Which assessment technique would the nurse use to check for Peyronie disease?

The exact reason why a curve to the penis began is often difficult to determine.  Some patients will report the curve after a rough sexual event.  Other patients find that it starts after beginning injection of medication in the penis for erectile dysfunction.  A genetic component is also possible especially in combination with Dupuytren’s contracture of the hand.  In most cases of penis curvature, scar tissue does not let the penis enlarge with erection.  This might stop the ability for sex to happen.

How many men have this problem?

The number of men presenting with symptomatic Peyronie’s disease is about 1%, but many experts feel the full number of men with a curve to the penis is likely closer to 5%.  Fortunately, most men do not have pain or trouble with sex because of the curve.

Will it get worse?

Most cases of Peyronie’s disease have an early time when pain is present with erection.  This then stops and the curve stays stable.  Nearly 33% of men may never have pain.  In general, most patients see the penis curve stay stable or improve after the pain goes away.

Many men have trouble with erections (erectile dysfunction) with the penis curving.  It is important to treat both problems for the best success.

What testing needs to be done?

In general, a normal office visit is needed in all cases.  Often men are asked to bring photos revealing the best erection they can get at home and showing the curve from above and the side.  This helps determine what will be the best treatment.  Occasionally more specialized tests such as ultrasound, plain x-ray, or even MRI are used to better assess the curvature.

What is the best treatment?

The best treatment will be different for each patient.  It is important to find an urologist with the ability to do multiple types of surgery to ensure the treatment is the best option for you.  Both medicine and surgery treatments are available.

Medical treatments

Many medications have been used with none being the best.  Vitamin E, Potaba, cholchicine, fexofenadine, verapamil, carnitine, and several cream preparations have all been used with success.  A penis vacuum erection device used every day has shown some helpfulness, as has a mechanical penis stretching device.  These often take months for a difference to occur.

Surgery

For the best surgery results, no pain should be present and the curve not changed for 6 months.  There are a number of surgeries available and best performed with knowledge of a patient’s ability to get an erection.  In general, the opposite side can be plicated (pulled to match the curve), the scar can be removed, or a penile prosthesis may be placed.

What happens after treatment?

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Most men are quite happy with the results after treatment.  Post-operative guidelines can be found on this website.

Recommended Links

www.sexhealthmatters.org

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Recovery Guidelines After Peyronie's Disease Repair

Most patients recover fairly quickly after the procedure but the swelling may take weeks to resolve.  Pain should improve in the first week after surgery.

We highly recommend the following guidelines to help healing:

Ice Pack

Ice packs may be used to limit scrotal and penis swelling after surgery especially in the first 48 hours.  Be sure not to leave the ice in direct contact with the skin for much time.

Swelling

As mentioned, it is normal to have a scrotum swelling after surgery. Contact your surgeon if the swelling is severe or if you are draining a large amount of fluid (soaking several pads per day). Other reasons to contact your surgeon after penile reconstruction include worsening pain after 48 hours, increased redness or tenderness around the incision site or a fever of greater than 101.

A basic understanding of the penile anatomy is required to appreciate the etiology and pathophysiology of Peyronie disease.[2][3] The penis consist of two erectile chambers called the corpora cavernosa that run along the length of the penis. During an erection, these chambers fill with blood, resulting in an increase in the size and rigidity of the penis.  Each corpus cavernosum has a sheath of elastic fibers called the tunica albuginea, which is made up of predominantly type 1 collagen fibers. The two corpora cavernosa are separated by a condensation of the tunica albuginea in the midline, forming a septum that attaches to the top and bottom of the penis. 

In Peyronie disease, a fibrous plaque forms in the tunica albuginea of the corpora cavernosa. This inelastic plaque changes the smooth upward curvature of the erect penis to a more kinked appearance. The exact mechanism the plaque forms is yet to be definitively established; however, many studies and theories have attempted to shed some light on the pathophysiology.

A generally accepted theory is that the plaque forms as a result of trauma to the penis. When the penis is abnormally squeezed or bent, the buckling forces result in overstretching and eventual delamination of the tunica albuginea fibers where the septum attaches. There is also damage to the microvasculature resulting in extravasation of blood, and a subsequent inflammatory cascade is triggered. The inflammatory process begins with a change of collagen from type I to type III collagen in the tunica albuginea; fibrin is deposited. Invading macrophages release elastase which breaks down the elastic fibers in the sheath of the corpora cavernosa, thus reducing the elastic properties of the tunica albuginea.[4]

This theory explains to some extent why PD occurs following penile trauma. Unfortunately, many patients do not recall any significant trauma. Other theories have been suggested to explain the formation of the plaques including, microvasculature injury, chromosomal instability of fibroblasts involved in plaque formation, aberrations in the inducible nitric oxide pathways, and patient human leukocyte antigen (HLA) subtype.[5][3][6] The reality is that we are unable to definitely say who will develop PD, it is more likely in susceptible men who engage in vigorous sexual or nonsexual activities (certain sports) that cause micro-injuries to the penis. Modifiable and non-modifiable risk factors of varying levels of evidence have been reported and are as follow:

• Penile injury

Previous injury to the penis is a strong predictor of developing PD. Genital or perineal trauma, iatrogenic injury, including catheterization, cystoscopy, and TURP, are all linked to increased risks of PD.[7][8] There is also some evidence to suggest that RP is associated with a 15.9% chance of developing PD, as shown in a study involving 1011 patients by Tal et al.[9]

• Connective tissue disorders

PD is commonly associated with other fibroproliferative diseases such as Dupuytren contracture and plantar fasciitis[10], suggesting a significant pathophysiologic and genetic overlap between these superficial fibrosing disorders. Nugteren et al. [11] studied the prevalence of DD in 415 men with PD and found that 89 (22.1%) also had DD. The prevalence of DD in the general population is thought to be between 1% and 7.3%, [12] supporting the proposal that these conditions may have overlapping mechanisms and predisposing genetic factors. Numerous studies have linked PD to other systemic fibrotic diseases such as idiopathic pulmonary fibrosis[13], Paget's disease of the bone[14], retroperitoneal fibrosis[15], scleroderma[16], polyfibromatosis[17], and systemic sclerosis.[18] 

• Family history

The genetic factors contributing to PD are complex, as summarised in a review by Gabrielsen.[19] There is evidence suggesting a genetic link; however, the exact mechanism or responsible genes remain undetermined. The literature suggests that multiple genes could be involved, which confer some susceptibility of developing PD to the individual when penile trauma occurs.

• Hypogonadism

Hypogonadism may increase the chances of developing PD and the severity of the disease. Moreno et al.[20] reported a prevalence of 74.4% of PD in 121 patients with hypogonadal testosterone levels <300. Interestingly, they also found that the degree of curvature was higher in the hypogonadal group compared with men with PD and normal T levels. This was confirmed in another study involving 106 patients by Hyung et al.[2] Androgens play an essential role in normal wound healing by modulating the matrix metalloproteinases. In deficient states, including hypogonadism, this normal healing process is disrupted, thus increases the chances of developing PD.

• Diabetes

A study by Arafa et al.[21] found that men who had erectile dysfunction secondary to diabetes were four to five times more likely to suffer from Peyronie disease compared to the general population. A similar higher prevalence of PD in this population has also been reported in other studies.[22][23][24] DM is believed to accentuate the fibrotic process involved in PD.

• Smoking and alcohol

There is some evidence to suggest that smoking is related to PD, although the correlation between the amount of smoking and risk is unclear. Similarly, the literature remains divisive with regards to alcohol, with a study by Bjekic [7] suggesting a strong correlation, but a larger-scale study by La Pera et al. disproving any relationship.[25]

• Age

Men in their 60s are most commonly affected by PD [26], with an average age at the time of diagnosis varying from 52 - 57 years old.[27][28][29][30] Although PD can still present at any age in adult life, with some reports of patients as young as 21 years old being affected.[28] 

History and Physical

Although Francois Gigot de la Peyronie first described PD over 250 years ago, PD's natural history has only recently been fully appreciated. Initially based on a small cohort study in the 1970s [41], most patients were thought to have symptoms that would resolve spontaneously. This has since been refuted, as shown by Gelbard et al., who reported a resolution rate of only 13%, with 40% worsening with time.[42] Similarly, Berookhim et al. noted a 12% resolution rate in untreated uniplanar PD patients; they found that younger age and time to the presentation of less than 6 months were predictors of good outcomes. In this study, 67% of patients showed no change in their disease over 12 months compared to 21% who had disease progression during this time. Another study by Kadioglu et al. [23]  involving 307 men over eight months reported a 30% disease progression rate and a resolution rate of only 0.65%. The bottom line is that patients should be counseled that their condition is unlikely to resolve without medical treatment, and a considerable proportion of men have worsening symptoms with time.

There are two phases in PD, the acute phase and the chronic phase. In the first 6-18 months [26], the penile deformity progresses; there is associated pain in either the erect and/or the flaccid states. This is the acute phase, and treatment is not recommended during this period. The chronic phase is characterized by a plateau of symptoms for at least 3-6 months; the deformity remains stable with some or complete improvement in pain. The chronic phase is when treatment is most appropriate. Pain seems to be the distinguishing characteristic between the phases, as shown by Mulhall et al.[26] They reported an improvement in pain in all 246 patients and a resolution of pain in the majority within a year of presentation; at 18 months, 89% were pain-free.

History

A thorough history and examination is the lynchpin of formulating a correct diagnosis in PD. This can be a delicate and distressing topic for patients as PD's ramifications on a man's sex life and relationships can profound. Consequently, clinicians should be empathetic and understanding when exploring the patient's symptoms and eliciting their ideas, concerns, and expectations of their condition. The psychosocial impact of the condition may warrant input from counselors and therapists.

A comprehensive history should include a detailed presenting complaint, past medical and surgical history. The sexual history is also particularly relevant in PD. The following are considered essential in a PD history taking:

Timing: Onset and progression of symptoms. Is the patient in the acute or chronic phase?

• Deformity: How would the patient describe the penile deformity? What is the direction and degree of curvature? Is there an hourglass deformity, hinge effect, or any other concerning abnormality?
• Erection: the degree of rigidity, ability to sustain and maintain an erection, presence of nocturnal erections.
• Pain: If pain is present, is it associated with the flaccid or erect state or both?
• Trauma: History of penile trauma/fracture, urologic procedures or surgeries
• Family history: Any family history of Peyronie’s disease or Dupuytren's disease?
• Medical/Surgical history: Diabetes, hypertension, and cardiovascular disease.
• Social history: Sexual history, smoking, and recreational drug use.
• Psychosocial factors: Impact of the condition on the patient’s mood, relationships, and self-esteem.

Examination

Accurate evaluation of penile deformity is critical for determining a baseline and planning treatment. The penis should be examined in the flaccid and erect state. This allows a better understanding of the extent of the deformity and corroboration with what the patient experiences. An objective assessment of the degree of curvature is also vital for disease monitoring and treatment progression as reliance on patient estimates is notoriously unreliable.[43][44] 

The penis stretch length is performed with the penis in the flaccid state. The penis is grasped at the glans and pulled gently at 90 degrees from the body. Examination in the erect state can be performed after intracavernosal injection of vasoactive substances [45] as per the American Urology Association guidelines. Ultrasound after intracavernosal injections is, in fact, superior to photographs or vacuum erectile device-assisted erection for accurately determining the type and degree of PD deformity (16697815). Plaque size, location, and calcification are objectively best assessed with duplex Doppler penile ultrasound. This method also assists in determining the etiology of ED if present.

PD is a clinical diagnosis; there is a limited role for diagnostic laboratory testing. However, they are valuable when a hypogonadal cause is suspected. In light of the strong correlation with other diseases, no workup would be complete without screening the patient for comorbidities such as diabetes, cardiovascular disease, and other fibroproliferative conditions such as Dupuytren's disease, plantar fasciitis, and scleroderma, amongst others.

Evaluation

The most important aspect of evaluation is the history and physical exam. There is no mandatory laboratory or imaging testing to complete a Peyronie disease workup.

As mentioned above, the AUA guidelines recommend performing an in-office ICI test with or without penile Doppler duplex ultrasound (PDUS) before any invasive intervention. A complete duplex ultrasound provides certain advantages, including identifying any calcifications, evaluating penile vascular flow, and evaluating the patient's erection quality after ICI. PDUS may help locate plaques not easily palpated and identify calcification in plaques. Levine et al. recently published a calcification grading system. The investigators found that patients with grade 3 or more extensive calcifications (greater than 1.5 cm in any dimension or multiple plaques greater than 1.0 cm) were more likely to undergo surgery when they also had a satisfactory erectile function. Patients with less severe calcifications of grade 1 (<0.3 cm) or grade 2 (0.3 to 1.5 cm) or no calcifications had no evidence of increased likelihood to proceed with surgery.[46] 

Thin section, high-resolution T2 MRI without fat suppression, has also been shown to be an excellent imaging modality for penile pathology, including PD.[47][48] Plaques will appear as low-signal intensity areas of thickened tunica albuginea. Calcifications are poorly appreciated. Given the expense and lack of widespread availability, the utility of MRI in the routine workup for PD is unclear.

Treatment / Management

Clinicians should assess and treat a man with Peyronie disease only when he or she has the experience and diagnostic tools to evaluate, appropriately counsel, and treat the condition.[49] Clinicians should then discuss all treatment options available and the known benefits and risks or burdens associated with each treatment.[49] For some patients, comprehensive counseling regarding the nature of PD and the typical disease course may be sufficient to alleviate concerns. There is no agreed-upon minimum curvature necessary before the intervention. The patient's distress over symptoms and level of concern and his willingness to undergo various types of treatment should be fully considered in the decision-making process, in addition to any objective measures of curvature and erectile function.

Nonsurgical Management

There are a variety of oral and injectable therapies utilized in the nonsurgical management of PD. However, very few of these therapies are supported by well-designed, double-blind, placebo-controlled, randomized trials. Obstacles in having good literature to support treatment include a low number of patients enrolled in studies resulting in low power, heterogeneity of treatments and duration of follow-up, and a variety of study endpoints. During the active phase, the hallmark symptoms are pain with or without erections.

Physicians may offer non-steroidal anti-inflammatory agents to help manage pain during this period. Current AUA guidelines recommend offering oral therapy with vitamin E, tamoxifen, procarbazine, omega-3 fatty acids, or a combination of vitamin E with L-carnitine.[49] There have been studies looking at all of these possible medications, some with encouraging results, though the vast majority are non-randomized, uncontrolled case series of various sizes. Intralesional injections are a viable non-operative option for the treatment of PD. AUA guidelines state that clinicians may offer intralesional injection with either collagenase Clostridium hystolyticum, interferon-a-2b, and verapamil. This is usually done in combination with modeling by the clinician and patient to reduce the penile curvature. It is recommended in patients with a curvature >30 degrees and less than 90 degrees and intact erectile function.[49]

Surgical Management

Indications for surgical treatment of PD include a deformity that impairs satisfactory sexual relations, stable deformity without pain for at least three months, extensive plaque calcification, and failed nonsurgical management. Procedure decision-making should include consideration of the nature and location of the deformity, magnitude of penile deformity, baseline erection function, penile dimensions, surgeon's experience, and patient's preference.[50] Surgical options include penile plication, incision or excision of plaque with graft, or penile prosthesis placement. These are described briefly below:

Penile plication: the patients who are considered for this surgery should have adequate preoperative penile rigidity with or without pharmacotherapy, adequate penile length for satisfactory intercourse, simple curvature of fewer than 60 degrees, and an absence of a hinge defect or hourglass deformity. The Nesbit procedure was the first technique used for plication, and since variations of this technique have been used for correction of PD.

The surgical approach involves making a midline incision or circumcising incision and placing plicating sutures in the tunica albuginea using permanent, synthetic braided sutures contralateral to the area of maximal curvature. There are many variations on this procedure; please see the list below of all possible penile procedures. The discussion of each technique is beyond the scope of this article. Patients can resume sexual activity after 4 to 6 weeks of recovery. Potential complications of this procedure include perceived loss of penile length due to shortening of the long side of the penis, unstable penis, persistent pain, persistence or recurrence of penile curvature, penile hematoma, urethral injury, and sensation loss for neurovascular bundle injury during dorsal plication procedures.[51] Plication procedures: Nesbit, tunica albuginea plication (TAP), Yachia procedure, Giammusso procedure, Lemberger procedure, the 16- or 24-dot procedure, Essed-Schroder tunica plication, penoscrotal plication procedure.

Plaque incision or excision and grafting: indications for this technique include full to near full pre-procedural rigidity, which might be accompanied with or without oral pharmacotherapy, complex penile deformity, simple deformity of greater than 60 degrees, large plaque, destabilizing hourglass, or hinge effect, and short penile length. For an incision procedure, an incision is made on the plaque at the point of maximal curvature on the convex side of the penis. The graft material is then placed within the defect to help lengthen the shorter side of the penis. An excision procedure involves removing part or all of the plaque and placing a graft in the defect. There are a variety of graft materials, including autologous grafts, allografts, xenografts, and synthetic grafts.

All allografts and xenografts are processed sheets of the collagen matrix. Synthetic grafts are not recommended for the management of PD. Autografts: rectus sheath, tunica vaginalis, dermal graft, buccal mucosa, fascia lata, venous patch. Allografts: pericardium, processed human pericardial grafting, fascia lata process human grafting, 4-layer 3-D printed graft. Xenografts: porcine 4-layer small intestinal submucosa (SIS), porcine 1-layer SIS, bovine pericardium, collagen sponge coated with the human coagulation factors fibrinogen and thrombin. Synthetic grafts: polyethylene terephthalate mesh reinforced silicone sheet patch graft. Complications include post-operative ED, infection requiring graft removal, penile hematoma, penile pain, recurrence of curvature.

Penile prosthesis placement. This technique is appropriate for men with ED, severe deformity refractory to medical therapy, or if profound penile instability exists. Prosthesis placement can be complicated due to the presence of plaque and corporal fibrosis. This can make dilation of the corpora difficult and increases the risk for corporal perforation. Options for prosthesis include 2 or 3 piece inflatable prosthesis or malleable prosthesis. Please see the erectile dysfunction section for further detail on prosthesis placement surgery.

Differential Diagnosis

Balanitis: Inflammation of the glans penis affects 11% of adult men and 3% of boys seen in urology clinics. In boys, it is caused by bacterial invasion of the soft tissue. In men, it is caused by a combination of poor genital hygiene, intertrigo, irritant dermatitis, maceration injury, and bacterial or candidal overgrowth, and treated with better hygiene practices, avoiding irritants to genitals and better glycemic controls in people with diabetes. Chordee: ventral penile curvature that occurs with or without hypospadias. Chordee is considered an arrest of normal embryological development. Typically surgical management is performed after six months of age.

Management should include intraoperative artificial erection tests at the time of repair to identify the point of maximal curvature and then to perform penile plication. Hypospadias should be corrected at the time of surgery if also present—penile fracture: trauma or contusion, fracture of the tunica albuginea during sexual intercourse. The typical story involves the sound of a "pop" with an immediate onset of severe pain and detumescence of the penis. On exam, there is typically penile swelling, ecchymosis, and possible palpable defect in the corpora cavernosa. Diagnosis can be obtained by physical exam and history and with MRI of the penis, which has excellent sensitivity for diagnosing penile fracture.

Treatment involves penile exploration with circumferential incision via subcoronal approach and closure of cavernosal injury with absorbable suture (typically 5-0 PDS). If concern for urethral injury, cystoscopy should be performed, and any urethral injury should be repaired in the same setting. Penile pain syndrome: sporadic etiology could include local conditions such as dermatitis, infection or ischemia, referred pain from the bladder, prostate, lower back or hips, neuropathic pain resulting from injury to the dorsal nerve, pudendal nerve or cauda equina, or psychiatric conditions. Persistent pain can be treated by treating the underlying disease.

Enhancing Healthcare Team Outcomes

Due to the embarrassing nature of this disorder, medical professionals need to coordinate care and communicate effectively with one another. Primary care providers (PCP) need to help identify patients who are potentially suffering from Peyronie disease. The sensitive issue requires sensitivity by the PCP. Often, males will not readily bring up this issue with their provider.

PCPs must be able to have an open and non-judgemental discussion with their patient's regarding their sexual activity and satisfaction with their sexual ability, which will often be the first checkpoint when it may be discovered that a patient has an issue such as PD. From that point on, PCPs need to understand that penile curvature or plaques are treatable problems, and the affected patients should be referred to a urologist for further management. At that point, the urologist can offer a variety of solutions to the problem, and the patient's care can take the next step forward. At the heart of the issue will be the ability to identify the patient's having the problem and get them to be seen by the proper medical professional. This will, for the most part, fall to the care of the patient's primary care provider.

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