Peyronie’s disease is a pathological change in the connective tissue of the penis, for which the formation of dense plaques in the protein membrane is typical. Complaints include painful erections, deformity of the penis, which at an advanced stage leads to the impossibility of sexual life. Diagnosis is based on the data of examination of the genitals, ultrasound, CT of the penis. Treatment of hyperplastic induration at the initial stage can be conservative, involves the use of hormones, vitamins, etc. In case of significant deformation, surgical correction is justified.
Peyronie’s disease (penile fibromatosis, Van Buren’s disease) is a chronic disease with little-studied etiology. Pathology was described in the middle of the XVIII century by the French researcher Francois Peyrony, the first mentions are found in 1561. Fibromatous process is more often registered in men over 40 years of age, currently there is a tendency to increase the incidence. The prevalence is 0.4-9%. The risk of pathology increases with age, in 25% of patients hyperplastic induration is accompanied by erectile dysfunction.
The causes of the disease have not been thoroughly studied. Most specialists indicate a recurring injury of the protein membrane with rupture of microvessels as a significant factor. Sometimes Peyronie’s disease is combined with Dupuytren’s contracture, Weber-Crischen syndrome, and other pathologies in which there is a diffuse lesion of connective tissue. Aspects leading to penile fibromatosis:
- too intense sex, especially when intoxicated, when control over pain is lost
- introduction of any solutions into the penis, implantation of a foreign body, fracture with rupture of cavernous bodies
- intracavernous treatment of erectile dysfunction with injections of drugs that promote erection
- suffered scrotal injury
- genetic predisposition
- frequent balanitis, balanoposthitis.
Predisposing factors include free sexual relations without the use of barrier contraception (the risk of STIs, chronic inflammation of the head and foreskin). Diabetes mellitus, lipid metabolism disorders, hypertension, smoking, alcoholism are considered as possible triggers, but their final effect on the development of the disease remains unexplored.
The altering factor contributes to the development of inflammation between the layers of the protein envelope. The differentiation of fibroblasts is disrupted, excessive production of myofibroblasts, which are responsible for the production of collagen, is started. Its deposition leads to degradation of elastin fibers. Any traumatization aggravates the pathological process, so all interventions are planned at the stabilization stage.
Long-term inflammation initiates the formation of coarse connective tissue, plaques in the thickness of the protein membrane. Due to the loss of elasticity, the penis bends, which makes it impossible or difficult to insert it into the vagina. Self-healing occurs extremely rarely (1-3%), the growth of fibromatous plaques can progress.
In clinical urology, there are many classifications of Peyronie’s disease. Systematization allows you to determine the tactics of patient management (conservative or operative). Taking into account the course of the pathological process , there are two stages:
- Acute inflammatory reaction. Pain in the penis is typical, regardless of the fullness of the cavernous bodies, i.e. pain can occur both at rest and with an erection. Palpationally, the plaque is soft, the first signs of curvature of the phallus appear.
- Stabilization. The final formation (organization) of the plaque occurs, which may be accompanied by calcification.
The line between the stages of penile fibromatosis is conditional, but the existence of changes for more than a year, the presence of the plaque itself for 3 months are considered by specialists as the transition of acute inflammation to the stabilization stage. According to the rate of development, the pathological process can progress slowly or quickly. For operating urologists, a classification that takes into account the degree of curvature of the penis is more important:
- no deformation;
- deformation up to 30°, which does not prevent sexual contact;
- deformation up to 60 °, limiting the penetration of the phallus into the vagina;
- deformation of more than 60 °, which does not allow intimate life.
The areas of compaction in fibromatosis have different sizes, can be single and multiple, their localization is also variable: at the root, in the trunk, head.
The main manifestations are pain in the penis, plaques or an area of compaction, a curvature of the organ, which is more often visualized during an erection. Upon completion of the organization of fibromatosis, palpation of nodules is not accompanied by pain, erections also become painless. In 60% of cases, hyperplastic changes affect the dorsal surface, plaques on the ventral or lateral surface are less common, but this localization often causes significant deformation of the phallus.
The formations are initially soft, elastic, separated from adjacent tissues, after a while they acquire a cartilaginous density. Pronounced curvature leads to a decrease in the size of the penis. The intensity of the pain syndrome during erection is variable, in the initial stage the pain is intense, but over time (8-12 months) it may decrease or disappear on its own.
A complication of hyperplastic induration is the development of erectile dysfunction, which worsens the quality of life, excluding intimacy. Often, the inability to lead a sexual life is accompanied by a depressive disorder, since testosterone continues to be produced normally (libido is preserved). The curvature of the penis when attempting to perform sexual intercourse can lead to a fracture of the male organ, rupture of the protein membrane, which aggravates the process.
A preliminary diagnosis is made by a urologist during a physical examination, before that the doctor analyzes the conditions for the occurrence of plaques, the body’s tendency to form keloid tissue. Sometimes it is difficult for the patient to describe the degree of deformation, which requires the introduction of a vasoactive agent into the cavernous bodies that promotes the onset of an erection in order to assess the curvature. Artificial filling of the cavernous bodies with blood is also facilitated by a vacuum erector. The survey algorithm includes:
- Ultrasound examination. Ultrasound of the penis locates the size of the plaque, its location. The structure of the formation is hyperechoic, calcium deposits give a clear acoustic shadow.
- Computer tomography. More accurate data can be obtained when performing CT. The study is justified for differential diagnosis with penile tumor.
- Biopsy. When receiving ambiguous ultrasound results, it is possible to perform a biopsy. The reason for morphological diagnosis can be ulceration of the formation, enlargement of the lymph nodes.
Similar manifestations, accompanied by deformation of the male organ and the appearance of dense areas, are observed in congenital curvature, fibrosis of cavernous bodies (a consequence of priapism), trauma, cavernositis, periurethral sclerosis. Pharmacodopplerography of penile vessels makes it possible to differentiate the vasculogenic form of erectile dysfunction, in which it is also impossible to insert a penis into the vagina.
Peyronie’s disease treatment
Treatment of the disease is aimed at blocking inflammation, preventing deformation of the protein membrane and, accordingly, the phallus. Therapeutic measures for penile fibromatosis are not always successful, before starting it is necessary to assess the ratio of benefits and potential harm, so many urologists, while maintaining an acceptable quality of sexual life, stop at dynamic observation. The tactics of patient management correlates with the stage of the pathological process, can be conservative or surgical.
The patient needs psychological help. The task of the urologist or andrologist is to explain that the palpable formations are not malignant, have no tendency to malignancy, the pain syndrome will pass, and a significant curvature of the male organ can be corrected by a simple operation.
- Physiotherapy. Positive dynamics are observed when using physiotherapy procedures: exposure to the affected area with an infrared laser in combination with magnetotherapy, ultrasound contributes to the regression of fibrous cords, relief of pain, reduction of deformation.
- Low-dose irradiation. Treatment with low-dose radiation is justified for persistent manifestations of pain, but the method is not recommended for widespread use, since there is a possibility of erectile dysfunction.
A number of drugs contribute to the reorganization of fibrous plaques:
- Vitamin E. The biologically active substance has an antioxidant effect, but recent studies have confirmed only its insignificant effectiveness in the treatment of Peyronie’s disease.
- Potassium paraaminobenzoate. The substance has an antifibrotic mechanism of action, improves oxygenation of tissue structures and can be used as part of complex therapy.
- Tamoxifen. The use of Tamoxifen remains controversial, according to some experts, it reduces the production of transforming growth factor by fibroblasts. Recent randomized studies consider this claim to be unproven.
- Kohlicin. The appointment of colchicine for the treatment of early changes in Peyronie’s disease in combination with vitamin E helps to reduce the size of seals, the degree of curvature of the penis.
- Pentoxifylline. Taking pentoxifylline, a non–specific phosphodiesterase inhibitor, leads to similar effects. It is noted that the drug slows down the secretion of growth factors, enhances fibrinolytic activity, and prevents calcification.
- Phosphodiesterase-5 inhibitors. The effect of phosphodiesterase – 5 inhibitors on reducing the size of fibrous formations is ambiguous, but there is evidence of a local increase in the apoptosis index.
This type of treatment involves the introduction of drugs into the thickness of the plaque. Steroid hormones potentially suppress immune responses, which contributes to a decrease in collagen synthesis. Transportation of glycosaminoglycans, fibronectin, and collagen in the intercellular space is impossible without calcium ions; verpamil, being a blocker of slow calcium channels, enhances collagenase activity, reduces inflammation, and slows down fibroblast proliferation.
Relatively recently, clostridial collagenase has been used to treat the disease, which selectively promotes the destruction of collagen. Clinical improvement was recorded in 36% of cases. The introduction of interferon alpha-2b slows down fibroblastic proliferation, collagen production, has been proven to reduce pain, the size of formations, curvature of the penis.
Local application of gels to the skin of the genital organ is successfully applied. The system action does not appear. Positive dynamics are noted when using:
- Verpamila. 15% gel relieves pain manifestations, reduces the size of the seal and helps restore the familiar appearance of the organ.
- Ionophoresis. The transport of verpamil and dexamethasone directly into the tissue enhances the effect of drug therapy, has a resorbing effect.
- Vacuum-erectorial therapy. The artificial erection created with the help of negative pressure creates conditions for the straightening of tissue structures. Not applicable at the stage of inflammation.
The type of operation is considered individually, depending on the degree of deformation, size, hemodynamic component. Surgical intervention is justified at the stabilization stage, six months to a year after the manifestation of the disease. In modern urology, there are two types of operations: with shortening or lengthening of the penis. The first include Nesbit surgery, including modifications, implication interventions, and the second – substitutive corporoplasty.
If the patient has developed a severe form of erectile dysfunction, it is preferable to prosthetics of the phallus with or without replacement corporoplasty. Synthetic and autologous transplants, allografts, xenografts, etc. are used as the forming material. The disadvantages include the likelihood of repeated surgery over the next 10 years. In the postoperative period, it is recommended to use a penile extender.
Prognosis and prevention
The prognosis for Peyronie’s disease determines the severity of penile deformity, the aggressiveness of the pathological process, the size of the penis and the addition of complications. Taking into account the possible performance of surgical treatment (according to indications), the outcome for the patient is favorable. Prevention implies the use of protective equipment in traumatic sports, the inadmissibility of self-administration of any implants or oils into the genital organ.