PROF ANTONIO RUFFO
Specialist in Urology
Andrology Genital and Urethral Recostructive Surgery
mobile +39 3511718896
PEYRONIE'S DISEASE
Penis induratio plastica also known as la Peyronie's disease is a collagenopathy that affects the tunica albuginea, which is the deeper penile fascia that covers the corpora cavernosa.
This condition is characterized by an inflammatory and then fibrotic process that results in the formation of plaques.
The disease is initially characterized by pain on erection and penile curvature in corripondence with the fibrotic area.
Epidemiology and risk factors
The incidence of symptomatic disease is slightly less than 1%, while in asymptomatic form it is believed to occur in more than 20% of men. It most frequently affects individuals over 40 years of age with a peak in the sixth decade of life. The etiology is unknown and probably multifactorial. However, there are some conditions in which the disease occurs more frequently than in the general population: diabetes mellitus (14%), high blood pressure (8%), chronic drug intake (19%), and smoking (30%).
It may be associated with other connective diseases such as palmar fibrosis or Dupuytren's disease, plantar fibrosis, and tympanosclerosis.
Symptomatology
Symptomatology initially is subtle: very often the patient feels the presence of a nodularity in the penis that leads to consultation with the physician.
Subsequently, the disease is usually characterized by pain that culminates when the penis is erect. The goal of the physician's examination is to reassure the patient of the benignity of the disease and investigate the patient's family and personal history. Especially if there is a family history of relatives with fibrotic disease, if libido is preserved, and if there is concomitant erectile dysfunction.
In 20-70% of cases an erectile deficit is present, but the percentage of patients complaining of "sexual inadequacy" can be as high as 90%. The pathogenesis of erectile dysfunction is multifaceted: often pain during erection and anxiety/frustration phenomena make it impossible to achieve satisfactory sexual intercourse. In about 60% of cases, erectile dysfunction is present due to alteration of the veno-occlusive mechanism; in 30% of patients, alteration of arterial dynamics is highlighted due to extension el pathological process to trabecular and cavernous vascular structures.
Diagnosis
Second, the degree of curvature is objectified by self-photography. The patient reports photographs with the erect penis to the physician that testify to how severe the Induratio Penis Plastica is.
Complementary examinations are ultrasonography that evaluates calcifications formed within the corpus cavernosum and as a last resort, almost never used, MRI.+
Recently, a new method for the diagnosis of fibrosity of the corpora cavernosa has been put in place: elastosonography. This method makes it possible to identify fibrosities of penile tissues even before they can manifest clinically.
Is there a medical treatment?
The pathology recognizes an initial inflammatory phase and a late stabilizing phase.
Medical therapy finds indication in the early phase with the use of supplements, vitamin E, POTABA, some chemotherapeutics, Pentoxifylin, PDE-5, intraplate injections of calcium antagonists such as Verapamil. Shockwaves have also shown some action especially on pain modulation.
Clostridium histolyticum collagenases (Xiapex®, Xiaflex®) are the only drug approved for this condition, giving improved curvature in treated patients.
Another effective treatment is using intraplaque injections of Platelet-Rich Plasma (PRP).
What is the ultimate treatment?
The gold standard for treatment of the condition is surgical treatment. Many alternative surgical techniques have been described in the literature that can be referred to depending on the degree of severity of the disease.
The patient must understand that the curvature may persist or return the penis, with some techniques such as plication may shorten and may decrease sexual function or libido.
I have a simple curvature, less than 70 degrees with preserved erectile function; what surgery can I do?
The choice should be directed toward the simplest technique, namely Nesbit's, and the patient, after adequate information, accepts the penis shortening that such entails.
The Nesbit procedure consists of an elliptical incision in the convex part of the curvature with subsequent transverse suturing.
The Yachia procedure consists of a longitudinal incision of the tunica albuginea on the convex side and subsequent transverse suturing without removing tunica albuginea.
Finally, Plication consists of multiple small transverse and parallel incisions separated by a space of about 0.5 cm. The incision is made between the longitudinal fibers of the tunica but the circular fibers of the tunica are not violated. Then the longitudinal fibers between the two parallel incisions are removed generating the plication. The defect is closed with a transverse suture.
I have a curvature greater than 60°, complex, with extensive plaque and preserved erectile function; what surgery can be performed?
In cases where Induratio Penis Plastica presents in a complex manner, it is definitely useful to perform grafting surgery.
In this type of surgery, the graft used should resemble as closely as possible the tunica albuginea of the penis; in this way it is minimally invasive, with a low probability of rejection reactions; it must be resistant to infection and must make sure that erectile capacity is preserved.
Many materials have been used trying to make up for the above characteristics; certainly, the best performing material is porcine dermis graft.
I have a complex curvature with presence of erectile dysfunction and refractoriness to PDE 5i; which intervention is suitable?
The surgery that ensures best success is definitely grafts and penile prosthesis grafting.
In this way, it is possible to recover both the function and aesthetics of the penile organ. There are various types of prostheses: malleable, rigid, bi-component or tri-component.
In this case, it will be the surgeon based on the complexity of the surgery and the patient's expectations who will decide which prosthesis can be implanted.
In the clinic, the most commonly used penile prostheses are tri-components: they consist of two parallel cylinders that are to be inserted inside the corpora cavernosa and a reservoir filled with a few cc of fluid, which, when pressed, fills the cylinders by stiffening them so that they mimic a physiological erection. The reservoir is placed inside the scrotal bursa or suprapubic level.
The post -operative stay is short: usually the patient is hospitalized for up to three days. The anesthesia practiced is loco - regional with minimal risk to the patient.
Complications
The post -operative course is characterized by few and mostly local complications; penile edema, local soreness, and possibility of mild infection. Sexual intercourse is contraindicated for three months from the date of surgery.
Edema of the penile skin, foreskin, and hematomas may occur, which are avoided with a lightly compressive dressing for 24-48 hours or with placement of a drain along the shaft in the case of more complex procedures. Postoperative erection deficits are very rare and depend on injury to the vascular-nerve bundle; vascular deficits are usually compensated by dorsal artery blood flow from the opposite side.
A skin sensitivity deficit of variable extent may remain. Distant complications include adhesions between skin and albuginea and aneurysmal dilatation of sutured areas.
