PEYRONIE’S DISEASE

What is it?

It is a benign inflammatory disease of the penis. It produces a fibrosis in the penis with the appearance of a plaque and/or deviation of the penis that will condition the sexual life of the person. It can be devastating, leaving the penis totally dysfunctional. There are different degrees of affection of the penis: mild, moderate, severe or very severe. When the disease is mild, sexual activity can still be maintained, but as the penis becomes more fibrous, it becomes more and more deviated, at the same time it shortens and can end up with a very fibrous, sclerosed, poorly distensible penis that will make it impossible even to have sexual intercourse.

Cause

The cause of Peyronie’s disease is unknown. The most accepted theory is the succession of microtraumas in the tunica albuginea. These traumas occur during sexual intercourse or even during masturbation. Secondary to them, an inflammatory process would be activated in the penis that would end up triggering the appearance of fibrosis in the penis.

It affects men of all ages, although it is more frequent between 40 and 70 years of age. It can affect 5-15% of the population or more, it is a disease little reported by the patient.

Symptoms

Two phases of the disease are distinguished.

• Acute phase: inflammatory reaction of unknown cause that provokes the appearance of fibrosis. It is usually accompanied by pain with erections and the patient observes a progressive deviation or deformation. It usually lasts between 6-12 months.
• Chronic phase: the inflammation is reduced and the palpable plaque and/or deviation remains. The patient no longer feels pain with erection and palpation. The plaque is usually palpable, and in some cases may calcify and even ossify. It may be associated with erectile dysfunction to varying degrees. And it always causes a significant decrease in penile size.

It is essential to see a specialist as soon as any of the symptoms described in the acute phase are noticed, since starting treatment at this stage can stop the progression of the disease and thus avoid more serious sequelae and more aggressive treatments.

Disgnosis

When a patient consults for penile curvature or penile deviation, a clinical interview should be performed where the patient will be questioned about his medical history. It is important to know what other cardiovascular risk factors the patient has in order to predict erectile function or sexual potency, to know the previous surgeries and medications the patient has received.

Next, we will ask about the time of evolution, degree of deviation, erectile function or ability to have an erection and maintain sexual intercourse. It is highly recommended to evaluate Peyronie’s disease with a validated questionnaire. We use the PDQ, as well as the IIEF to assess the patient’s sexual function.

Afterwards, we explore the patient to see if he has pain on palpation of the penis, to detect the consistency and extension of the plaque and to see what his penis looks like.

As complementary tests we routinely perform a blood test to assess the patient’s overall cardiovascular risk factors. We evaluate the lymphocyte/neutrophil ratio, since, in our experience, it is a good indicator of the stage of the disease: acute or chronic.

Finally, we perform a penile ultrasound and a dynamic vascular study of the penis. This test provides us with a great deal of morphological information on how the plaque is: size, location, degree of calcification, how much it penetrates, as well as informing us of its relationship with the penile arteries. Thus, in case of surgery, we know the location of the arteries and it allows us to design a better surgical plan for our patients. It also allows us to assess the vascular and erectile status of the patient. Associated with this, we perform a Kelami test or photographs of the penis in erection to see exactly the deviation and other important anatomical considerations that may condition the patient’s treatment.

Conservative treatments:

It is usually the first therapeutic step in the disease, especially in incipient disease and in mild curvatures. Different types are included here:

• Oral treatments: have not been shown in any clinical trial to work, so we do not generally recommend them.
• Penile extenders: have been shown to decrease curvature and prevent associated penile length loss on their own. They are especially useful in the acute phase of the disease, when fibrosis has begun to establish, to prevent fibrosis from causing further curvature or shortening of the penis. They should be used for a minimum of 6 hours a day and never during sleep, since during this period the organism has spontaneous erections which are very beneficial for the penis and which would be prevented by their use.
• Intralesional injections: verapamil and collagenase from Clostridium Histolyticum (Xiapex®). In both cases it is a matter of introducing a drug into the fibrous plaque that causes a change in it.
  – In the case of verapamil, it is a calcium antagonist drug that has an anti-inflammatory effect, being useful in the active phase of the disease. Its periodic injection (the standard treatment consists of four injections one week apart) together with the constant use of the penile extender allows, in many cases, to reduce inflammation and, therefore, to stop the progression of the disease. In some cases, it can even improve the curvature.
  – In the case of Collagenase from Clostridium Histolyticum, or Xiapex®, is an enzyme that dissolves the collagen of which the plaque is composed, so its injection, together with traction maneuvers and continued use of the extensor, improves the degree of curvature. It is the only drug approved by the FDA and the EMEA for the treatment of Peyronie’s disease. In this case, it is a therapy indicated for stable stage disease, provided that the plaque is palpable and when it is not heavily calcified. It has potentially serious complications such as fracture of the plaque, so its administration must be performed by andrologists who have received specific training.
  There are different protocols for administering the drug, but generally speaking it should consist of one cycle with 2 injections and re-evaluate whether to continue with another cycle in 6 weeks. Unfortunately the laboratory that marketed it has withdrawn the indication of this drug in Europe for economic reasons.
• Shock waves: Also used for erectile dysfunction, this is a treatment that causes a remodeling of the fibrotic plaque and an increase in vascularization in the scar area, increasing the presence of cells capable of destroying the plaque. Although there is no evidence that it improves curvature, it is useful in reducing the pain experienced during the acute phase of the disease.

Surgical treatment:

Any surgical treatment aims to definitively resolve the penile curvature and/or deformity and, if applicable, the secondary or concomitant erectile dysfunction. Therefore, surgical solutions are only considered in the chronic or stable phase of the disease. There are different types of surgery:

• Plicatures: this group includes a series of surgical procedures whose essential foundation is the same: stitches on the opposite side of the curvature in order to straighten the penis. It is the simplest technique and is used in curvatures that are not very pronounced (<60º). In addition to its simplicity, it has the advantage that postoperative erectile dysfunction is rare, but it can lead to shortening of the penis by 2-3 cm.
• Patching: consists of the surgical removal or cutting of the plaque and the placement of a patch in its place to cover the space occupied by the plaque. The patches are tissues that can have different origins and compositions, being the bovine pericardium one of the most used. This technique avoids the loss of penile length, although erectile dysfunction may appear in up to 25% of cases. This technique is used in complex curvatures or curvatures >60º.
• Implantation of penile prosthesis: this procedure is reserved for patients who present severe erectile dysfunction before surgery or who, given their previous risk factors and the nature of the procedure they are going to undergo, are expected to present it with a high probability after surgery. Thus, in a single act, we proceed to section and, if necessary, place a patch in the defect that occupied the plate, having the prosthesis placed inside. There is practically no shortening of the penis but it has the possible complications associated with the placement of the prosthesis (see section “Penile prosthesis”).

PENILE PROSTHESIS

The penile prosthesis is a device that is implanted inside the penis in order to give it the ability to have rigidity and to be able to have sexual intercourse with penetration.

It consists of two cylinders that are inserted inside the corpora cavernosa and act as a substitute for these to achieve a state of erection.

A surgical intervention is necessary for its placement and, because once implanted it is not possible to resume other treatments, it is the last step among the therapeutic options for erectile dysfunction. However, it presents the best satisfaction rates among all erectile dysfunction treatments.

Its implementation by expert centers and surgeons has been shown to reduce complications associated with the procedure. Our group is recognized by the Ministry of Health as one of the two groups accredited in Spain to perform these procedures.

There are different types of prostheses currently available:

1. Malleable prostheses: they are composed of two silicone cylinders with a rigid but malleable skeleton (usually silver) inside. Each cylinder is inserted into the corpora cavernosa after making an incision in them. In this way, the penis is left with the necessary consistency to carry out penetration. The disadvantage of these prostheses is that the penis remains constantly rigid and can only change its position. However, they have two great advantages: they are cheaper and simpler to use, since it is not necessary to activate and deactivate them. The postoperative period and recovery are also usually faster.
2. Hydraulic prostheses: In these prostheses the cylinders are hollow and, by means of a hydraulic mechanism, they are filled with serum to achieve erection. Depending on the complexity of the mechanism, they are divided into:
   • Two-component: The cylinders are joined with a pump that will be housed in the scrotum. In this way, when the patient presses the pump, the serum will pass into the inflatable cylinders, thus achieving rigidity. To deflate the prosthesis, it is enough to press on the corpora cavernosa until it is completely emptied.
   • Three-component: they are the most functional. They resemble natural erection and achieve an almost physiological state of flaccidity. In addition to the cylinders, they consist of a pump (placed in the scrotum) and a reservoir (behind the pubis) connected to each other. This pump has two buttons for emptying and filling the cylinders. During the emptying phase, the serum remains in the reservoir. They are the most economical.

There are several ways to place the prosthesis. The incision can be made subpubic (behind the pubis), subcoronal (under the glans) or penoscrotal (between the base of the penis and the scrotum). The choice depends on the surgeon and the type of prosthesis.

As in other interventions, the placement of a prosthesis can present complications such as urinary retention or the appearance of hematomas or edema, which will not entail long-term problems. However, the most feared complication is infection of the device, which can lead to its removal. For this reason, infection prevention measures are very strict and make infection infrequent, affecting only 1-8% of cases. The mechanical failure rate at 5 years is approximately 10%.

One of the most frequent questions asked by patients who are considering prosthesis implantation is whether sexual desire, orgasm sensation and ejaculation may be affected. Prosthesis implantation surgery does not interfere with any of these three aspects. Also, the patient should know that the length of the penis is not increased, in fact in some cases a shortening of 1-2 cm is observed.

Satisfaction after placement of a penile prosthesis is among the highest of all the therapies described for erectile dysfunction. Patients with three-component hydraulic prostheses achieve the highest degree of satisfaction. Some studies indicate that 92.5% of the cases maintained at least 1.7 weekly relations at 5 years after surgery.