this seminar is for urology residents all over india .

1. BY: DR.PARTH M NATHWANI
GUIDE: DR.NITIN S JOSHI

2. INTRODUCTION
 It was first described by francois gigot de la in 1743.
 Also known as induratio plastica of the penis.
 In most patients reassuarnce is sufficient and a
necessity.
 Most patients with this disease do not require surgery
 Surgery is done when there is mechanical effect of
peyronie’s disease or erecticle dysfunction

3.  The disease also known to be associated with
dupuytren disease in 30-40% of cases.
 Other associated fibrotic conditions are contracture of
plantar fascia & tympanosclerosis
 It can also occur following trauma
 The relationship of peyronie’s disease to DM remains
unclear.

4.  Patients with DM were shown to have statistically
significant more curvature & worse vascular status.
 It is also related to gout , paget’s disease of bone , use
of beta blockers, urethral instrumentation , phenytoin
intake
 Repeated trauma due to intra cavernosal injection of
papaverine can initiate peyronie’s like process.

5.  Symptomatic incidence is 1% and asymptomatic
incidence is 4 – 5 %
 Average age of onset is 53 years.

6. ANATOMICAL CONSIDERATION &
ETIOLOGIC FACTORS
 The tunica albuginea is bilaminar throughout most of
its circumference.
 It is composed of an outer longitudinal layer and an
inner circular layer.
 The corpora are separated by an incompetent septum.
 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.
 The tunica albuginea varies in thickness from 1.5 to 3
mm, depending on the position on the circumference.

7.  The outer longitudinal layer attenuates in the ventral
midline, and thus the tunica is monolaminar at that point.
 The outer longitudinal layer is thickest on the ventrum
adjacent to the corpus spongiosum and on the dorsum and
thinnest on the lateral aspects.
 Most patients with Peyronie's disease demonstrate lesions
dorsally.
 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

8.  Peyronie's disease most likely begins with buckling
trauma that causes injury to the septal insertion of the
tunica albuginea.
 Intravasation of blood occurs with activation of
fibrinogen.
 The body responds to the effects of trauma, and
macrophages, as well as neutrophils and mast cells,
migrate to the area.
 Platelets are present because of the intravasation of
blood, and fibrin becomes incarcerated in the healing
process.

10.  Platelets, neutrophils, and mast cells secrete cytokines,
autacoids, and vasoactive factors, many of which
become involved in fibrosis.
 Platelets release serotonin and platelet-derived growth
factors as well as transforming growth factors.
 The formation of thrombus leads to the deposition of
fibronectin, which binds a number of growth factors,
keeping them localized to the area of injury.
 Fibrinogen leakage leads to the deposition and
incarceration of fibrin

11.  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.

12.  The presence of TGF-β stimulating further release
of TGF-β1 could possibly lead to an ongoing,
smoldering, inflammatory process ending with
disordered healing.
 There is good reason to suspect TGF-β1 as possibly
involved with the formation of Peyronie's plaque
because it has been implicated in a number of soft
tissue fibroses as well as with erectile dysfunction

13.  On activation, TGF-β1 binds to cell surface receptors
and eventually results in synthesis of connective
tissues with inhibition of collagenases .
 The net result of this trauma with disordered healing
is the formation of plaques that appear as scars and
impede expansion of the tunica albuginea during
erection, which results in curvature, and/or
indentation, and/or foreshortening .
 On histologic examination, there is aberrant
cicatrization with nonpolarization of collagen and
diminished and erratic distribution of the elastin
fibers.

15.  There is also role of matrix metalloproteinase in
this abnormal scarring process.
 Matrix metalloproteinases are enzymes that are
involved in the remodeling of extracellular matrix
proteins.
 These remodeling enzymes are regulated by tissue
inhibitors of metalloproteinase.
 Failure of downregulation of matrix
metalloproteinase has been implicated in a
number of disease processes.

16.  In the case of Peyronie's disease, if matrix
metalloproteinases are not downregulated,
they could function as a possible
mechanism for the scarring process in
Peyronie's disease.
 Thus, inhibition of antiscarring enzymes
can perhaps represent another facet of the
etiology of the lesion we recognize as
Peyronie's plaque

18.  Studies also demonstrate the role of oxidative stress in
addition to cytokine release in the development of
Peyronie's disease plaques.
 Acting as profibrotic factors, they interact with antifibrotic
defense mechanisms, which, as already mentioned, may be
inhibited.
 Oxidative stress intensifies in the fibroblasts of human
Peyronie's disease plaques and rat-modeled fibrosis.
 Reactive oxygen species trigger profibrotic processes in a
number of disease processes.
 There is interplay between a number of mechanisms as
they relate to fibrosis.

19.  Possibly of particular importance is cyclic guanosine
monophosphate (GMP), one of the mediators of penile
erection.
 Cyclic GMP has been found to be antifibrotic in
Peyronie's disease plaques.
 Long-term administration of PDE5 inhibitors prevents
plaque formation in rat fibrosis models. PDE5 is
expressed in tunical and Peyronie's disease fibroblasts.
 Thus, as earlier mentioned, the use of PDE5 inhibitors
in patients with Peyronie's disease may be helpful on a
number of fronts

21. PATHOPHYSIOLOGY
 In most cases of Peyronie's disease, there are two
phases.
 The first is an active phase, which not uncommonly is
associated with painful erections and changing
deformity of the penis.
 It is followed by a quiescent secondary phase, which is
characterized by stabilization of the deformity, with
disappearance of painful erections, if they were
present, and, in general, stability of the process.
 Up to a third of patients, however, present with what
appears to be sudden development of painless
deformity

22.  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; however, site-specific venous leak was not
noted.

23.  Veno-occlusive dysfunction was most prevalent in
patients with ventral curvature.
 Also , “Patients with ventral curvature do not do well
with graft operations.”
 Thus, what is in the literature is not clear other than
the fact that patients preoperatively complain in large
numbers of the psychological impact of their
Peyronie's disease, and those psychological aspects
continue to plague good surgical results.

24. Dorsal plaque & normal tunica

25. Ventral plaque

26. SYMPTOMS
 The presenting symptoms of Peyronie's disease
include, in many patients, penile pain with erection;
penile deformity, both flaccid 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.

27.  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 inflammatory 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.

28.  Spontaneous improvement in pain virtually
always occurs as the inflammation resolves.
 A small group of patients with extensive
disease will have “circumferential plaques”
and an unstable penis due to the resulting
hinge effect.
 Most patients complain of distal flaccidity

29. 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.

30.  Cardiovascular disease and erectile dysfunction share a
host of risk factors including age, smoking,
hyperlipidemia, hypertension, and diabetes mellitus.
 Further, the severity of coronary artery disease has
been shown to correlate with the severity of erectile
dysfunction
 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.

31.  The penis should be examined on stretch.
 This amplifies the plaque and often allows the
examiner to feel plaques that are not obvious when
the penis is examined flaccid.
 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

32.  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.

33. USG

35. B – mode scan

36. X RAY

37. CT SCAN

38.  The place of vascular testing is not clearly defined
 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.

39. DOPPLER

40. MEDICAL MANAGEMENT
 The use vitamin E for Peyronie's disease, it should be
used in divided doses of 800 to 1000 units a day.
 Treatment should be continued for no longer than 3 to
6 months, and patients must be cautioned about the
possibility of anticoagulative side effects.
 potassium aminobenzoate is poorly tolerated by
many patients because of gastrointestinal upset and is
relatively costly.
 The use of potassium aminobenzoate cannot be
strongly advocated on the basis of the evidence to
date.

41.  Jordan has used terfenadine and now
fexofenadine (Allegra).
 It is used as a nonspecific antihistamine and has
been used in patients who have had an unusually
long, painful course.
 The medication is expensive; it is well tolerated
and, if used, should be in a dosage of 60 mg twice
a day.

42.  Ralph and coworkers (1992) have suggested the use
of oral tamoxifen.
 Tamoxifen, it is believed, facilitates the release of
TGF-β from fibroblasts.
 In a small controlled report, tamoxifen versus a
placebo was used and it did not demonstrate a
therapeutic advantage.
 Should one desire to prescribe tamoxifen, it is used
at a dosage of 20 mg twice daily.

43.  The use of colchicine was originally proposed by M. K.
Gelbard
 In that study, diminished plaque size and improved penile
curvature were reported in approximately 50% of the
patients.
 Colchicine binds tubulin and causes it to depolymerize;
thus, it inhibits mobility and adhesion of leukocytes.
 It inhibits cell mitosis by disrupting spindle cell fibers and
thus functions as a potent anti-inflammatory agent.
 It blocks the lipoxygenase path-way of arachidonic acid
metabolism, furthering its anti-inflammatory effect.

44.  It interferes with the transcellular movement of
protocollagen.
 Colchicine is reasonably well tolerated.
 Approximately one third of patients, however, will
have diarrhea. It is inexpensive.
 If it is used, the dosage is 0.6 mg three times per day
with meals.

45.  Teasley (1954) reported the use of intralesional
corticosteroids, as did other studies .
 It is the recommendation of the consensus committee
on penile curvatures that the use of intralesional
corticosteroids be eliminated or at least initiated with
extreme caution because of the significant local side
effects, the inconsistent pattern of improvement in
well-established curvature, the lack of studies showing
proven efficacy, and the reports of patients who
believed that their condition deteriorated after the
injections

46.  The calcium antagonist verapamil was first used as
intralesional therapy by Levine and colleagues (1994) .
 Verapamil is thought to have efficacy on the basis of its
ability to inhibit the exocytosis of collagen, fibronectin,
and glycosaminoglycans.
 This inhibition works at the basic metabolic step involved
with the manufacture of collagen and hence is thought to
inhibit the ultimate formation of scar
 A “full course” could consist of 12 injections (10 mg/10 mL)
given once every 2 to 4 weeks
 The use of intralesional verapamil for patients with acute
disease is thought reasonable on the basis of the available
data to date.

47.  Radiotherapy had been proposed as a treatment of
Peyronie's disease.
 In recent years, radiotherapy was proposed for the
treatment of pain that was thought to be “abnormally
persistent.”
 It is the consensus of the World Health Organization
committee that radiotherapy be avoided because of
potential risk of malignant change and the potential
for increasing the risk of erectile dysfunction in aging
patients .
 As of today there is no role of radiotherapy.

48. The vacuum erection device has not
been adequately studied.
 The place of extracorporeal shockwave
therapy has likewise not been
adequately determined.

49. SURGICAL CORRECTION
 For a patient to be a surgical candidate his disease
must be stable & mature.
 Most surgeons suggest to wait for 1.5 – 6 months
from the onset of symptoms
 Indication for surgery includes deformity that
precludes intercourse and/or erectile dysfunction
that precludes intercourse.
 There are many surgical techniques that are
available

50.  Pryor and Fitzpatrick (1979) described a procedure of
excision and plicating closure of the aspect opposite
the Peyronie lesion.
 This procedure counteracted the effects of the inelastic
lesion by shortening the opposite, more compliant
aspect of the corpora cavernosa.
 Lue performs a correction in which he omits the
excision of the tunica albuginea and merely plicates
the opposite aspect of the corpora cavernosa

51.  Lue emphasizes the use of permanent suture that is
“loosely tied” to correct the deformity.
 Although the techniques of both Pryor and Fitzpatrick
(1979) and Lue are valid in some patients, many
patients are already concerned by the shortening of
their penis as a result of Peyronie's disease; thus,
surgery that offers the suggestion of further shortening
of the penis is unacceptable to them.

52.  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 .

53.  Gelbard (1989) described a surgical technique that
involved incising the plaque of Peyronie's disease.
 He reported a series of patients in whom incisions
were made in the plaque and grafts of temporalis fascia
were used to fill the defects.
 His technique was based on the theory that by
making a number of incisions, thus expanding the
scar, and then filling them with compliant material, a
smoother correction of curvature would result.
 He has reported good results with this procedure.

54.  Das and Amar (1982) described a procedure in which
the plaque is excised and the corporotomy defect is
grafted with tunica vaginalis.
 They believed that the tunica vaginalis is an easy
donor site for the urologist and that it gives the same
results as the dermal graft.
 Tunica vaginalis is a good substitute for patients with
small lesions.

55.  Lockhart has employed a procedure in which the
plaque is excised and the corporotomy defect is closed
with tunica vaginalis as an island based on a dartos
fascial and cremasteric flap
 He found that his results were better with the
improved vascularity of the tunica vaginalis
transposed as a paddle on a flap.

56.  Devine and Horton (1974) described a procedure
for correction of deformity of Peyronie's disease in
which the plaque is excised and replaced with a
dermal graft.
 Austoni and coworkers (1995) reported a large
series of 418 men. In that series, 17% required
further surgery for curvature and 20% had
troublesome postoperative erectile dysfunction.
 This procudere has selected use.

57. Circumferential incision

65. PENILE PROSTHESIS
 The penile prosthesis is a reliable option for the older
man with vascular impairment, erectile dysfunction,
and acquired deformity of the penis .
 It is hence not the only treatment for Peyronie's
disease but rather a prudent treatment for the patient
with significant erectile dysfunction in association
with Peyronie's disease.
 In past years, semirigid devices have been preferred;
however, with improvement in the three-piece
hydraulic devices, they would appear to be preferable .

66.  The recent publications showing superiority of the
antibiotic-coated prostheses or the hydrophilic-coated
prosthesis with regard to infection rate were suggested in
cases of Peyronie's disease, the antibiotic-coated devices
had a good result in the study performed but long term
efficacy is still under evaluation.
 It is not the only treatment of Peyronie's disease but rather
a prudent treatment for the patient with significant erectile
dysfunction in association with Peyronie's disease.
 Hydraulic prostheses are preferred, and those prostheses
that have true controlled expansion cylinders have been
shown to provide better results.

67. TAKE HOME MESSAGE
 Peyronie's disease is not the “terminal-no hope”
diagnosis that many patients believe it is.
 Peyronie's patients and their partners must be
educated about what is happening and what might
happen.
 They must be told that in the majority of cases, their
sexual relationship can be adequately restored.
 They must also understand that for most cases, all we
have to offer will, at best, make their sex lives adequate

68.  There is not one best operation or approach but rather
a menu of options that for a given individual will have
benefits and disadvantages.
 With counseling, they must match their “have to
haves and can't stand to haves” to those advantages
and disadvantages.
 This approach, will lead to the best management for
most.