Awkward angulation of an erect penis is not to be considered an uncommon problem any more, as more and more men come out of the woodwork, desperate to communicate or share their concerns with their clinicians. So it’s time clinicians dealt with it openly and bravely just as they did with erectile dysfunction (ED) over the last two decades.
Peyronie’s disease (PD) is the commonest cause of bent penis and although known to medicine for over 250 years ago, it’s causative mechanism still remains ill understood and as a consequence the treatment efforts have been directed towards the effect rather than the cause.
What is PD?
By definition, it is an acquired penile abnormality characterized by fibrosis of tunica albuginea (TA) and may be accompanied by pain, deformity, erectile dysfunction and/or distress. It is a collagen disorder and could be associated in some cases with co-existent Dupuytren’s contracture. Other associated risk factors with unclear contribution to the pathophysiology are diabetes, hypertension and dyslipidemia.
How common is PD?
Prevalence of PD varies widely from 0.5 - 20% in the literature and if that is true; it’s a significant patient burden on any health care system. However, this could be the tip of the iceberg, as most men tend to shy away from approaching their doctor due purely to embarrassment. It would therefore be imperative that the clinician probes into this problem when men present with ED and/or lower urinary tract symptoms (LUTS), as the two co-exist.
Understanding Impact of PD:
PD is known to have physical and psychological impact; with a high incidence of clinical depression in men with PD; up to half of them admit to an adverse impact on their relationships, never mind the negative effect on their macho self -image and quality of sexual life. So they tend to suffer silently and so also their partners.
Natural History of PD:
Men with PD initially go through an Active or Acute phase characterized by dynamic and changing symptoms in particular penile pain and deformity on erection leading to increasing distress. Erections may or may not be compromised.
Subsequently, the disease enters its Stable or Chronic phase, with the symptoms unchanged for 3 - 6 months with pain subsiding but deformity/curvature and induration/plaque remaining static.
However, in 3-15% of men the disease process is known to resolve spontaneously over 6 -12 months, particularly in younger men.
Presentation of PD:
Men commonly present in their mid-fifties with recent onset penile deformity without any precipitating event to account for it. Pain present in the initial stage resolves with time in >90%. Penile deformity is progressive in 30-50% of men and stabilises in 47-67% with a hard / calcifies plaque. The resultant curvature may make penetrative sexual intercourse difficult or painful to patient and/or his partner causing further physical / psychological distress and difficulties with relationship. ED may set in due to pain / deformity / distress.
How to manage PD:
As we understand the natural history of PD without its aetiology, the emphasis is on symptom control rather than disease cure. Concomitant ED should be addressed with appropriate oral therapy using a PDE5 inhibitor / vacuum device.
After a clinical diagnosis supported by an Ultrasound scan (USS) or MRI if necessary, the active phase is best managed by masterly inactivity to allow the natural history to take its course until the disease process is stabilized or resolved.
During this phase what the patient really needs most is:
- Baseline Assessment of disease/deformity inc. distress scores for PD, VAS for pain
- Detailed discussion of treatment options and their risks/benefits
- Setting goals of treatment for patient / clinician
- Setting realistic expectations for the patient / clinician
Therapeutic Options for PD:
During active phase men with PD could be offered NSAIDs for symptomatic relief of their pain however, for the rest of the oral agents described in the literature, there is no convincing evidence of any lasting benefit and as such none should be offered.
In men with stable deformity without ED, further management depends upon following issues:
- Impact on Self image
- Difficulty with sexual intercourse to self/partner
- Psychological distress
- Effect on relationship
- Expectations from the chosen treatment option
The clinician ought to have a frank discussion about the options available based on the extent of deformity / angulation (<30, 30 - 90, > 90) and offer:
- Surgical correction: penile shortening (plication techniques)
- Surgical correction: penile lengthening (incision/grafting technique) +/- penile prosthesis
- Intralesional injection using verapamil / interferon alpha-2b
The New Kid on the Block
The new kid on the block is Xiapex (EU) or Xiaflex (US): intralesional collagenase clostridium histolyticum, administered as a course of up to 8 injections over a period of 24 weeks depending upon the curvature and response to treatment.
It is an outpatient based, minimally invasive, non-surgical treatment option and recently licensed for managing PD (following its original license for Dupuytren’s contracture).
In clinical trials a reduction in the curvature of up to 17 degrees (37%) was noted at 1-year follow up.
Although it is not the panacea of treatment for PD, it is most certainly a significant addition to the armamentarium for the management of PD; the evidence for most of the existing options being at best moderate to conditional.