Peyronie's disease - more information
Peyronie's disease affects between 1 and 3% of the male population. It occurs most often in men in their forties to fifties. The incidence of Peyronie's appears to be increasing, though this may be due in part to men feeling less embarrassment about the disease and greater reporting to GP's.
The classic signs of the disease are bending of the erect penis, penile pain, erectile dysfunction, and a palpable plaque in the tunica albuginea. The plaques may progress to become nodular. Very severe cases show signs of calcification. However, the good news is that the disease spontaneously reverts to normality in between 10 and 40% of patients. There has been some suggestion that the disease occurs in men with a genetic predisposition, or in association with an auto-immune condition.
The normal tunica albuginea of the penis is a lattice of collagen and elastic fibres arranged in two layers. The outer layer controls the lengthening of the penis during erection, the inner layer controls the expansion in girth. Emissary veins and arterial branches traverse the layers of the tunica and allow communication between erectile tissue and dorsal vasculature of the penis.
In the early stages of Peyronie's, lymphocytes, macrophages and plasma cells accumulate around small blood vessels in the tunica; this inflammation is followed by areas of fibrosis that develop into plaques. Fibrin and collagen are densely aggregated within the plaques.
Most authorities believe that Peyronie's begins with mechanical stress in the tunica that causes damage to the minute blood vessels in the tunica. This occurs during sexual intercourse. If the wound fails to heal correctly, there may be scar tissue formation. However, some authorities believe that plaque formation is an expression of autoimmune disease. There may also be a genetic predisposition, since it is associated with Dupuytren's contracture.
The development of a tunical plaque is associated with an imbalance between profibrotic and antifibrotic factors. There is abnormal fibrosis as a result, with persistent presence of myofibroblasts.
The most common presenting symptom of Peyronie's is penile deformity and penile pain. Not all men with Peyronie's have penile pain; it occurs in between 20 and 70% of men. Despite the rather severe nature of some of the cases of Peyronie's, only one man in ten or so finds sex impossible, although as many as one man in two experiences pain during intercourse. The initial inflammatory phase of Peyronie's is characterized by progressive penile pain and curvature, and can last for twelve months or so. There should be no attempt at surgery during this period. This is followed by a stable painless period.
The shape of the penis with Peyronie's is quite distinctive. The most common form of the disease is to find a plaque in the dorsal midline of the shaft of the penis. Lateral and ventral plaques are less common, but if they do occur they can cause greater angulation of the penis and may make sex almost impossible. Sometimes a plaque may develop around the entire circumference of the shaft, which gives the penis a characteristic hourglass shape. There may be no erection beyond the constriction.
Not all cases of erectile dysfunction are associated with the hourglass variation of Peyronie's. In some cases, erectile dysfunction is anxiety related. And yet other cases are associated with vascular changes in the internal structure of the penis. Where a vein passes through a plaque, it may not be subject to the compressive forces of the tunical layers, thereby preventing the compression which normally leads to accumulation of blood in the corpora cavernosa.
Treatment options include pharmacological interventions, shock wave therapy, radiotherapy and surgery.