Dr. V. Arul is a urology resident at the Institute of Urology at Madras Medical College. Peyronie's disease is a wound healing disorder of the tunica albuginea that causes penile curvature, indentation, shortening, and erectile dysfunction. Evaluation involves assessing symptoms, examining the penis for plaques, and testing for erectile dysfunction. Treatment options include wait and see, oral medications, intralesional injections, devices, surgery like plication and grafting, and inflatable penile prosthesis for severe cases.

1. DR.V.ARUL
UROLOGY RESIDENT
INSTITUTE OF UROLOGY
MDADRAS MEDICAL COLLEGE

2. outline
 Introduction
 Natural history
 Anatomical consideration
 Etiology
 Symptoms
 Evaluation
 Non surgical treatment
 Surgery

3. INTRODUCTION
•It was first described by francois gigot de la peyronie
in 1743.
•Also known as induratio plastica of the penis.
•wound healing disorder of tunica albugenia
•Injury to penis – exuberant scar – abnormal wound
healing
•Inelastic plaque formation, no remodelling of scar
•Curvature, indentation, hinge effect, shortening, ED

4. Natural history
 Active phase – painful erection, changing deformity
 Chronic phase – stable deformity , no painful erections
 Curvature – secondary to inflamation

5. Spontaneous resolution
 Full resolution – rare
 If in active phase – wait for 6 months
 13% have some resolution upto 12 months
 If no treatment from 12 – 18 months – 50% - worsening
of deformity

6. Associated conditions
 Ageing – 50’s
 DM with PD – 33.2%
 Severity of symptoms / deformity increase with
duration of DM
 Plaque size and pain decreases with DM control
 Less rigid penis – injury
 Decreased compliance d/t increased collagen cross
linking
 ED with PD – upto 58%

7.  Depression upto 48% d/t inability for intercourse,
penile shortening
 Post radical prostatectomy
 Hypogonadism / testosterone defeciency – increased
severity
 Testosterone + intralesional verapamil – increased
efficiency
 Dupytrens contrature with PD – upto 56%
 Contracture of plantar fascia – ledderhouse disease &
tympanosclerosis

9. ANATOMICAL CONSIDERATION
 The tunica albuginea is bilaminar throughout most of
its circumference.
 It is composed of an outer longitudinal layer and an
inner circular layer. Have type 1 collagen.
The corpora are separated by an incompetent septum.
The anchor areas are suceptable for microvascular trauma
and tunical delamination – trigger for disease
 In the pendulous portion of the penis, there are
intracavernous supporting fibers that anchor the inner
layer of the corpora cavernosa at the 2-o'clock and 6-
o'clock positions.

11.  The outer longitudinal layer attenuates in the ventral
midline, and thus the tunica is monolaminar at that point.
The outer longitudinal layer is thinnest at 3 – 9 o clock.
Absent at 5 – 7 o clock
 Most patients with Peyronie's disease demonstrate lesions
Dorsally (60% - 70%)
 Because the tunica albuginea is bilaminar on the dorsum, it
is possible that these layers might delaminate with
buckling trauma.
 Also, on the ventrum, the longitudinal layer is absent, thus
potentially allowing dorsal buckling more easily

13. Remodelling phase
1 – 2 yrs
MMP VS TIMP

15.  It has been proposed that the avascular nature of
the tunica albuginea may impede clearance of
many of these growth factors.
 The transforming growth factors, particularly
transforming growth factor-β (TGF-β), are capable
of autoinducement.
 Thus, the accumulation of TGF-β1 is capable of
inducement of further accumulation.

18.  It has also been seen that patients with peyronie’s
disease have a higher incidence of penile trauma
associated with intercourse.
 In one third of patients erectile dysfunction precedes
the onset of peyronie’s disease.
 Patients were examined with dynamic infusion
cavernosometry and cavernosography (DICC) and
found that venous leak is seen more commonly in men
who develop erectile dysfunction with Peyronie's
disease

19.  Veno-occlusive dysfunction was most prevalent in
patients with ventral curvature.
 Also , “Patients with ventral curvature do not do well
with graft operations.”

20. SYMPTOMS
 The presenting symptoms of Peyronie's disease
include, in many patients, penile pain with erection;
penile deformity, both f laccid and erect; shortening
with and without an erection; plaque or indurated
areas in the penis; and in many patients, erectile
dysfunction.
 On physical examination, virtually all patients have
either a well-defined plaque or an area of induration
palpable.
 The plaque is usually on the dorsal surface of the
penis, intimately associated with the insertion of the
septal fibers.

21.  Patients not uncommonly can remain sexually active
with significant dorsal curvature (up to 45 degrees).
 Patients with lateral components or ventral Peyronie's
disease tolerate the deformity far less well.
 Pain may be persistent in the inf lammatory stage of
the disease; it is usually not severe, but it can interfere
with sexual function.
 Some patients also complain of being awakened in the
morning or at night with pain during erection.

22.  Kelami classification
 39.5% of patients had 30 degrees (mild)
 35% had 31 to 60 degrees(moderate)
 13.5% had more than 60 degrees of curvature (severe)

23. EVALUATION OF PATIENT
 the medical history should include the mode of onset
(sudden versus gradual) and time at onset
 The history is obtained of prior penile surgery, urethral
instrumentation or external trauma, medication or
drug abuse and fibromatosis including Dupuytren's
contracture and Ledderhose's disease.
 Family history of the other fibromatoses is revealing.
 Because most patients with Peyronie's disease have an
element or at least the aura of erectile dysfunction, risk
factors for erectile dysfunction should also be assessed.

24.  Cardiovascular disease and erectile dysfunction share a
host of risk factors including age, smoking,
hyperlipidemia, hypertension, and diabetes mellitus.
 A detailed psychosexual history is imperative.
 Photographs of the patient's erect penis are helpful in
identifying the direction of curvature and degree of
curvature, and they provide some information about
the patient's erectile function.

25.  The penis should be examined on stretch.
 This amplifies the plaque and often allows the
examiner to feel plaques
 The location and size of the plaque as well as the
consistency (e.g., tender, indurated) should be
defined.
 Look for duputryens contracture, ledderhose
disease & tympanosclerosis

28.  Demonstration of calcification is easily
accomplished with ultrasound examination.
 The calcified plaque will be shown as shadowed
areas.
 Plain radiography is also equally effective in
demonstrating calcification within the plaque
 CT scan does not pick up the plaque routinely &
MRI can still pick up the plaque better.

29. USG

31. B – mode scan

32. X RAY

33. CT SCAN

34.  Patients who need to undergo surgery are
subjected to duplex ultrasound.
 If the peak systolic velocity , end diastolic velocity
& resistive index are normal than they are not
tested further & if it is abnormal than they are
subjected for dynamic infusion cavernosometry &
cavernosography.

35. DOPPLER

37. DRUGS

38. INTRALESIONAL AGENTS

39. EXTERNAL FORCE APPLICATION

41. Indications for Surgery
• Stable deformity for at least 6 months from onset of
symptoms
• Inability to engage in satisfactory penetrative sexual
intercourse because of deformity and/or
inadequate rigidity
• Failed conservative treatment
• Desire for most rapid and reliable result

43. PREOP CONSENT
. Set expectations regarding outcome.
• Persistent or recurrent curvature: The goal is “functionally
straight” (curvature <20 degrees)
• Change in length: The result is more likely shorter with
plication than with grafting.
• Diminished rigidity
≥5% in all studies—grafting more than plication
≥30% if suboptimal preoperative rigidity—dependent on
preoperative erectile quality
• Decreased sexual sensation
Typically resolves in 1 to 6 months
• Rarely compromises orgasm or ejaculation

44. TUNICA SHORTENING
 Penile plication aims to shorten the longer (or
convex) side of the tunica albuginea to match the
length to the shorter side
 shorter surgical time, good cosmetic outcomes,
minimal effect on rigidity, simple and safe
surgery, and effective straightening
 Disadvantages include shortening and failure to
correct an hourglass or hinge.

45. NESBIT PROCEDURE

46. YACHIA PROCEDURE

47. DOT PROCEDURE

48. TAP PROCEDURE

49. Tunical Lengthening Procedures
(Plaque Incision or Partial
Excision and Grafting)
 curvature greater than 60 to 70 degrees
 shaft narrowing,
 hinging,
 extensive plaque calcification
 he must have strong preoperative erections

50. GRAFTS
 autologous grafts have been used
 fat, dermis, tunica vaginalis, dura mater, temporalis
fascia, saphenous vein, crura or albuginea, and buccal
mucosa
 PTFE / DACRON NOT RECOMMENDED
 Tutoplast (Coloplast US, Minneapolis, MN), processed
human and bovine pericardium,
 porcine small intestinal submucosa (SIS) grafts

51.  Plication and corporoplasty techniques seem to be
useful especially for patients with associated erectile
dysfunction, in whom grafting procedures could be
expected to cause further deterioration of erectile
function.
 This procedure is used for those patients with ventral
curvature .

52. Circumferential incision

60. PENILE PROSTHESIS
The penile prosthesis is a reliable option for the older
man with vascular impairment, erectile dysfunction,
and acquired deformity of the penis .
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, as well as
improved girth enhancement

61. MANUAL MODELLING:
•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
•modeling procedure repeatedly until satisfactory
curvature correction has been attained.
•The modeling technique should be a gradual
bending
•most common postoperative complaint heard from
men who have undergone penile prosthesis
placement is length loss