Peyronie Disease and Penile Fractures

CHAPTER 24 Peyronie Disease and Penile Fractures

Stephen W. Leslie, MD, FACS

PEYRONIE DISEASE

What is Peyronie disease?

Peyronie disease is a fibrotic disorder of the penis in which a tough fibrous plaque forms in the tunica albuginea. These plaques may become calcified. Peyronie disease is often but not always associated with penile pain and progressive deformity, either curvature or narrowing, during the “acute” phase. The “chronic” phase involves resolution of pain with stabilization of the deformity.

What is the incidence of Peyronie disease?

Approximately 9% of the adult male population and increasing.

Describe the pathophysiology of Peyronie disease.

While the pathophysiology of the disorder is not entirely clear, it is thought to be due to abnormal wound healing in men with some minimal level of penile trauma or injury, most often from sexual activity.

Is Peyronie disease genetic?

There appears to be a genetic component as it tends to occur more frequently in relatives with the condition.

Peyronie disease is related to what other conditions associated with abnormal wound healing?

It is associated with several other conditions related to abnormal wound healing such as Dupuytren contractures and tympanosclerosis.

What percentage of men with Peyronie also have depression?

Approximately 50%.

How often is ED associated with Peyronie disease?

Approximately 30% of the time.

What is the natural history of Peyronie? How many patients will improve spontaneously, remain stable, or worsen over time?

Approximately 12% to 13% will improve spontaneously, 40% to 50% will tend to remain stable, and the remainder will tend to get worse.

What is the specific critical cytokine involved in Peyronie disease, where is it normally found, and how does it work?

Transforming growth factor-β1 (TGF-β1). It is an activator of collagen synthesis released by neutrophils and macrophages during wound healing.

What is the differential diagnosis of Peyronie? (Name at least 5)

• Penile fracture.

• Sarcoma (very rare).

• Fracture of the penile septum—with or without hematoma formation.

• Congenital curvature.

• Dorsal vein thrombosis.

• Cavernosal fibrosis.

• Leukemic infiltrate.

Name 3 oral agents that were used for Peyronie but are no longer recommended by most experts.

Vitamin E, potaba, tamoxifen, and colchicine are no longer recommended. Vitamin E and tamoxifen do not appear to be effective, while potaba and colchicine have significant side effects with little or no benefit consistently reported.

Name at least 5 other promising medical treatments for Peyronie other than intralesional injections and surgery.

Promising therapies currently include

• Arginine

• Carnitine

• Trental

• Medical-grade penile extenders such as Fastsize (www.fastsize.com)

• PDE5 inhibitors (Viagra, Levitra, and Cialis)

• Iontophoresis (with verapamil and dexamethasone)

Name 3 intralesional agents that appear to be potentially useful for Peyronie disease.

1. Verapamil

2. Interferon

3. Clostridial collagenase

Which intralesional agent appears to be the most effective and what is the dosing regimen?

Verapamil has shown the most benefit. Typically, verapamil is injected in 10-mg doses twice a week for 12 weeks. If no benefit is seen after 6 weeks, the dose is increased to 20 mg.

How does Verapamil work in Peyronie?

Verapamil theoretically works by inhibiting the exocytosis of collagen, fibronectin, and glycosaminoglycans. This effectively interferes with collagen production and ultimately results in reduced scar formation.

What is the role of oral verapamil in the treatment of Peyronie disease?

Currently, oral verapamil plays no role in the treatment of Peyronie disease. The reason is that the local concentration of verapamil necessary to inhibit fibroblast activity is many times greater than any safe level potentially possible with oral therapy.

What is the optimal role of intralesional or oral steroids in this disorder?

Steroids are not effective in this disease.

What is the benefit of shock wave lithotripsy and radiation therapy in Peyronie?

Shock wave lithotripsy has not been effective. Low-dose radiation therapy has shown some benefit in relieving pain when used early in the disease, but it has no effect on the outcome.

How effective is verapamil 15% topical gel for Peyronie?