peyronies disease urology

1. Peyronies disease
Dr sonu kumar plash

2. General considerations
 first known as induratio penis plastica.
 It was subsequently named after Francois Gigot de la
Peyronie.
 Definition-Devine and Horton - It as a wound-
healing disorder of the tunica albuginea that
results in the formation of an exuberant scar,
occurring presumably after an injury to the penis
activates an abnormal wound-healing response.

3. General considerations
 The resulting scar or plaque is inelastic and therefore
results in penile deformity including-
1. Curvature
2. Indentation
3. Hinge effect
4. Shortening and is frequently accompanied by erectile
dysfunction (ED).
 One of the most important characteristics- once the
scar has occurred, it does not undergo normal
remodelling and therefore the scar and deformity
persist.

4. Epidemiology.
 Prevalence-3% to 20%.
 The prevalence may be even higher in diabetes
mellitus and ED.
 Incidence-
 From 0.39% to 20.3%, with most current estimates of
the incidence of PD being between 3% and 9%.
 The peak age of onset of pd is in the early 50s.

6. NATURAL HISTORY
 There are two phases.
 1.The first is the active (acute) phase, which is
commonly associated with painful erections
and changing progressive deformity of the
penis.
 2. This is followed by a stable (chronic) phase,
which is characterized by stabilization of the
deformity and disappearance of painful
erections and no further progression.

7. Natural history
 No more than 13% of patients will have
some improvement of their deformity
over the first 12 to 18 months after onset
of the disease process when not treated.
 The key point to remember is that
complete spontaneous resolution of pd is
a rare occurrence.

9. Associated conditions
 AGING.
 MC diagnosed in 5TH decade.
 Linear increase in prevalence can be seen from 30 to 49 years
of age
with an exponential increase in prevalence at 50 years of age.
 Approximately 10% of men with PD are younger than 40 years of
age.
 The increased prevalence of PD with age is likely a reflection of
the increased likelihood of comorbid medical conditions
contributing to the development of ED such as hypertension,
hyperlipidemia, diabetes, and low testosterone.
 Also due to the reduced tissue elasticity that naturally occurs with
aging, predisposing this tissue to stretch-related injury.

10. Diabetes
 Prevalence of diabetes in men with PD- as high as
33.2%, which is much higher than in the general
population.
 Longer duration of diabetes and poor glucose control-
shown to significantly increase the severity of pd,
including duration of pd, deformity, curvature, and
erectile function.
 Men with diabetes- higher risk for ed, which may
predispose to injury during intercourse because of the
less rigid penis pivoting back and forth, potentially
resulting in a tissue fatigue–type fracture, activating
the scarring disorder.

11. Erectile dysfunction
ED appears to be more common
in men with PD than in the
general population.
The prevalence of ED in men
with PD has been reported to be
37% to 58%.

12. Psychological aspects
 Penile shortening and the inability to have
intercourse are the two most common and
consistent risk factors for emotional distress
and relationship problems associated with PD.
 Psychosocial stress is reported by 77% to 94% of
men with PD.
 Moderate to severe depression in 48% of PD
patients, with these rates typically increasing
with the duration of PD.

13. Radical prostatectomy
 Men undergoing radical prostatectomy by an open or
robotic approach have a higher risk for developing PD
than the general population.
 The mechanism responsible for this is not known but
may include perioperative penile trauma, neurogenic
consequences, or via a local release of cytokines that
activate the abnormal wound healing process in men
susceptible to pd.
 Further prospective studies are required to confirm
this association.

14. Hypogonadism
 The presence of hypogonadism in patients with
PD - exaggerate the severity of PD.
 Plaque area and penile curvature were also more
severe in hypogonadal men with PD.
 There is no clear evidence that it is a risk factor.
 Further study is indicated, and assessment of
serum testosterone is recommended.

15. Collagen disorders
 There is an association of PD with other
collagen disorders such as dupuytren disease
(DD).
 As with pd, the prevalence of dd increases with
age, from 7.2% among men in the 45- to 49-year-
old age group up to 39.5% in those 70 to 74 years
of age
 Other associated fibrotic conditions are:-
 Contracture of the plantar fascia (ledderhose
disease) and tympanosclerosis, both of which are
uncommon disorders

16. PENILE ANATOMY AND PEYRONIE’S
DISEASE
 Tunica albuginea-multilayered structure-predominantly
composed of type 1 collagen that is oriented with an
inner circular and outer longitudinal layer interlaced
with elastin fibers separated by an incomplete septum.
 This septum is anchored into the inner circular layer and is
key to the structural integrity of the tunica.
 These anchor sites are susceptible to microvascular
trauma and tunical delamination, which may be one of
the triggers leading to this disease.

17. PENILE ANATOMY AND PEYRONIE’S
DISEASE
 The structure is reinforced by intracavernous pillars, which anchor
the tunica albuginea across the corpora cavernosa at the 2 to 6
o’clock and 10 to 6 o’clock positions, with finer pillars at the 5 and
7 o’clock positions .
 60% to 70% of plaques are located on the dorsal aspect of the
penis and are usually associated with the septum.
 The longitudinal layer of the tunica albuginea- thinnest at the 3
and 9 o’clock positions of the corpora.
 It is completely absent between the 5 and 7 o’clock positions.
 This may contribute to greater ease of dorsal buckling and may
explain why most pd patients exhibit dorsal curvature.

18.  In normal tunical
tissue, each layer
appears to be
distinct and is able
to slide on the
adjacent layer. The
normal three-
dimensional
structure of the
tunica affords great
flexibility, rigidity,
and tissue strength
to the penis despite
the fact that the
tunica albuginea is
quite thin—1.5 to 3.0
mm, depending on
the position around
the circumference.

19.  Normal architecture is
essentially lost
consequent to this
disease, resulting in what
is known as a Peyronie’s
“plaque,” which, when
examined histologically,
demonstrates
disorganization of
collagen fibrils and a
decrease in and
disorganization of elastin
resulting in penile
deformity caused by
asymmetrical expansion

20. Mechanism of injury
(A) Fibers of
the septal strands dorsally fan
out and are interwoven with
the inner circular lamina fibers
of the tunica
albuginea. The outer lamina
consists of longitudinal fibers.

21. (B) In the chronic mechanism
of Peyronie’s
disease, less turgid erections
allow flexion of the penis
during intercourse, producing
elastic tissue fatigue,
further reducing elasticity of
the tissue and leading to
multiple smaller ruptures of
the fibers of the tunica
with smaller collections of
blood, possibly producing
multiple scars.

22. (C) In the acute mechanism of
Peyronie’s disease- bending the
erect penis out of column produces
tension on the strands of the
septum,
delaminating the layers of the tunica
albuginea. Bleeding occurs, and the
space fills with clot. The scar
generated by the response of the
tissue to this process becomes the
Peyronie’s disease plaque.

23. (D) Illustration of the situation on the
ventrum of the penis-where the
bilaminar arrangement of the tunica
albuginea becomes thinned, with
the midline being monolaminar. The
fibers of the septal strands fan out
and are interwoven with the inner
circular layer. There is no outer
circular layer.

24. E) In the chronic
mechanism
of Peyronie’s
disease, less
turgid erections
allow buckling of
the penis as in
(B).

25. (F) In the acute mechanism
of Peyronie’s disease, buckling of
the erect penis out of column
produces tension on the strands of
the septum, causing the septal
fibers to tear.

26.  When expansion is limited at one point along
the circumference of the corpora by the
inelastic scar of the Peyronie’s plaque,
deviation to that side occurs
 A circumferential plaque may lead to an
hourglass deformity.

28. ETIOLOGY
 Exact cause-not known.
 All agree-some injurious stimuli is necessary.
 Trauma may be perceived as a single event experienced
by the
Patient or may take the form of repetitive microtrauma to
the penis.
 Proposed mechanism- in the erect state, the pressures
inside the penis is high and acutely higher when external
forces are placed on the penis during intercourse. These
pressures exceeds the elasticity and strength of the
tunica tissues, resulting in a microfracture.
 Misconception- trauma to the penis must occur only
when it is erect.
 Trauma to the flaccid penis may also trigger this process.

29. 16-fold increase in PD in those who had
undergone prior invasive procedures and a
nearly 3-fold increase in PD in patients who
had experienced genital and/or perineal
trauma.
No more than 30% of men recall a specific event
involving injury to the penis close to the time
when the scarring or pain began.
An injury occurring during sexual activity appears
to be the most common recognized event
associated with the onset of pd.

30. Role of oxygen free radicals and
oxidative stress.
 Microvascular trauma--blood
extravasation--inflammation ensues--
inflammatory cells produce ros—increase
in oxidative stress in the form of free
radicals induce overexpression of
fibrogenic cytokines and augmented
transcription and synthesis of collagen.

31. Role of Nitric oxide in peyronies disease
 PROTECTIVE ROLE.
 NO synthesized by inos reacts with ROS, thus
reducing ROS levels and inhibiting fibrosis.
 The antifibrotic effects of NO--mediated by the
reduction of myofibroblast and may lead to a
reduction in collagen I synthesis.
 NO--play an antifibrotic role by activating guanylyl
cyclase,producing cgmp--suggested to inhibit
plaque formation.

32. Role of Myofibroblasts in Peyronie’s Disease
Myofibroblast activation is a key event in
the development of fibrosis.
Trauma to the tunica albuginea secondary
to microscopic delamination increases the
adherence of fibroblasts to their
surroundings, exposing them to changes
in ECM tension, and in the presence of
appropriate cytokines initiates their
differentiation into myofibroblasts.

33. Role of Transforming Growth Factor-β1 in the Etiology of
Peyronie’s Disease
 TGF-β1 has been shown to be
significantly associated with PD.
 TGF-β is a strong activator of
myofibroblasts and is known to be a
potent fibrotic growth factor by
stimulating the deposition of ECM.

34. Fibrotic Gene Expression in Peyronie’s Disease.
 The most highly upregulated gene found in the PD
plaque, PTN or OSF1, codes for-- heparin-binding
protein thought to stimulate--growth of fibroblasts
and osteoblast recruitment, and is possibly related
to plaque ossification.
 The second most upregulated gene, MCP-1, is
critical to the inflammatory response and
ossification.

35. Symptoms
 MC –
1. Penile pain
2. Erect deformity
3. Palpable plaque
4. ED
 Once the disease process is stable, most pain will resolve.
 Many men are capable of sexual activity with curvature up to 60
degrees, particularly if the curvature is dorsal and more gradual
along the shaft.
 Men with ventral or lateral curvatures may have a more difficult
time with intromission. More discomfort.
 The PD plaque can manifest in a variety of configurations
including cords; simple nodules; coinlike, irregular dumbbell
shapes; or I-beam plaques.

36. Symptoms
 The orientation of the plaque usually defines the
deformity.
 Therefore, patients with a simple dorsal plaque are
most apt to have dorsal curvature; but if there is
transverse or spiraling scarring, which can be partial or
circumferential, this could result in varying degrees of
indentation including an hourglass deformity, which
can result in an unstable penis, or a hinge effect as a
result of the inability to tolerate axial forces in the erect
condition.

37. Evaluation of the patient
 History-focus on presenting signs and symptoms such as
pain, deformity, and palpable plaque.
 Ask--Whether onset was gradual or sudden. The estimated
time that symptoms began.
 If there was any inciting event that may have triggered the
process, including direct
 External penile trauma to the flaccid or erect penis or
instrumentation.
 Any personal or family history of other fibrotic disorders
including Dupuytren disease and ledderhose disease.
 Patients should be carefully queried as to their erectile
capacity,the ultimate question is whether he is capable of
intromission or incapable because of deformity and/ or
diminished rigidity??.

39. evaluation
 If the patient does not feel his erections would be
satisfactory, this can help direct the patient to treatment
with a penile prosthesis and straightening maneuvers.
 Nonsurgical or other surgical approaches could result in
improvement of deformity, but if there is persistent ED, such
treatment would likely not give the patient a sexually
functional erection.
 Ask about whether there are any vascular risk factors
for ED, including a history of diabetes, hypertension,
elevated cholesterol, and smoking.

40. PD questionnaire (PDQ)
 The current questionnaire has 15 questions
assessing three domains, including
 (1) Peyronie’s psychological and physical
symptoms (six items).
 (2) Penile pain (three items).
 (3) The effects of PD symptoms (six items).
 Each domain is intended to be an independent
measure, and the scores are not summed for a total
instrument score. Higher scores indicate a greater
negative impact.

41.  The value of a photograph taken at home of the
erect penis has been controversial because of
the inability to adequately represent and
measure a three-dimensional deformity.
 A photograph can be taken by the patient from
above and from the side in the erect state, it can
be useful during the initial consultation to get a
general impression of the direction and severity of
the deformity.

42. PHYSICAL EXAMINATION
 A general assessment of the femoral pulses, appearance of the flaccid
penis, and whether it is circumcised.
 Assessment of Peyronie’s plaque.
 Penis should be examined on stretch-- easier identification of the plaque .
 The location of the plaque should be recorded, but measurement of the
size of the plaque with any modality has been found to be inaccurate
because the plaque is rarely a discrete lesion.
 It has irregular borders and often extends into a septal cord.
 The stretched penile length (SPL) is a critical parameter to measure at the
initial consultation.
 This is performed by placing the penis on stretch by grasping the glans
and pulling at a 90-degree angle away from the body.

44. Evaluation
 It is preferred to measure from the pubis to the
corona dorsally, as these are two fixed points
and facilitate repeated measurement during the
course of treatment and follow-up.
 consistency of the plaque may be recorded.
 A “rock hard” plaque may be an indicator of
calcification but will need to be confirmed with
some form of imaging, preferably
ultrasonography.
 Computed tomography and magnetic resonance
imaging have little value in the evaluation of the
patient with PD.

45. Calcification of plaque
 Calcification may occur early after the onset of the
scarring process, and therefore the previously held
notion that calcification is an indication of chronic,
severe, and/or mature disease appears untrue.
 Calcification is most likely the result of a different
genetic subtype of pd in which there is activation of
genes involved in osteoblastic activity.
 men with more extensive calcification are less likely
to benefit from nonsurgical treatment.
 Patients with extensive calcification are more apt to
proceed to placement of a penile prosthesis.

46. Calcification grading system
Grade 1- <0.3 mm calcification
Grade 2- 0.3 to 1.5 cm
Grade 3- > 1.5 cm in any
dimension or multiple plaques
>1.0 cm.

47. KELAMI CLASSIFICATION
Penile curvature can be
classified as
1.Mild (< 30°)
2.Moderate (30° to 60°)
3.Severe (>60°)

48. Assessment of penile deformity
 Done in erect state
 Most accurately measured after an office
vasoactive injection as compared with a
home photograph or vacuum-induced
erection.
 The AUA 2015 Guideline on Peyronie’s
Disease now recommends that in-office
intracorporeal injection therapy should
be performed in every patient before
invasive intervention.

50. Duplex USG
 Duplex ultrasound analysis (usually with intracorporeal injection therapy) is
routinely performed as part of the initial evaluation, especially for those who
are considered surgical candidates.
 These parameters are absolutely critical to the decision process for the
patient who is considering surgery.

52. Other investigations
 A morning serum total testosterone level during the
initial evaluation is recommended for men with ED, as per
the recently updated AUA ED guideline, but not for men
with PD and no ED.
 Dynamic infusion cavernosometry(DICC)- to assess
penile vascular integrity and, in particular, venous leakage
before surgery.
 DICC adds unnecessary invasiveness and expense and
provides little value to the diagnostic evaluation over a
well-done dynamic penile duplex ultrasonography.
 Assessment of penile sexual sensitivity-light touch and
biothesiometry can be used.

53. Goniometer

54. Treatment
NON SURGICAL
1. Oral medications
2. Intralesional injection
3. Topical drug application
4. Extracorporeal shock wave therapy.
5. Electromotive drug administration
6. Penile traction
7. Vaccum therapy
8. Radiation therapy
SURGICAL
1. Tunical shortening procedures-
plaque incision.
2. Tunical lengthening procedures-
plaque incision or partial excision
and grafting.
3. Penile prosthesis.

55. Non-surgical treatment
 Patients who have no pain or difficulty in accomplishing
penetrative sex may require only reassurance.
 Conservative treatments often yield inconsistent and clinically
insignificant improvements in deformity.
 Currently, no oral agent has been shown in placebo controlled
trials to result in clinically meaningful improvement in curvature.
 The only oral medication recommended by the aua guideline on
pd is nsaids to reduce pain.
 Topical therapy and eswt have not been shown to reduce penile
deformity.

56. Non-surgical treatment
 Intralesional verapamil and IFN alfa-2b have
shown evidence of reduced curvature and
improved sexual function. Yet most studies are not
controlled trials. These agents at a minimum
appear to result in deformity stabilization during the
acute phase.
 The first FDA-approved drug for the treatment of
PD, CCH (Xiaflex).

57. Oral medications
 Potaba
 Potassium para-aminobenzoate (potaba) is a
member of the vitamin B complex.
 Can reduce the formation of collagen.
 “Potaba appears to be useful to stabilize the
disorder and prevent progression of penile
curvature”.
 little evidence of benefit with Potaba in placebo-
controlled trials and it is expensive and difficult
to consume (24 tablets daily), the aua 2015 pd
guideline does not recommend its use.

58. Oral medications
 Vit –E-
 limit oxidative stress of ROS known to be
increased during the acute and proliferative
phases of wound healing.
 no significant improvement in pain, curvature, and
plaque size when compared with placebo
 Vitamin E is the most frequently recommended
oral agent in spite of studies showing no benefit
over placebo.
 The AUA 2015 PD guideline does not recommend
its use.

59. Oral medications
 Tamoxifen-
 No significant improvement with respect to pain, penile
deformity, or plaque size when compared with placebo.
 The aua 2015 pd guideline does not recommend its use.
 Colchicine-
 By binding to tubulin and causing it to depolymerize,
colchicine inhibits cell mitosis, mobility, and adhesion of
leukocytes; inhibits transcellular movement of collagen; and
stimulates the production of collagenase.
 Significant drug-related adverse effects in the colchicine
group included gastrointestinal upset with diarrhea.
 The AUA 2015 PD guideline does not recommend its use.

60. Oral medications
 Carnitine-
 L-carnitine is hypothesized to act by increasing
mitochondrial respiration and decreasing free radical
formation.
 Studies did not show significant improvement in pain,
curvature, or plaque size in patients with pd treated with
propionyl-l-carnitine as compared with those treated with
placebo.
 The aua 2015 pd guideline does not recommend its use.
 Pentoxifylline-
 Shown to block the tgf-β1–mediated pathway of
inflammation and to prevent deposition of collagen type i
and is a nonspecific phosphodiesterase inhibitor with
combined anti-inflammatory and antifibrogenic properties.

61. Oral medications
 Improvement in penile curvature and plaque volume was
significantly greater in patients treated with pentoxifylline
than with placebo. The increase in international index of
erectile function (IIEF) total score was significantly higher
in the pentoxifylline group.
 The aua pd guidelines panel judged that some uncertainty
remains regarding
 The efficacy of pentoxifylline given the limited evidence base;
replication in a randomized design is needed before
pentoxifylline can be recommended as a PD treatment.
 Phosphodiesterase type 5 inhibitors-
 There was no advantage with respect to deformity.
 Not recommended for the treatment of peyronie’s disease.

62. INTRALESIONAL INJECTION
 Verapamil-calcium channel blocker -shown to significantly affect
fibroblast function on several levels, including cell proliferation,
ECM protein synthesis and secretion, and collagen degradation.
 Currently, intralesional verapamil is a popular treatment
option for the conservative management of pd despite the
fact that some studies have not shown as favorable a
response.
 Although 10 mg/10 ml is the most commonly used dose and
volume,a greater response to injection was seen when 10 mg of
verapamil was diluted with 20 ml of injectable saline.
 Currently, the AUA PD guideline states that a physician may
offer intralesional verapamil for the treatment of patients with
peyronie’s disease but should counsel the patients on potential
injection site side effects.

63. INTRALESIONAL INJECTION
 Nicardipine- A dihydropyridine (DHP) type of calcium channel
blocker. more effective than a non-DHP type, verapamil, in
reducing glycosaminoglycan biosynthesis and ECM production.
 There were no severe side effects, such as hypotension or
other cardiovascular events.
 Nicardipine currently has no recommendations in the AUA 2015
PD guideline.
 Interferon Alfa-2b-
 Decreased rate of fibroblast proliferation in a dose-
dependent fashion, decreases the production of
extracellular collagen, and increases the production of
collagenase.

64. INTRALESIONAL INJECTION
 Treatment group- mean decrease in curvature of 27% or 13.5
degrees.
 Versus 9% or 4.5 degrees in the placebo group.
 Results were statistically significant, but whether the small
difference between the ifn and saline is clinically significant
when taking into account the significant cost of the drug
and its side-effect profile, which frequently includes flulike
symptoms (fever, chills, and arthralgia) and minor penile
swelling with ecchymosis.
 As per the aua 2015 pd guidelines, clinicians may administer
intralesional interferon α-2b in patients with pd. However,
patients should be counseled on the potential adverse events,
including sinusitis, flulike symptoms, and minor penile swelling.

65. Intralesional injection of Collagenase Clostridium
Histolyticum
 The first FDA approved drug for the treatment of PD.
 Produced by the bacterium c. Histolyticum.
 Selectively degrades collagen types i and iii.
 The phase III IMPRESS (investigation for maximal peyronie’s
reduction efficacy and safety studies) I and II trials examined
the clinical efficacy and safety of CCH in PD.
 Treatment group- 34% improvement in penile curvature,
representing a mean change of 17.0 degrees.
 Placebo group-a mean 18.2% improvement in penile
curvature, representing a mean change of 9.3 degree.

66. Intralesional injection of Collagenase Clostridium Histolyticum
 The most serious complication of CCH is penile fracture-injection
weakens the corporal albuginea surrounding the plaque, making
it more vulnerable to breaking- rate of corporal fracture ranges
from 0% to 4.9%.
 The current standard of care based on the IMPRESS trials is
up to 4 total treatment sessions consisting of two injections
of 0.58 mg of CCH each session (total of 8 injections).
However, CCH is expensive, and it is unknown if eight
injections are required to achieve an optimal outcome.
 The 2015 AUA PD guideline recommends that physicians may
administer CCH in patients with a stable curvature greater than
30 degrees and less than 90 degrees with intact erectile
dysfunction (with or without use of medications).

67. Topical drug application
β-aminopropionitrile, Topically
applied liposomal recombinant
human superoxide dismutase
(lrhSOD),and topical verapamil
have been studied.
At this time, no topically applied
agent has been established to be
effective in the treatment of PD.

68. Electromotive Drug Administration
Transdermal drug delivery was
proposed to be superior to oral or
injection therapy because it bypasses
hepatic metabolism and minimizes the
pain of injection.
The 2015 AUA PD guideline
recommends that clinicians should not
offer electromotive therapy with
verapamil.

69. Extracorporeal Shock Wave Therapy
 MOA-two purported hypotheses:
 (1) Shock waves cause direct damage to the penile plaque.
 (2) ESWT increases the vascularity of the targeted area by
generating heat, which leads to the induction of an
inflammatory reaction, resulting in lysis of the plaque and
removal by macrophages.
 The authors concluded that despite some potential benefit of
ESWT with regard to pain reduction, it should be emphasized
that pain usually resolves spontaneously with time. Given this
and the fact that deviation may worsen with ESWT, the
treatment cannot be recommended.
 The 2015 AUA PD guideline states that clinicians should not use
ESWT for the reduction of penile curvature or plaque size.
Clinicians may offer ESWT to improve penile pain.

70. Penile Traction
 Controlled stretching of the penis, by a device that holds the
penis in a cradle and subjects it to tension is indicated for
treatment of PD patients as a noninvasive, nonsurgical first-
option treatment modality.
 Moa- induce cellular proliferation, triggers scar remodelling, leads to
reorientation of collagen fibrils parallel to the axis of stress.
 These changes are the result of a process referred to as mechanotransduction
whereby mechanical stimuli are converted into chemical responses within the cell.
 Use of a penile extender device provided only minimal improvements in penile
curvature but a reasonable level of patient satisfaction, probably attributable to
increased penile length. Length increased 0.5–2.0 cm; girth increased 0.5–1.0 cm;
curvature mean decrease of 20 degrees; pain decreased; softening or shrinking of
plaque; overall satisfaction 85%.
 Device has to be worn for 3 or more hours per day to get satisfactory results.
 There is no recommendation offered by the AUA 2015 PD guidelines panel

71. VACCUM DEVICES.
 Vacuum erection devices are usually
considered safe. Moa- similar to stretch
therapy.
 Complications-development of PD, urethral
bleeding, skin necrosis, and penile ecchymosis
have been reported with concomitant use of
constriction rings and when inappropriately
elevated pressures are applied to the penis for
an extended period.
 There is no recommendation offered by the
AUA 2015 PD Guidelines Panel regarding
vacuum therapy as Monotherapy.

72. Combination Therapy
 Combination of the mechanical effects of penile
traction with the chemical effects of intralesional
verapamil and oral medications (pentoxifylline and
L-arginine) could have a synergistic effect on the
tunica albuginea and Peyronie’s plaque.
There is no recommendation offered by the
AUA 2015 PD Guidelines Panel regarding
combination therapy.

73. Radiation Therapy
 In vitro studies suggest that low-dose radiation therapy has a
potent anti-inflammatory effect, inhibiting leukocyte-
endothelium interactions.
 No more effective than no treatment.
 Expert consensus - radiation should be avoided because of
potential risk for malignant change and increase in the risk for ED
in aging patients.
 The 2015 AUA PD guideline recommends that clinicians should
not use radiotherapy (RT) to treat Peyronie’s disease because of
the known risks and uncertain benefits.
 Conclusion
 It appears that the goal of nonsurgical treatment at a minimum
should be to prevent progression of deformity during the acute
phase. Reducing deformity to improve sexual function and reduce
the effects of the scarring is the ultimate goal of all treatment for

74. Summary of non surgical therapy

77. SURGICAL TREATMENT
 Gold standard -to most rapidly and reliably correct the
deformity associated with PD.
 For men who also have ed, placement of a penile prosthesis can
provide rigidity for penetrative sexual activity.
 The indications for surgical correction include:-
1. Stable disease- defined as disease that is at least 1 year
from onset, and at least 6 months of stable deformity.
2. Inability to engage in sexual intercourse because of the
nature of the deformity and/or inadequate rigidity.
3. If conservative therapy has failed.
4. Desire for most rapid and reliable result.

80. PREOPERATIVE CONSENT
 No single surgical approach is universally defined as the
standard of care.
 Preoperative consent is critical as patients with PD are
distressed and frequently emotionally devastated.
 Important to have a frank discussion-so that pt
understands the limitations of the operation, and to set
appropriate expectations regarding outcomes to optimize
patient satisfaction.
 The patient should understand that there is a possibility of
persistent or recurrent curvature, reduction of penile erect
length, diminished rigidity, and decreased sexual
sensation.
 The patient should understand that the goal is to make the

81.  The European Association of Urology (EAU)
guidelines committee on PD defines successful
curvature correction as 15 degrees or less of
residual curvature.
 Having stretched flaccid penile length documented
preoperatively permits comparison with
postoperative length.
 Patient should understand that any operation
done to correct PD may result in diminished
rigidity, and that this may subsequently be
treated successfully with oral PDE5 inhibitors,
injection therapy, or a vacuum device; and
those in whom these approaches fail can have
a penile prosthesis implanted with little to no
additional difficulty.

82. The primary determinants
for the choice of surgical approach
 Based on two factors:
 1.Quality of the preoperative erection hardness.
 2.Severity of deformity, including curvature and
indentation.
 In men who have rigidity that is adequate for coital
activity with or without pharmacotherapy, tunica
plication techniques and plaque incision or partial
excision with grafting may be used.
 Tunica plication techniques are recommended for
those who have a simple curvature of less than 70
degrees, those with absence of an hourglass or hinge
effect, and those in whom the anticipated loss of

83. Estimated penile length loss can be
determined during preoperative testing while
the penis is erect by measuring the difference
in length between the long and short sides of
the penis.
Grafting procedures are recommended for
those with more complex curves of greater
than 60 to 70 degrees and/or a destabilizing
hourglass resulting in a hinge effect. This
hinge effect results in a buckling or unstable
penis, which makes penetrative sex difficult.
These men must have strong, sexually

84.  For the man who has PD and ED that is refractory
to medical therapy- penile prosthesis placement is
the procedure of choice.
 If curvature is not satisfactorily corrected with the
prosthesis inflated during surgery, additional
straightening maneuvers may be performed.
 Manual modeling as the first step is
recommended.
 If there is residual curvature in excess of 30 degrees
after modeling, then a relaxing incision in the tunica
albuginea overlying the area of maximum curvature
can be made.
 It is recommended that if the incisional defect is
greater than 2 cm, a biograft (i.e., pericardium or small
intestine submucosa) should be placed over the defect

85. Plication techniques have been
recommended to be performed before
placement of the prosthesis to correct
curvature instead of manual modeling.
If the curvature is dorsal, the erectile
deformity can be defined with injection of
a vasoactive drug and infusion of saline,
then sutures are placed in a Lembert
fashion to cause ventral shortening and
correction of the curve.

86. Tunical Shortening Procedures
 Penile plication aims to shorten the longer (or convex) side
of the tunica albuginea to match the length to the shorter
side.
 Advantages.
 1.Shorter surgical time.
 2.Good cosmetic outcomes.
 3.Minimal effect on rigidity.
 4.Simple and safe surgery.
 5.Effective straigtening.
 Disadvantage:-Penile shortening and failure to correct an
hourglass or hinge.

87. NESBIT PROCEDURE
This technique uses excision of an
elliptical segment of the tunica on
the contralateral side of the
curvature.
In the setting of a ventral curvature,
once Buck’s fascia has been
elevated, small wedges of the
dorsal tunica albuginea are excised
and then the defect is closed,

89. YACHIA PROCEDURE
 Uses heineke-mikulicz technique.
 In the setting of a dorsal curvature, a short (0.5 to 1.5
cm), full-thickness vertical incision is made on the
ventral shaft tunic, opposite the area of maximum
curvature, which is then closed transversely to shorten
the ventral aspect and correct the curvature.
 This approach must be used carefully so that the
length of the incision is not too long, such that
transverse closure could result in further narrowing of
the shaft, possibly resulting in an unstable erection.
 Has a lower risk for perceived penile shortening.

91. 16 DOT PROCEDURE.
The 16-dot procedure has become a
popular variation of tunical shortening.
There is no incision into the tunic but
the tunica albuginea is plicated with
permanent suture using an extended
lembert-type suture placement
technique.

93. Tunica albuginea plication
(TAP).
 Another plication variation is the levine modification of the
duckett-baskin TAP.
 Originally used for children with congenital curvature.
 A partial-thickness incision is made transversely on the
contralateral side to the point of maximum curvature.
 A pair of transverse parallel incisions 1 to 1.5 cm in length are
made through the longitudinal fibers but do not violate the inner
circular fibers of the tunica albuginea therefore the underlying
cavernosal tissue is not disturbed, which is thought to reduce the
likelihood of postoperative ED.
 Incisions are separated by 0.5 to 1.0 cm depending on the desired
amount of shortening.
 The longitudinal fibers between the two transverse incisions

95. Disadvantages of tunica plication procedures.
 Does not correct shortening.
 May enhance loss of penile shaft length.
 Does not address hinge or hourglass effect and may
exacerbate it, resulting in an unstable penis.
 The plaque is left in situ.
 Penile narrowing or indentation- reported in up to
17%.
 Pain associated with the knots and suture
granulomas.
 Surgical straightening with plication procedures can
be expected in 79% to 100% of patients, with a
reported satisfaction rate of 65% to 100%.

96. Disadvantages of tunica plication procedures.
 Risk for new ED ranges from 0% to 38%.
 Diminished sensation in- 4% to 21%
Less common complications include
 Hematoma in up to 9%.
 Urethral injury in less than 2%.
 Phimosis in up to 5%.
 “No evidence that one surgical approach provides
better outcomes over another, but curvature
correction can be expected with less risk of new
ed” when compared with grafting procedures.

97. Tunical Lengthening Procedures (Plaque Incision or
Partial Excision and Grafting)(PIG/PEG).
 Indications
Greater complexity of disease with
several (or all) of the following:
Curvature greater than 60 to 70 degrees,
shaft narrowing, hinging.
Extensive plaque calcification.
 Most important- for the patient to be a
candidate for PIG or PEG, he must have
strong preoperative erections.

98.  Advantage of grafting procedure-
It would likely correct curvature and
reestablish more normal shaft caliber while
increasing the likelihood of some length
recovery in the range of 0.5 to 3.0 cm.
 Linear association between preoperative
and postoperative ed.
 Patients with ventral deformity do not do
well with grafting procedures.

99.  Historically, total excision of the plaque was
practiced to “cut out the disease,” resulting in
onlays of large grafts with an unacceptably high
rate of ED.
 Therefore,plaque incision was introduced in which
a modified-H or double-Y incision is made in
the area of maximum curvature.
 This allows the tunic to be expanded in this area,
thereby correcting the curvature and shaft caliber
but minimizing the underlying exposure of the
cavernous tissue and thereby reducing the
potential fibrosis of the cavernosal tissue and/or
interrupting the delicate veno-occlusive
mechanism.

100.  Partial excision and grafting may be preferable in
cases in which the area of maximum deformity is
excised, particularly if it is associated with severe
indentation.
 To reduce the risk for postoperative ed, the key
is to limit trauma to the underlying cavernosal
tissue to maintain the venoocclusive
relationship between the cavernosal tissue and
the overlying tunica graft.
 Clinicians may offer plaque incision or excision
and/or grafting to patients with deformities whose
rigidity is adequate for coitus (with or without
pharmacotherapy and/or vacuum device therapy) to
improve penile curvature, as per the 2015 aua pd
guideline.

101. GRAFT MATERIALS
 The 2015 AUA PD guideline offers no opinion on choice of graft material.
 IDEAL GRAFT.
1. Should approximate the strength and elastic characteristics of normal
tunica albuginea.
2. Have minimal morbidity and tissue reaction.
3. Should be readily available
4. Should not be too thick
5. Should be pliable
6. Easy to size and suture
7. Inexpensive
8. Resistant to infection
9. Should preserve erectile capacity

102. GRAFT MATERIALS
 Autologous grafts have been used historically, including fat,
dermis,Tunica vaginalis, dura mater, temporalis fascia,
saphenous vein, crura Or albuginea, and buccal mucosa.
 Fallen out of favor because of a need for extended surgery to
harvest the graft and a second surgical site, which possesses its
own potential complications of healing, scarring, and possible
lymphedema.
 Crural and buccal grafts are compromised by the inability to
get enough graft material for large defects.
 Synthetic polyethylene terephthalate (PETE, Dacron) and
polytetrafluoroethylene (PTFE, Teflon) grafts have been used
historically and are not recommended now because of the
potential risk for infection, localized inflammatory response, and
fibrosis.

103. GRAFT MATERIALS
 The two most common grafts currently used are
Tutoplast (Coloplast US), processed human and
bovine pericardium, and porcine small intestinal
submucosa (SIS) grafts (Surgisis).
 Advantage- ease of use and reduction in
operating times.
 The pericardial grafts are thin, strong, do not
contract, and have no reports of infection or
rejection.

105. Tissue-engineered graft materials
Advantage of having a graft seeded
with cellular material-may enhance the
take of the graft and potentially reduce
local tissue fibrosis with diminished
postoperative ED.
Adipose tissue–derived stem cell–
seeded sis, human acellular matrix
tunica albuginea grafts, and autologous
tissue–engineered endothelialized
tunica albuginea grafts have been
investigated for incision and excision
procedures.

106. Tachosil (Baxter Healthcare, Deerfield,
IL)
 Tachosil is a collagen fleece coated
with a tissue sealant that adheres to
tissue after several minutes of
compression.
 Because no surgical fixation is
required, collagen fleece is easy to
administer, and may shorten
operating time.
 At a mean follow-up of 25 months,
there were no major complications
and recurrence was observed in

107. Grafting Surgical Technique
 The dorsal Stretched Penile Length should be measured.
 An artificial erection is created by injecting a vasoactive
drug (papaverine, Trimix, prostaglandin E1) via a 21-gauge
butterfly needle placed through the glans into the corpus
cavernosum.
 Saline can be infused to create a full rigid erection, which
allows visualization and measurement of the deformity,
including curvature and areas of indentation with or without
hinge effect.
 Preferred approach- circumcising incision made
approximately 1.5 to 2 cm proximal to the corona, or
through a previous circumcision site.
 Penis is degloved down to the Buck fascia, at which
point hemostasis is obtained with bipolar cautery.
 It is advisable to use loupe magnification to reduce the

108. Grafting Surgical Technique
 In case of a dorsal or dorso-lateral curvature--the Buck
fascia, with the enclosed neurovascular bundle, is
elevated by making a pair of parallel incisions just lateral
to the urethral ridge, through the Buck fascia to the tunica
albuginea.
 Once the Buck fascia is elevated off the area of maximum
deformity, a full erection is re-created.
 The area of maximum deformity is marked for incision or
partial plaque excision.
 It should be noted that even with a pure lateral curvature,
the tunic to be excised must traverse through the dorsal
septum, because this is the anchor point of the scar and if

109. Grafting Surgical Technique
 The graft should be sized no more than 10% larger
than the measured defect on stretch.
 Once the graft has been cut to size, it is secured in
place with the previously placed stay sutures; then,
with 4-0 PDS placed in a running fashion, the graft
is secured to the defect.
 Once satisfactory deformity correction has been
accomplished, the Buck fascia is reapproximated
with running 4-0 chromic, and the shaft skin is
reapproximated to subcoronal skin with interrupted
4-0 chromic in a horizontal mattress fashion.

110. Grafting Surgical Technique
 For those patients who are uncircumcised and
do not have any evidence of phimosis, a
circumcision is not necessary.
 If there is any question of excessive redundant
foreskin and/or phimosis, then circumcision
should be performed to reduce the likelihood of
postoperative paraphimosis.
 Typically the dressing is left in place for 3 days
and then removed, at which point the patient
may shower.

111. Postoperative management
 Patient is seen 2 weeks after surgery, at which
point massage and stretch therapy are initiated.
 The patient is instructed to grasp the penis by the
glans and gently stretch it away from the body
and then with his other hand to massage the shaft
of the penis for 5 minutes twice per day for 2 to 4
weeks.
 Use of nocturnal PDE5 inhibitors to enhance
postoperative vasodilation, may help support graft
take, reduce cicatrix contraction, and theoretically

112. Postop management
 External penile traction devices have been
encouraged and have been shown to reduce
length loss postoperatively and can even
enhance length gain after both grafting and
plication procedures.
 Traction is recommended to be used for 3 or
more hours per day, beginning 3 to 4 weeks
after surgery, once the wound can tolerate the
pressures of the stretching device, for 3
months.

113. Penile Prosthesis for Men With Peyronie’s Disease
Indications
In men with PD and concurrent ED
refractory to PDE5 inhibitors-penile
prosthesis placement- procedure of
choice.
Additional straightening maneuvers
may be necessary, including manual
modeling and incising of the tunica
albuginea with or without grafting.

114. Algorithm for the surgical correction of peyronies disease
with co-existent erectile dysfunction.
Penile prosthesis
Manual remodeling (if residual curvature
more than 30 degree).
Tunical incisions or plication (if persistent
curvature even after remodelling).
Plaque incision/excision and grafting(persistent
curvature even after releasing incisions or if
defect more than 2 cm).

115. Techniques for Straightening When Placing a Penile
Prosthesis for Peyronie’s Disease
 An inflatable penile prosthesis (IPP) appears to
be the preferred surgical implant, as the
pressure within the cylinders allows for superior
correction of curvature with manual modeling,
and improved girth enhancement.
 Manual modeling via the penoscrotal approach
is recommended with a high-pressure inflatable
cylinder, but all available three-piece and two-piece
devices have been used successfully to correct
deformity.
 Place the prosthesis cylinders first, followed by
closing of the corporotomies.

116. Techniques for Straightening When Placing a Penile
Prosthesis for Peyronie’s Disease
 The penis is then bent in the contralateral direction to
the curvature.
 It is recommended to try to hold the penis in this
position for 60 to 90 seconds, The modeling
technique should be a gradual bending rather
than a violent maneuver, because this will reduce
the likelihood of inadvertent tearing of the tunic
or injury to the overlying neurovascular bundle.
 Successful straightening can be expected in 86% to
100% with no higher incidence of device revision.

117. MC postoperative complaint
heard from men who have
undergone penile prosthesis
placement is length loss.

118. EUA TREATMENT ALGORITHM

121. Thankyou