PEYRONIE’S DISEASE: Diagnostic work-up. PATIENT EVALUATION. DISEASE COURSE.PHYSICAL EXAMINATION. IMAGING.

1. Esther García Rojo
Madrid, Spain
@rojo_esther
PEYRONIE’S DISEASE
Diagnostic work-up

2. “Its so important to diagnose
correctly and good to know that
people are becoming better at
diagnosis”

3. PATIENT EVALUATION
• Family history: fibromatosis…
• Medical history: personal history, penile surgeries, drugs, urethral
instrumentation, external trauma, fibromatosis diseases (Dupuytren,
Ledderhouse), detailed phsychosexual history, erectile dysfunction
risk factors…

4. DISEASE COURSE
• Careful disease history: Onset, precipitating factors, changes over time, prior
treatments used.
Presenting symptoms and their duration (erectile pain, palpable nodules, curvature,
length, rigidity and girth) and erectile function status.
• Mandatory to obtain information on the distress provoked by the symptoms : penile
deformity, interference with intercourse, penile pain…
• Major attention whether the disease is still active, as this will influence medical
treatment or the timing of surgery.

5. ERECTILE FUNCTION EVALUATION
• ED is common in patients with Peyronie’s disease (> 50%)
• ED and psychological factors may impact on the
treatment strategy.
• Important to define whether it pre- or post-dates the
onset of Peyronie’s disease.
• Erectile function can be assessed using validated
instruments such as the International Index of Erectile
Function (IIEF) although this has not been validated in
PD.

6. A disease-specific questionnaire (PDQ) has been designed to collect
data, and it has been validated for use in clinical practice.
QUESTIONNAIRES

8. PHYSICAL EXAMINATION
• ROUTINE GENITOURINARY ASSESMENT, extended to the hands and
feet for detecting possible Dupuytren’s contracture or Ledderhose scarring
of the plantar fascia.
• PENILE EXAMINATION: palpation nodes or plaques.
Locaton, size, consistency if the plaque should be defined.
Length during erection (impact on treatment decisions).
Objective measurement of penile curvature is essential given
that patient report of curvature is inaccurate.
• Factors affecting the loss of length associated with tunica albuginea plication for correction of penile curvature. Greenfield JM1, Lucas S, Levine LA.

9. • It is mandatory an OBJECTIVE ASSESSMENT OF PENILE CURVATURE with an
erection. At home (self) photograph of a natural erection (preferably) or using a
vacuum-assisted erection test or an intracavernosal injection using vasoactive
agent.
PHYSICAL EXAMINATION

10. FLACCID
Stretched penile length and note palpable penile
plaque location and size.
ERECT
Length during erection,
curvature, erectile function.

11. LABORATORY TESTS
• Laboratory testing is not necessary for PD diagnosis. No specific blood tests.
• Given the possible association between PD, diabetes mellitus and CV
disease screening for these comorbidities should be considered.
• Evaluation for ED risk factors, serum hormones and the hypothalamic-
pituitary-gonadal axis should be performed.
• Correlation with a higher expression of the antigen HLA-B7, TGF-β1,
anti-DNA, antinuclear and anti-elastin antibodies have been seen,
but they cannot be considered specific markers.
Peyronie’s disease: a literature review on epidemiology, genetics, pathophysiology, diagnosis and work-up. Sultan Al-Thakafi1 and Naif Al-Hathal
Transl Androl Urol. 2016 Jun; 5(3): 280–289.

12. “Clinicians should perform an in-office intracavernosal
injection test with or without duplex Doppler ultrasound
prior to invasive intervention”

14. Hatzimouratidis et al. Guidelines on Erectile Dysfunction, Premature Ejaculation, Penile Curvature and
Priapism. Uroweb, 2018.
“Ultrasound (US) measurement of the plaque’s size is inaccurate and it is not
recommended in everyday clinical practice. Doppler US may be required for
the assessment of vascular parameters “

15. • “Penile color duplex ultrasonography (CDU) provides a safe, low-
cost, and rapid means of objectively characterizing PD.”
• “Routine use of plain radiography, computed tomography, and
magnetic resonance imaging is not recommended.”

16. How Doppler US helps in PD management
1.Peyronie’s disease anatomy.
2.Plaque’s characteristics.
3.Penile vascularization.
4.In-office Kelami test.
DOPPLER US FINDINGS
Jung et al. Penile Doppler Ultrasonografy Revisited. Ultrasonografy 2018;37(1): 16-24

17. • Thickening if the tunica albuginea (>2 mm).
Pawlowska E et al. Imaging modalities and
clinical assesment in men affected with
Peyronie’s disease. Pol J Radiol, 2011; 76(3): 33-
37
• Septal fibrosis.
Smith et al. Penile Sonographic and Clinical Characteristics in Men with Peyronie’s Disease. J Sex Med
2009;6:2858–2867
•Corpora cavernosa fibrosis.

18. •After administration of 10 µg of
intracavernous alprostadil.
•Measurement of the peak systolic
velocity (PSV) and end dyastolic
velocity (EDV) at 10’ and 20’.
Diagnosis PSV EDV
Normal >25 cm/s <5 cm/s
Veno-oclusive >25 cm/s >5 cm/s
Arterial insufficiency <25 cm/s <5 cm/s
LeRoy et al. Doppler Blood Flow
Analysis of Erectile Function: Who,
When and How. Urol Clin N Am 38
(2011) 147–154.

19. Grade I: ≤0.3 cm.
Grade II: 0.3-1.5 cm.
Grade III: >1.5 cm or ≥2 plaques >1 cm.

22. PENILE ULTRASONOGRAPHY
• The most cost-effective method of assessment of penile vascular system.
• Veno-oclussive dysfunction (VOD) is reported to be present in 30-86%
and the role of arterial disease has also be shown in 44-52% of PD
patients with ED.
• Erectile function and penile vascular status are key factors in deciding
treatment modality.

23. OTHERS: Not routinely recommended
• X-rays: Efective demostrating calcification.
• CT SCAN: Does not pick up the plaque
routinely.
• MRI: An effective, non-invasive way to identify
the plaque in its early stages but expensive
and not easily available. Can be helpful in
certain cases.

24. Thank you!