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How is Peyronie's disease diagnosed?



How is Peyronie's disease diagnosed?
Peyronie's disease is a disorder affecting the penis that can cause:
a lump within the shaft of the penis
pain in the shaft of the penis
abnormal angulation of the erect penis ('bent' penis).
Not all of these features are necessarily present, but, typically, a man would first notice a tender lump in the penis, which might later be followed by bending of the penis when erect, sometimes at very odd angles. The flaccid penis is not usually deformed.
It is important to remember that a degree of upward (towards the head) angulation of the erect penis is quite normal and not a feature of Peyronie's disease.
Noticing a lump in the penis can be a frightening experience. Men are often concerned that they have developed a cancer.
Cancer within the penile shaft is very rare indeed, while Peyronie's disease is by far the most common cause of such lumps. If you find a lump, it is important to seek prompt medical advice, but you should not be too fearful that a serious cause will be found
What causes Peyronie's disease?
The penis consists of basically three cylinders, covered by several sheaths of tissue and, finally, by skin.
Running the length of each side of the penis are spongy cylindrical structures called the corpora cavernosa. These form the erectile tissue that becomes engorged with blood during erection, acting like the inner tube of a tyre. They are surrounded by the tunica albuginea, a tough, inelastic, fibrous sheath, which might be compared with the tyre itself.
When the penis becomes erect, the inner tubes (corpora cavernosa) inflate, filling the space within the tyre (tunica albuginea), making it more rigid.
In Peyronie's disease, tough, fibrous plaques spontaneously appear within the tunica albuginea, and are felt as tender lumps. When the penis becomes erect, it inflates unevenly and tends to bend around the plaque, causing the characteristic deformed appearance of Peyronie's disease.
One in three men with Peyronie’s have pain or penile bending when erect as their principal symptom.
Experts are not certain why some men get Peyronie's disease and others do not. Several factors might be involved, including:
genetics: occasionally the disease has a tendency to run in certain families (inherited or genetic predisposition), but this is not common.
injury: Peyronie's disease is more common after injury to the penis, such as penile fracture or forceful bending of the erect penis. It also occurs more frequently in men that give injections into the penis for the treatment of erectile dysfunction (impotence).
circulatory disorders: more men with Peyronie's disease seem to be affected by high blood pressure (hypertension) and hardening of the arteries (atherosclerosis), so these conditions might possibly be involved in its development.
diabetes: this is more common in men with Peyronie's disease. As a result diabetes might also be involved in its development.
What are the symptoms?
Peyronie's disease occurs at any time from adolescence onwards, but most commonly in men aged 40 to 60 years. It affects around 1 in a 100 (0.4 to 1.0 per cent) of the middle-aged male population, but some experts suggest up to 4 per cent of men aged over the age of 40 may suffer from it.
The disease causes very variable degrees of deformity and inconvenience.
Some men are barely troubled by it, while others find sexual intercourse physically impossible. Many men will not require treatment, but all should seek prompt medical advice.
The symptoms are:
a lump within the shaft of the penis: this can slowly develop over several months and frequently takes 12 to 18 months to reach its full extent.
pain in the shaft of the penis: two-thirds of men with Peyronie's disease will experience pain in the penis. In most cases, it will gradually settle down and disappear without treatment in a few months.
abnormal angulation of the erect penis ('bent' penis): during the 12 to 18 months that the plaque or lump is developing, the deformity of the erect penis can change - 30 to 40 per cent get worse, 10 to 20 per cent get better and 50 per cent remain the same.
Some men will develop varying degrees of erectile dysfunction (impotence) as a consequence of Peyronie's disease. This can vary from a complete inability to attain and/or maintain an erection adequate for satisfactory sexual experience to a slight reduction in penile rigidity.
Some men report a tendency for the penis to buckle around the lump during sex. The frequency of this problem has been reported as between 4 and 80 per cent, although experience suggests that the true rate is towards the lower end of this range.
How is Peyronie's disease diagnosed?
Peyronie's disease is diagnosed on the basis of the history (how the problem has developed, as you describe it to your doctor) and examination (what the doctor can see and feel).
Between 10 and 25 per cent of men with Peyronie's disease have Dupuytren's contracture, a claw-like deformity in which the little finger, the ring finger and, sometimes, other fingers bend over towards the palm of the hand.
No special investigations are needed and biopsy (surgically removing a piece of the lump for examination under a microscope) is only needed for rapidly enlarging lumps that are not developing in the usual manner. Ultrasound scanning can be used to assess the exact size and position of the lump, but is rarely necessary.
What else could it be?
Although extremely rare, sarcoma of the penis (a form of cancer) can present in a similar way. Your doctor will consider this if the lump enlarges very rapidly or develops in an unusual manner.
What can you do?
If you think that you might have Peyronie's disease, you should seek medical advice. You should consult your GP or family doctor initially, although you could also ask for advice in a genitourinary medicine (GUM) clinic. The doctor will want to hear how the problem has developed and how it affects you, and to examine you.
If the problem has been present for a long time, is not changing, and is not causing you much trouble, the doctor might recommend no treatment and simply ask you to return if the condition starts to worsen.
If the problem has been present for a long time and is causing you sexual difficulties (such as impotence, difficulty with penetration, or pain during sex for either partner), they may refer you to a urologist. You might need surgical treatment to correct the deformity. It is unwise to seek surgical treatment solely for cosmetic reasons.
If the problem has recently developed, particularly if the lump is continuing to develop or is painful, the doctor may consider offering drug treatment themselves or refer you to a urologist, genitourinary physician, or other specialist for advice.
Although Peyronie's disease is not that uncommon, men do not frequently ask about it so some GPs might be unfamiliar with treatment options. It is reasonable to request referral or to refer yourself to a GUM clinic, if you are unhappy with the explanation and advice you have received.
There is nothing you can do to prevent the development of Peyronie's disease after it has appeared. However, avoiding penile trauma might prevent it. Men who are injecting into the penis to treat erectile dysfunction might reduce their risk of developing Peyronie's disease by careful injection technique and by varying the site of injections. This advice is usually given when patients are first taught to use injections.
What can your doctor do?
First, your doctor should be able to reassure you that you do not have cancer.
Drug treatment
This is a controversial area, as only limited evidence of the effectiveness of drug treatment exists. However, such treatment is worth considering in men with early or active Peyronie's disease, that is when the lump is expanding or is painful. The aim is to reduce pain, lump size and the eventual deformity.
Vitamin E and potassium aminobenzoate: these drugs have been shown to improve pain in 30 to 60 per cent of affected men, but do not seem to affect lump size or deformity of the erect penis.
Tamoxifen: one study demonstrated that tamoxifen (eg Nolvadex D) not only improved pain in about 80 per cent of affected men, but reduced lump size and deformity in about 30 per cent of men. The study was in men with early disease and soft plaques. No evidence exists of benefit in men with long-established disease. Tamoxifen is usually used in the treatment of breast cancer, but has relatively few side effects. Although not licensed for use in Peyronie's disease, some specialists will recommend it.
Steroid injections: several studies have looked at injecting steroids into Peyronie's plaques in an attempt to reduce pain, deformity and lump size, but the results have been very disappointing.
Verapamil injections: one study in a very small group of men has shown that repeated injections of verapamil into the Peyronie's plaque improved pain, deformity and lump size. Given that penile injection is a potential cause of Peyronie's disease, more evidence from larger, long-term studies must be gathered before this can be recommended as a treatment.
Extracorporeal shockwave therapy
Studies in the UK and Germany have shown that extracorporeal (outside the body) shockwaves directed at Peyronie's plaques can reduce penile deformity in established, stable disease.
This technique has been used to smash kidney and gallstones for many years, and might avoid the need for surgery in established Peyronie's disease. Treatment is given over several sessions on an outpatient basis. This technique is still under investigation and is not yet widely available.
Surgery
Because the development of Peyronie's disease varies so much between individuals, a wise strategy is to adopt a conservative approach to treatment and avoid early surgical intervention. Surgery should be done only to correct penile deformity in men with stable Peyronie's disease that has been present for at least a year and has not changed whatsoever for at least three months.
It is essential that the disease has stabilised and become inactive before surgery is attempted, otherwise the condition can continue to progress after the operation has been performed.
The indications for surgery are:
unacceptable difficulty with penetration during sex
pain during sex for either partner that is a consequence of the penile deformity.
Unacceptable cosmetic appearance of the erect penis is not a good reason to have surgery unless it is causing severe and intractable psychological distress.
Success of surgery is usually measured by the correction of deformity but there are no guarantees that the penis will be perfectly straight after surgery. In addition, some men will develop erectile dysfunction or even numbness of the penis following surgery, so it is not a treatment to contemplate without considerable caution.
Types of surgery
Plaque excision and grafting
Simply cutting out the plaque from the tunica albuginea and filling the defect with a skin graft from the abdominal wall seems to be a logical way of treating Peyronie's disease. However, results are disappointing, with success rates from studies reported between 20 and 70 per cent. Worse still, between 16 and 70 per cent of men suffer erectile dysfunction after surgery.
Plaque incision and grafting
Incising (cutting through) the plaque, either with a scalpel or laser, and then filling the defect with a graft has the advantage of preserving the tunica and maintaining penile length. Although results from studies seem better than for plaque excision, the research only involved a very small number of men and more work is need to confirm its safety and effectiveness.
Corporoplasty
Plication of the corpora: plication of the corpus cavernosum (in simple terms, stitching a small tuck into the corpus) on the opposite side to the plaque may improve deformity but will shorten the erect penis. Success rates of 50 to 60 per cent have been reported with this technique.
Nesbit's operation: this operation involves removing a section of corpus cavernosum on the opposite side to the plaque, then suturing the edges together. This corrects the deformity but, again, will result in penile shortening. Success rates of up to 80 per cent have been reported with this technique.
In both of these procedures, circumcision will also normally be performed, as foreskin problems frequently follow these operations in uncircumcised men.
Prognosis
Peyronie's disease runs a very variable course. Many men with Peyronie's disease will not require or desire treatment, and will enjoy very satisfactory sex with their rather unusually shaped penis
Men who have had Peyronie's disease are more likely to have a further episode in the future than the general population. Nothing is proven to prevent a recurrence.