This document provides information about Peyronie's disease, including its epidemiology, etiology, symptoms, evaluation, and treatment protocols. It defines Peyronie's disease as a wound-healing disorder of the penis that results in scar formation. Evaluation involves assessing the location and size of plaques, penile deformity, and erectile function. Treatment options include nonsurgical approaches like intralesional injections and surgical options like plaque incision or grafting to correct the curvature.

1. PEYRONIE’S DISEASE
DEPT OF UROLOGY
GOVT ROYAPETTAH HOSPITALAND
KILPAUK MEDICAL COLLEGE
CHENNAI
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2. MODERATORS:
Professors:
 Prof.Dr.G. Sivasankar,M.S., M.Ch.,
 Prof.Dr.A. Senthilvel, M.S., M.Ch.,
Asst Professors:
 Dr.J. Sivabalan,M.S., M.Ch.,
 Dr.R. Bhargavi,M.S., M.Ch.,
 Dr.S. Raju, M.S., M.Ch.,
 Dr.K. Muthurathinam,M.S., M.Ch.,
 Dr.D.Tamilselvan,M.S., M.Ch.,
 Dr.K. Senthilkumar,M.S., M.Ch.
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4. GENERAL CONSIDERATIONS
 “It is 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”
 first known as induratio penis plastica.
 named after Francois Gigot de la Peyronie - first to describe and offer treatment for it in a paper published in
1743
 prevalence - 3% to 20%
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6. NATURAL HISTORY
Two phases:
 1) Active (acute) phase - commonly associated with painful erections and changing deformity of the penis.
 2) Stable (chronic) phase - stabilization of the deformity and disappearance of painful erections
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7. EPIDEMIOLOGY
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8.  incidence of PD - 3% and 9%.
 peak age of onset - early 50s
 prevalence of diabetes in men with PD - 33.2%
 prevalence of ED in men with PD has been reported to be 37% to 58%
 moderate to severe depression noted in 48% of PD patients
 increased incidence of PD in men who have undergone radical prostatectomy
 Hypogonadism - low serum testosterone may be associated with PD
 collagen disorders - Dupuytren disease, contracture of the plantar fascia (Ledderhose
disease) and tympanosclerosis. 8
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9. PENILE ANATOMY AND PEYRONIE’S DISEASE
 tunica albuginea:
- multilayered structure,1.5 to 3.0 mm thick.
- mainly composed of type 1 collagen - 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
 without septum,stress generated by a full erection of one contiguous corporeal body would be sufficient to
rupture the tunica albuginea.
 septum is further reinforced by intracavernous pillars, which anchor the tunica albuginea across the corpora
cavernosa
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11.  longitudinal layer of TA is thinnest at the 3 and 9 o’clock positions of the corpora;
completely absent between the 5 and 7 o’clock positions
This contributes to more common - dorsal buckling and dorsal curvature.
 “plaque” - disorganization of collagen fibrils and a decrease in and disorganization of elastin resulting
in penile deformity caused by asymmetrical expansion of the corpora.
 deviation occurs to the side of inelastic scar
 a circumferential plaque may lead to an hourglass deformity.
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13. ETIOLOGY
 Mechanism
- in the erect state,the pressures inside the penis increases.
- These pressures may exceed the elasticity and strength of the tunica tissues,resulting in a microfracture.
 trauma to the flaccid penis may also trigger this process.
 abnormal wound-healing response in the “genetically” susceptible man.
 oxidative stress( free radicals) - overexpression of fibrogenic cytokines and augmented transcription and synthesis
of collagen.
 NO - reduction of myofibroblast abundance and reduction in collagen I synthesis.
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14.  Myofibroblast activation - key event in the development of fibrosis.
Trauma to the tunica albuginea > increases the adherence of fibroblasts > differentiation into
myofibroblast
 TGF-β1 - is a strong activator of myofibroblasts and a potent fibrotic growth factor by stimulating
the deposition of ECM.
 most highly upregulated gene found in the PD plaque,PTN or OSF1,codes for a secreted heparin-
binding protein thought to stimulate mitogenic growth of fibroblasts and osteoblast recruitment.
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15. SYMPTOMS
 frequent presenting symptoms - penile pain, erect deformity, palpable plaque, and ED
 Once disease is stable, most pain will resolve.
 many are capable of sexual activity with curvature up to 60 degrees (particularly if the curvature is
dorsal)
 Men with ventral or lateral curvatures have a more difficult time with intromission (more
discomfort)
 Plaque configurations - cords; simple nodules; coinlike, irregular dumbbell shapes; I-beam plaques.
 orientation of the plaque usually defines the deformity
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18. EVALUATION
 whether the patient is capable of intromission or incapable because of deformity and/ or diminished rigidity ??
 vascular risk factors for ED - diabetes,hypertension,elevated cholesterol,and smoking
 photographs taken at home (from above and from the side in the erect state) – controversial !!
 Assessment of Plaque:
- penis examined on stretch - easier identification of the plaque
- location
- size of the plaque - inaccurate (rarely a discrete lesion)
- irregular borders and often extends into a septal cord
- stretched penile length (SPL) should be measured.
- consistency - “rock hard” plaque is indicator of calcification 18
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20. calcification of plaque:
 may occur early after the onset of the scarring process,
 genetic subtype - activation of genes involved in osteoblastic activity
 Extent of mineralization - more extensive calcification >> less likely to benefit from nonsurgical treatment
 extensive calcification - more apt is penile prosthesis.
 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)
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21. Assessment of penile deformity
 done in erect state
 Methods – home photograph, vacuum-induced erection,office vasoactive injection (most accurate)
 AUA 2015 recommends - in-office intracorporeal injection therapy should be performed in every patient before invasive
intervention.
OtherTests:
 assessment of penile sexual sensitivity - light touch and biothesiometry
 Morning serum total testosterone level - recommended for men with ED
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23. IMAGING
 calcified plaque is readily identified
on USG
 hyperdensity of the plaque with
shadowing behind it.
 CT and MRI have little value in the
evaluation PD
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25. Dynamic infusion cavernosometry (DICC)
 assess penile vascular integrity – checks venous leakage before surgery
 unnecessary invasiveness
 little value to the diagnostic evaluation over a well-done dynamic penile duplex USG
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26. TREATMENT PROTOCOLS
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27. NONSURGICAL
 Oral medications
 Intralesional Injection
 Topical drug application
 Extracorporeal ShockWaveTherapy - ESWT
 Electromotive DrugAdministration
 Penile Traction
 Vacuum therapy
 Radiation therapy
SURGICAL
 Tunical Shortening Procedures - Plaque incision
 Tunical Lengthening Procedures - Plaque
Incision or Partial Excision and Grafting
 Penile prosthesis
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28. : NON-SURGICAL TREATMENT
 If no pain or no difficulty in accomplishing penetrative sex >> require only reassurance.
 conservative treatments often yield inconsistent and clinically insignificant improvements in
deformity.
 no oral agent has been shown clinically meaningful improvement in curvature.
 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.
 Intralesional verapamil and IFN alfa-2b have shown evidence of reduced curvature and
improved sexual function. (Also deformity stabilization during the acute phase)
 The first FDA-approved drug for the treatment of PD - CCH (Xiaflex)
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32. SURGICAL MANAGEMENT
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34.  primary determinants for the choice of surgical approach
1) quality of the preoperative erection hardness
2) severity of deformity - including curvature and indentation.
 Estimated penile length loss ( preoperative testing,in erect state) - by measuring the difference in
length between the long and short sides of the penis.
 Hinge effect - results in a buckling or unstable penis ( difficult penetrative sex)
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36. 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:
 shorter surgical time
 good cosmetic outcomes
 minimal effect on rigidity
 simple and safe surgery
 effective straightening
Disadvantages : shortening and failure to correct an hourglass or hinge
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37. NESBIT PROCEDURE
 excision of an elliptical segment of the
tunica on the contralateral side of the
curvature.
 In ventral curvature,once Buck’s fascia
has been elevated, small wedges of the
dorsal tunica albuginea are excised and
then the defect is closed,typically with
permanent suture
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38. YACHIA PROCEDURE
 uses Heineke - Mikulicz technique
 In 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
 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 38
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39. 16-DOT PROCEDURE
 no incision into the tunica
 tunica albuginea is
plicated with permanent
suture using an extended
Lembert-type suture
placement technique
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40. TUNICA ALBUGINEA PLICATION (TAP)
 Levine modification of the Duckett-Baskin TAP
 originally used for children with congenital
curvature.
 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
 do not violate the inner circular fibers of TA >
the underlying cavernosal tissue is not disturbed
> > less 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 are excised so as to reduce
the bulk of the plication
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41. TUNICAL LENGTHENING PROCEDURES
 Plaque Incision or Partial Excision and Grafting (PIG / PEG)
Indications
 curvature greater than 70 degrees
 shaft narrowing / hour-glass deformity,hinging
 extensive plaque calcification
Pre-requisite : patient must have strong preop erections.
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42.  total excision of the plaque - unacceptably high rate of ED
 limit trauma to the underlying cavernosal tissue to maintain the venoocclusive relationship between the
cavernosal tissue and the overlying tunica graft >> reduces postop ED
 plaque incision - modified-H or double-Y incision - made in the area of maximum curvature
This allows the tunic to be expanded in this area,
corrects the curvature and shaft caliber
minimizes the exposure of the cavernous tissue
 PEG is preferable in cases with severe indentation.
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43. GRAFT MATERIALS
 2015 AUA PD guideline offers no opinion on choice
of graft material.
Ideal graft
 should approximate the strength and elastic
characteristics of normal tunica albuginea;
 have minimal morbidity and tissue reaction
 readily available
 not too thick; pliable
 easy to size and suture
 inexpensive,
 resistant to infection
 should preserve erectile capacity
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44.  Synthetic – Dacron,Teflon grafts are not recommended now - risk for infection,localized inflammatory response,
and fibrosis
 Tutoplast processed pericardial graft (Coloplast) are preferred - little graft contraction.
The graft should be sized no more than 10% larger than the measured defect on stretch
 Tissue-engineered graft materials - Adipose tissue–derived stem cell–seeded SIS, human acellular matrix tunica
albuginea grafts,and autologous tissue–engineered endothelialized tunica albuginea grafts
 Tachosil – a collagen fleece coated with a tissue sealant that adheres to tissue after several minutes of
compression.
no surgical fixation is required,
easy to administer 44
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45. Postoperative Management
 patient is seen 2 weeks after surgery - massage and stretch therapy are initiated
 patient is instructed to grasp the penis by the glans and gently stretch it away from the body
then with his other hand to massage the shaft of the penis for 5 minutes twice per day for 2 to 4
weeks.
 nocturnal PDE5 inhibitors - enhance vasodilation >> support graft take, reduce cicatrix contraction,
and preserve cavernosal tissue >> reducing postoperative ED
 external penile traction devices - enhance length gain
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46. PENILE PROSTHESIS
 Indication - PD with concurrent ED refractory to PDE5 inhibitors
 inflatable penile prosthesis (IPP) - preferred implant.
pressure within the cylinders allows for superior correction of curvature with manual modeling, and
improved
girth enhancement
 most common postop complaint in penile prosthesis - length loss.
 Manual modeling:
done via the penoscrotal approach
should be a gradual bending
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