Peyronie’s disease (PD) is believed to arise from the growth of a fibrous inelastic plaque in the tunica albuginea (J Clin Imaging Sci 2012; 2:63). The disease spectrum varies, but the physical and psychological impacts of PD can be devastating. Spontaneous resolution of PD is rare. Moreover, the full manifestation of the disease may take a significant period of time to declare itself.
Paradigms and algorithms for the evaluation and treatment of PD differ greatly among clinicians. Some standardization in practice has been achieved with creation of AUA guidelines (J Urol 2015; 194:745–53) and the Third International Consultation on Sexual Medicine guidelines on PD (J Sex Med 2010; 7:312–3; J Sex Med 2016; 13: 905–23), but adherence to these recommendations remains uncertain. The comfort level of the urologist with specific medical treatments or procedures plays a significant role in influencing approach.
To date, there are no randomized, controlled trials that prove superiority of one surgical approach over the other. Moreover, not only do the physical manifestations of PD vary greatly among patients but so does the impact of this complex disease upon quality of life. Consideration of these factors as well as the patient’s baseline erectile function are imperative in pursuing the optimal treatment strategy.
In this article, we describe our thought processes in treating patients with this challenging disorder, which are summarized in an algorithm (figure).
The initial evaluation includes a comprehensive history and physical exam. Specific points pertaining to history include perception of erectile function, onset and duration of penile curvature, the nature and evolution of the deformity, degree of bother with PD, Peyronie’s Disease Questionnaire and Sexual Health Inventory for Men scores, and the impact of the curvature on coitus and penetration. Moreover, the presence of penile pain should also be determined to assess the status of the disease process (ie, acute or chronic phase).
Home photographs can be helpful in providing a baseline assessment of the severity of the deformity and erection quality. Smartphone apps and disposable goniometers have added to patients’ ability to track changes in curvature and progress during treatment. A thorough discussion pertaining to the consequences of PD upon quality of life should be facilitated.
The physical examination should focus on the presence, size, and location of the plaque. Note should be made of plaque calcification, which may preclude the use of certain treatment options such as collagenase clostridium histolyticum (XIAFLEX). The stretched length of the penis should also be determined with potential implications for penile prosthesis placement, appropriate counseling, and establishing patient expectations.
Prior to committing to any further workup or treatment, it is imperative to ensure the disease has entered the chronic phase. From the time of onset, our recommendation is to wait at least 6 to 12 months to make certain the plaque has stabilized. Objective assessment of PD can then be obtained utilizing penile Doppler ultrasonography with intracavernosal injection of vasoactive medication. At our institution, we most commonly inject a single 10-microgram dose of alprostadil for tumescence. However, higher doses of alprostadil or Trimix (alprostadil, phentolamine, and papaverine) may be required in some patients with severe erectile dysfunction (ED), or anxiety, to achieve adequate rigidity.
The purpose of this low-cost study is threefold. First, we are able to fully visualize the location and length of the penile plaque as well as the presence of plaque calcifications. Second, the vasoactive injection provides an assessment of erection quality. Third, with the penis erect, the full extent of the Peyronie’s deformity can be delineated with angulation quantified with the use of a goniometer. Once the full extent of PD is delineated, we can more confidently categorize a patient’s treatment options based on degree of curvature and erectile function. Establishing a patient’s goals of care (eg, reduction of curvature, assistance with pain, resolution of concurrent ED) is paramount in treatment selection.