Sexual Dysfunction - Peyronie's Disease

Peyronie's disease is characterized by the formation of hardened tissue (fibrosis) in the penis that causes pain, curvature, and distortion, usually during erection. The penis is the male organ for reproduction and urination. It is composed of two columns of erectile tissue (the corpora cavernosa); the corpus spongiosum, which contains the tube that carries urine and semen from the body (urethra); and the sheath that surrounds the erectile tissue (tunica albuginea). In Peyronie's disease, dense, fibrous scar tissue (plaque) forms in the tunica albuginea.

Signs and Symptoms

Peyronie's disease may be mild or severe, and may develop rapidly or over time. Symptoms include the following:

• Hardened tissue (plaque) in the penis
• Pain during erection
• Curve in the penis during erection
• Distortion of the penis (e.g., indentation, shortening)

Plaque usually develops on the top of the shaft, causing the penis to bend upward during erection, but it may occur on the bottom, causing a downward bend. If plaque develops on the top and the bottom, indentations and shortening may occur. In about 13% of cases, plaque does not cause severe pain or curvature, and the condition resolves on its own. In severe cases, pain and curvature result in erectile dysfunction (impotence). If there are several areas of plaque, incomplete erection may occur.

Diagnosis

Diagnosis of Peyronie's disease involves taking a complete medical history, including any circumstances surrounding the onset of symptoms, and a physical examination. The hardened tissue caused by the disorder can be felt upon examination (palpable). Sometimes, it is necessary to perform the examination with the penis erect. This is achieved by injecting a vasoactive substance that affects the blood vessels in the penis, causing erection. Photographs (digital or Polaroid) of the deformity may eliminate the need to produce an erection in the physician's office. Calcified plaque can be identified using x-ray or ultrasound.

If the physical examination does not support the diagnosis of Peyronie's disease, or if the condition develops rapidly, the physician may perform a biopsy. Biopsy involves removing plaque cells for microscopic examination and is used to detect cancer.

Treatment

Treatment options for patients with Peyronie's disease are limited. The goal of treatment is to reduce pain and maintain sexual function. Surgery is the only effective treatment, and because Peyronie's may resolve on its own, physicians often advise waiting 1 or 2 years before choosing this option.

Nonsurgical treatment should be implemented within 6 months of the onset of symptoms and before the plaque has calcified. Vitamin E supplementation and para-aminobenzoate tablets (B- complex substance) may be taken for several months. Chemical agents such as a calcium channel-blocker (e.g., verapamil), an enzyme that breaks down connective tissue (collagenase), and steroids (e.g., cortisone) may be injected into plaque or delivered by iontophoresis.

Iontophoresis is a painless method of delivering medication to localized tissue using electrical current. Like electrical charges repel, therefore a positive charge applied to a positively charged solution repels the medication into the tissue. Low-dose radiation (high-energy rays) therapy may reduce pain, but it does not effectively diminish plaque.

Surgery

Surgical treatment may be used in severe, persistent cases of Peyronie's that have not responded to nonsurgical treatment. Procedures involve the removal (excision) of hardened tissue and skin graft, the removal or pinching (plication) of tissue opposite the plaque to reduce curvature (called the Nesbit procedure), a penile implant, or a combination of these.

The removal of plaque requires a skin graft from another area of the patient's body and may result in a partial loss of erectile function (e.g., less rigidity). The Nesbit procedure reduces the length of the erect penis.

Penile implant involves implanting a device in the corpora cavernosa that increases rigidity. This procedure may be combined with incisions and skin grafts, or plication to effectively reduce curvature. During the recovery period, patients are prescribed medication that prevents them from having an erection and are advised to avoid sexual activity. Antibiotics are also prescribed to reduce the risk for infection

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