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Internal Medicine

Peyronie’s disease

Introduction

Induratio penis plastica (IPP) or Peyronie’s disease is an acquired benign connective tissue disorder without known systemic sequelae with presenting symptoms that include the presence of a plaque/induration of the penile shaft, penile curvature or deformity during erection, penile pain, and erectile dysfunction.

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Anatomy of peyronie’s disease | Love, C., Katz, D., Chung, E., & Shoshany, O. (2017). Peyronie’s disease – Watch out for the bend. Australian Family Physician, 46, 655–659. Retrieved from http://www.racgp.org.au/afp/2017/september/peyronies-disease/

History

François Gigot de la Peyronie was the first to report a clinical series on penile curvature in 1743. More than 250 years later, the exact aetiology and mechanism of the well-recognized symptom complex still remain unclear.

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François Gigot de la Peyronie (1678 – 1747) was a French surgeon eponymously associated with the condition, Peyronie’s disease.

Aetiology

Risk factors:

  • Acute penile trauma/microtrauma (8-9% cases)
  • Penile/genital trauma from urologic procedures (e.g. Foley catheterization, cystoscopy, transurethral resection of the prostate, radical prostatectomy)
  • History of nongonococcal urethritis
  • History of inflammatory diseases or fibromatous lesions of the genital tract in sexual partner(s)
  • Smoking
  • Hypogonadism

Pathophysiology

Anatomy:

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Cross section of the penis | Tsambarlis, P., & Levine, L. A. (2019). Nonsurgical management of Peyronie’s disease. Nature Reviews Urology, 16(3), 172–186. https://doi.org/10.1038/s41585-018-0117-7

Peyronie’s disease (PD) is caused by chronic inflammation (progressive fibrosis) of the tunica albuginea (CITA) of the corpora cavernosa resulting in curvature or other deformities of the erect penis.

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Proposed pathogenesis of Peyronie’s disease | Tsambarlis, P., & Levine, L. A. (2019). Nonsurgical management of Peyronie’s disease. Nature Reviews Urology, 16(3), 172–186. https://doi.org/10.1038/s41585-018-0117-7

Clinical features

Variable presentation:

  • Penile curvature (80-91% cases)
  • Penile shortening (14-60% cases)
  • Erectile dysfunction (ED) (15-24% cases)
  • Nodule (15% cases)
  • Penile pain (3-22% cases)

Diagnosis

Clinical assessment

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Diagnosis of curvature of the penis on the apparatus AMVL-01 (apparatus vacuum-laser therapeutic urological) in patient A., 54 years old, with Peyronie’s disease. Local negative pressure with maximum discharge in the flask affects the baro-and thermoreceptors of the skin of the penis, enhances microcirculation in its vessels. An insignificant curvature (angle of curvature – 30 degrees) of the penis | Love, C., Katz, D., Chung, E., & Shoshany, O. (2017). Peyronie’s disease – Watch out for the bend. Australian Family Physician, 46, 655–659. Retrieved from http://www.racgp.org.au/afp/2017/september/peyronies-disease/

Imaging

Ultrasound (USG):

Ultrasound (USG) dopplerography:

X-ray:

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Projectional radiography (“X-ray”), penetrating the soft parts of the penis, showing radiopaque images that correspond to calcifications in the corpora cavernosa (arrows). | Maitê Aline Vieira Fernandes, Luis Ronan Marquez, Ferreira de Souza and Luciano Pousa Cartafina3 – (2018). “Ultrasound evaluation of the penis”. Radiologia Brasileira 51 (4): 257–261. DOI:10.1590/0100-3984.2016.0152. ISSN 1678-7099.CC-BY license, CC BY 4.0, https://commons.wikimedia.org/w/index.php?curid=77309499

Management

Systemic (oral):

  • Procarbazine (cytotoxic alkylating agent, anti-inflammatory)
  • Vitamin E (antioxidant, inhibits collagen deposition)
  • Potaba (↓ tissue serotonin levels and scarring)
  • Colchicine (inhibits collagen synthesis)
  • Tamoxifen (Modulation of TGF-β1 secretion by fibroblasts → ↓ fibrosis)
  • Propinyl/acetyl-L-carnitine (inhibits free radicals: ↓Ca2+ in endothelial cells)
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Mechanisms of action of oral therapies for Peyronie’s disease | Tsambarlis, P., & Levine, L. A. (2019). Nonsurgical management of Peyronie’s disease. Nature Reviews Urology, 16(3), 172–186. https://doi.org/10.1038/s41585-018-0117-7

Intralesional:

  • Verapamil (Ca2+ channel antagonist → ↓ collagen synthesis and/or ↑ collagenase activity)
  • Collagenase Clostridium histolyticum (Clostridial collagenase)
  • Interferons: IFNα2a, IFNα2b (↓ fibroblast proliferation → ↓ collagen synthesis)
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Mechanisms of action for topical and intralesional therapies for Peyronie’s disease. | Tsambarlis, P., & Levine, L. A. (2019). Nonsurgical management of Peyronie’s disease. Nature Reviews Urology, 16(3), 172–186. https://doi.org/10.1038/s41585-018-0117-7
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Demonstration of IFN-α-2b injected directly into a Peyronie’s disease plaque. | Lacy II, G. L., Adams, D. M., & Hellstrom, W. J. G. (2002). Intralesional interferon-alpha-2b for the treatment of Peyronie’s disease. International Journal Of Impotence Research, 14, 336. Retrieved from https://doi.org/10.1038/sj.ijir.3900867

Other non-invasive techniques:

  • Extracorporeal shock wave therapy (ESWT) (direct damage to plaque and/or ↑ vascularity 2/2 heat → plaque lysis)
  • Penile traction therapy (mechanical straightening and/or lengthening)
  • Vacuum erection device therapy (mechanical straightening and/or lengthening)
  • Hyperthermia therapy (modulation of heat shock proteins)

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Surgical management:

  • Tunical albugineal plication (tunical shortening: opposite side of plaque)
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Penile plication procedure | Love, C., Katz, D., Chung, E., & Shoshany, O. (2017). Peyronie’s disease – Watch out for the bend. Australian Family Physician, 46, 655–659. Retrieved from http://www.racgp.org.au/afp/2017/september/peyronies-disease/
  • Plaque incision/excision and grafting (tunical lengthening: side of plaque)
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Plaque incision and graft | Love, C., Katz, D., Chung, E., & Shoshany, O. (2017). Peyronie’s disease – Watch out for the bend. Australian Family Physician, 46, 655–659. Retrieved from http://www.racgp.org.au/afp/2017/september/peyronies-disease/
  • IPP (with possible penile modeling, tunical plication, or plaque incision/excision and grafting)
    • Mechanical straightening (w/ or w/o plaque manipulation, tunical shortening or lengthening procedures)

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