Peyronie's disease is a medical condition characterized by the development of a lump on the shaft of the penis. This lump is a scar (plaque) that forms on the lining (tunica) of the erectile body (corpus cavernosum) and is believed to be the result of injury to the penis during sexual relations. Early on following the trauma, an inflammatory reaction occurs, often bringing a man's attention to the problem because of pain associated with erection. With time, the inflammation progresses and a scar develops. The time to develop this scar and the degree to which it occurs varies from patient to patient. Often the process heals itself over the first 12 months after the scar forms. In some cases, however, the scar formation is severe. In these cases, the scar becomes progressively harder and more obvious, causing the penis to curve during erection. While the scar is benign (non-cancerous), the resulting curvature may lead to the inability to have sexual intercourse.
The incidence of Peyronie's disease is estimated to be approximately 1-3%, although this figure is most probably an underestimate. Recent research lead by Dr. Mulhall suggests that the incidence is far higher at approximately 8.9%. In this research study one third of patients did not know that they had the condition. Peyronie's disease occurs most often in middle-aged men but can occur in men from 20-70 years of age. Peyronie's disease is characterized by a localized scarring of the tunica albuginea of the penis. The inelasticity of the plaque in the normally stretchy tunica albuginea results in restricted expansion of the affected corporal body during erection resulting in curvature or incomplete rigidity of the erect penis. The consequent erectile deformity frequently results in the inability of the male to participate in satisfactory coitus. The condition is associated with other conditions, including Dupuytren's contracture of the hand. The cause of Peyronie's disease appears to be multi-factorial and has not been fully explained. As bending of the penis occurs in all men during penetrative sexual relations, one of the questions concerning Peyronie's disease is, why is it that only a small percentage of men manifest plaque formation? While trauma is believed to be the initial event, many theories have been proposed for the pathogenesis of Peyronie's disease, including auto-immune factors (Peyronie's disease appears to be more common in certain ethnic groups, particularly northern European Caucasians; it is uncommon in African-American men and rare in Asian men), excess production of chemicals (known as cytokines) in the tunical tissue of the penis, and abnormalities of tunical cell behavior.
Men with Peyronie's disease typically present to a physician in a number of ways, including painful erections, penile curvature or erectile dysfunction (ED). It is estimated that approximately 20% of men who have Peyronie's disease will have improvement or complete correction of their penile curvature within the first 12 months of their condition. Thus, as the plaque in Peyronie's disease may shrink or disappear without treatment, medical experts suggest waiting a full year before attempting to correct it surgically. During that period, patients are often willing to undergo treatments, none of which have been scientifically proven to be of significant benefit.
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- Mulhall JP, et al. Subjective and objective analysis of the prevalence of Peyronie's disease in a population of men presenting for prostate cancer screening. Journal of Urology 167(4):821A, 2002.
The physical examination of the patient presenting with sexual dysfunction should focus on (1) secondary sexual characteristics, (2) abdominal examination, (3) major pulse examination, (4) S2-4 neurological assessment, and (5) external genitalia examination. Abdominal examination should focus on the assessment for an abdominal aortic aneurysm. It has been estimated that approximately 1 percent of all men presenting for the evaluation of erectile dysfunction will have an enlarged abdominal aorta. The major pulses should be assessed, specifically, the femoral and popliteal pulses as these are excellent markers for systemic atherosclerotic disease. In cases where there is a concern regarding neurogenic ED, an assessment of S2-4 neural pathways is indicated. An assessment of the bulbocavernosus reflex (BCR) is only of significant benefit if the reflex is positive as 30% of neurologically intact patients will have a BCR.
Examination of the penis in this patient population should focus primarily on the presence of Peyronie's disease plaques. A good assessment of the integrity of the erectile tissue may be gained from stretching the penile shaft. In patients with significant corporal fibrosis, such as in men with poorly controlled diabetes, there is significant diminishment in the ability of the penis to stretch, in contrast to young patients with psychogenic or mild arteriogenic ED where penile stretch capabilities are normal. Examination of the testicles is aimed primarily at defining the presence or absence of masses and also to ascertain the testicular volume and consistency. All men over the age of 40 years and those with lower urinary tract symptoms undergo digital rectal examination for prostate assessment.
Obtaining basic hematologic and biochemistry laboratory analyses in men with ED has been recommended by the NIH consensus panel. The screen should include serum glucose estimation in an effort to rule out the presence of diabetes. Many of the patients seen for ED will already have had such laboratory testing by their primary care physician and will not need to have this repeated. Assessment of liver function tests and thyroid function tests are best reserved for those patients who manifest symptoms and or signs suggestive of hepatic or thyroid dysfunction.
One of the great controversies in sexual medicine revolves around the definition of an adequate hormonal assessment of the patient with ED. There is an absence of medical literature that clearly answers this question. At the Sexual Medicine Program at The New York Presbyterian Hospital a single early morning total testosterone level is drawn. Most significant endocrinopathies that are of concern will generally manifest with a low serum testosterone level. In the presence of a low total testosterone level we repeat the blood work to include a total and free testosterone level, combined with an LH and a prolactin level. Most would agree that men presenting with classic symptoms or signs of hypogonadism should undergo a full hormone screen as outlined above at the outset.
In routine clinical practice the majority of men presenting with erectile dysfunction do not require any further testing. However a number of investigations exist which are available to aid the clinician in assigning a cause to the patient's ED. Such investigations include (1) vascular testing such as duplex ultrasound and dynamic infusion cavernosometry/cavernosography, (2) neurological testing such as a biothesiometry, somatosensory evoked potentials and pudendal electromyography and (3) nocturnal penile tumescence and rigidity analysis. Much debate has been conducted on the indications for such investigations. In my practice, adjunctive investigations are reserved for the following groups of patients: (1) patients who are potentially curable: this group includes patients with a high risk for primarily psychogenic ED, patients with endocrinopathy, young males with traumatically induced pure arteriogenic erectile dysfunction and young males with isolated crural venous leak, (2) patients with penile curvature prior to undergoing penile reconstructive surgery and (3) medicolegal cases.
There is also a significant variability in the utilization of psychological assessment during evaluation of the male with ED. Certainly, any patient who presents with an obvious untreated psychiatric disorder should be directed to the appropriate expert. Patients who are routinely sent for psychological evaluation and management in my practice are those who have an overt complex psychological risk factor for sexual dysfunction and those with significant interpersonal difficulties either arising from or leading to their sexual dysfunction.
Two investigations that are frequently used by clinicians in the office setting in evaluation of the impotent male include biothesiometry and office injection testing. The former testing utilizes an electronic device for the assessment of penile vibratory thresholds. Although nomograms have been published for appropriate penile sensory thresholds, the value of routine biothesiometry is debated. Office injection testing involves the administration of intracavernosal vasoactive agents to the ED patient and the assessment of the degree of erectile rigidity in response to this agent. Some clinicians use this test to assess if the patient has psychogenic ED (the development of a fully rigid durable erection) or venogenic ED (failure to obtain a penetration rigidity erection), however, given the fact that approximately 30% of men with normal erectile hemodynamics will fail to obtain a penetration rigidity erection in response to a single dose of intracavernosal vasoactive agent, drawing conclusion from this test may be flawed. A positive response to this test, that is the development of the durable rigid erection, indicates that the patient's venocclusive mechanism is intact.
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- Mulhall JP, et al. Improving The Accuracy Of Vascular Testing Of The Impotent Male: Correction Of Hemodynamic Alterations Using A Vasoactive Medication Redosing Schedule. Journal of Urology. 166: 923-6, 2001.
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