Treating Peyronie’s Disease
Peyronie’s Disease is hypothesized to be traumatic arthritis of the penis, especially the tunica albuginea of the corpora cavernosa, likely caused by a fracture in the tunica that occurs during sexual activity. It is most common with the partner in the superior position (on top) during sexual activity. The fracture leads to attempted healing, but healing is excessive which results in a fibrous scar – that causes pain, deformity and erectile dysfunction.
A study in the US found 0.4% of men had Peyronie’s Disease, with an average age of onset of 53 (range 19-83). A study in Germany by Schwarzer et al using a questionnaire had response from 4,432 men. The mean age was 57.4 y/o and 3.2% had plaque, and 1% had plaque, pain, angulation. Broken down by age, 1.5% of men 30-39 y/o had symptoms, 3% between 40-59 y/o, 4% of those 60-69 y/o and 6.5% of men older than 70 had Peyronie’s Disease (thickening of the tunica albuginea on physical examination). Symptoms included 84% with angulation, 46% painful erection, 40% with erectile dysfunction (ED). An on-going clinical evaluation study in Boston of the MMAS (Massachusetts Male Aging Study) subjects shows that Peyronie’s Disease is present is 80%.
Evaluation of all sexual dysfunctions is done through identification, education and modification, then first, second and third line therapies. Symptoms of Peyronie’s Disease vary according to the time since the trauma. The early phase triad (up to 12 months) leads to plaque, painful erection and deformity (curvature or narrowing). The late phase triad (after 12 months) results in harder plaque (1/3 calcified), with a stable deformity and ED.
The diagnosis of Peyronie’s Disease is made through a history of trauma, Dupuytren’s or family history. Physical examination reveals a lump in the penis. If the lump is rock hard, the Peyronie’s is in the chronic phase, and may have tenderness. The plaque may be evaluated by ultrasound; the deformity may be assessed by an office intracavernosal injection test and photograph, and a vascular assessment may be made by Color duplex ultrasound. If surgery is planned a Color duplex ultrasound must be done.
There is no known cure for arthritis and it is not known how to cure arthritis of the penis. There are no FDA-approved treatments for the management of Peyronie’s Disease. There have been limited (virtually none) placebo-controlled, double-blind studies for the treatment of Peyronie’s Disease. Most often the best treatment option for Peyronie’s Disease is no treatment, or at least conservative treatments with limited risks. Surgery is the last treatment option.
Vitamin E is an antioxidant. It is inexpensive and non-toxic. It’s use shows a modest improvement in deformity (10-15 %). The dose is 800-1000 units/day. The main side effect is hypocoagulability.
Potaba showed in a recent placebo-controlled trial with one year follow-up improvement in plaque size which was statistically significant but no significant change in deformity. The dose was 12gm/day, and side effects were GI intolerance.
Colchicine is an anti-microtubule, anti-inflammatory that inhibits collagen production. There are limited published studies and no controlled trials. Objective measures of improvement in deformity are reported in 30-40 % of patients primarily with early stage disease. The dose is 0.6 mg three times a day p.c. (starting with 0.6 mg q.d.). Side effects include diarrhea, GI upset and bone marrow depression. For safe use, CBC and LFT blood values should be measured if colchicine is used for more than 3 months.
Verapamil results in changes in fibroblast behavior and cytokine inhibition. Two controlled trials have been done with verapamil: one showing benefit in all objective measures, with objective measures of deformity improvement in 50-60 % of patients treated; the other showing no benefit over saline control. The dose is 10 mg verapamil in total of 10cc volume injected every 2-4 weeks x 12. The side effect is ecchymosis.
Collagenase alters the collagen content of plaque, Several published reports including one controlled trial show benefit for the deformity to be less than 30 %. The toxicity profile is low, but a side effect is that collagenase may cause tunical fracture.
Iontophoresis with 3 drugs, a mixture of orgotein, dexamethasone and lidocaine, are used for treatment sessions lasting 20 minutes each 3 times a week for 3 weeks with a current of 3 mA. Montorsi et al showed improvement in penile nodulea or plaque in 79% to 90% of patients and penile deformity in 62% to 88%.
Shock Wave was studied prospectively in 481 patients by Mirone et al. Group A received shock waves alone in 56 patients; group B received a combination of shock waves and calcioantagonist (perilesional injection) in 324 patients; and group C received an Injection of calcioantagonist, 101 patients (control). Reduction of size of the plaque was shown by ultrasound in group A (27/56), group B (159/324) and group C (39/101). There was considerable improvement in pain and of sexual performance.
Colombo et al also studied the use of shock wave. In 82 patients, 44 with painful erections and 78 with curvature, 36 had calcific plaque and fibrotic. The pain disappears in 70% post-treatment, 41% had reduction in the echogenicity while 39% were unchanged or larger. Fibrotic lesions improved in 46% and stabilized or worsened in 54%. Calcific plaques improved in 36% while they remained unchanged or worsened in 64%.
Surgical Intervention is always the last option. Two kinds of reconstructive surgery are available, plication reconstructive surgery and grafting reconstructive surgery. The first is a wedge resection making many modifications, resulting in a shortening of the penis, but with no chance of causing ED. The grafting procedure is a combination of excision or incision of the plaque plus the grafting, using either an autologus (dermis, tunica vaginalis, saphenous vein, temporalis fascia), synthetic (gortex, silastic, dacron) or cadaveric (Tutoplast-human pericardium, SIS-porcine small intestine submucosa) graft. This surgery has a risk of causing ED.
If erectile dysfunction already exists in the presence of Peyronie’s Disease, the best option is implantation of a penile prosthesis with or without grafting.