disease. In review, the signs of disease stability (quiescence) include resolution of pain and stabilization of curvature or other deformity. Likewise, the experienced examiner will recognize the palpatory findings of a mature plaque. Most investigators arbitrarily impose a 12- to 18-month period from onset of disease. Most suggest a period of at least 6 months of disease stability (i.e., stable deformity). Indications for surgery include deformity that precludes intercourse and erectile dysfunction .
The surgeon must consider all options of surgical therapy. Plication and corporoplasty techniques can be lumped under those operations that shorten the less involved side, and the application of those techniques is preferential in many patients. Procedures that incise or excise the plaque require the use of graft materials, and a number of graft materials have been successfully employed.
Overall, plication or corporoplasty techniques seem to preserve the patient's erectile function more effectively; however, excellent results can be achieved with incision and grafting techniques. The use of prosthesis for all Peyronie's patients is condemned.
In view of this data the patient should be offered one of the medical treatments until the disease stabilizes. Surgical treatment should be considered at that time only if he will have a deformity that will preclude him from intercourse.
