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.
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.