Peyronie’s disease (PD) is a relatively common disorder characterized by the development of a fibrous plaque or scar tissue within the tunica albuginea of the penis. This condition can present with one or a combination of symptoms, such as curvature, indentation, buckling, and penile pain. Penile shortening is also a common underlying concern among patients.

PD can also lead to erectile dysfunction (ED) in some men due to altered hemodynamics of cavernosal blood flow. Treatment of this condition ranges from reassurance to medical, mechanical, or surgical therapy. Treatment goals center on preserving or restoring erectile function and patient satisfaction.
History and Epidemiology

François Gigot de La Peyronie, a French surgeon and founder of the Académie Royale de Chirurgie (Royal Academy of Surgery), was credited with the description of PD in 1743; however, there are reports of the disorder dating back to 1265.

Initial reports estimated the prevalence of PD at approximately 1%. More recent population studies indicate that this may be a significant underestimate of the true prevalence. One of the largest population studies examined 8000 German men and found an overall prevalence of 3.2% as defined by a palpable penile plaque.[2] The incidence also increased with age, which contradicts previous prevalence reports stating that the highest incidence was found among men in their fifties. Another recent study examining objective evidence of PD in men undergoing prostate cancer screening found a prevalence of 8.9%.

One theory for the increasing incidence of PD, especially in older men, could be the increasing use of pharmacotherapy for ED. Phosphodiesterase (PDE) type 5 inhibitors are not believed to cause PD; however, intracavernosal injection agents may increase the risk for plaque formation. Presumably, this increased risk stems from local trauma secondary to the injection technique. Recent evidence also suggests that the development of PD is increased after radical prostatectomy.

Natural History of PD

Contrary to what was once thought, evidence suggests that there is minimal spontaneous resolution of PD. In fact, in a study following men up to 8 years, only 13% of participants felt that there had been any spontaneous improvement. Forty-seven percent of patients in this study thought that the disease had stabilized and 40% noted worsening of symptoms.[5] These findings are in accord with those of the most long-term study to date, which followed 246 men for at least 12 months. These patients presented within 6 months of the onset of PD and were followed without treatment. Of these men, 12% reported improvement, 40% stable disease, and 48% worsening.[6]

PD appears to be a “2-stage” disease process. Initially, about a third of patients present with painful erections during the acute phase. This period can also be characterized by worsening deformity of the penis. The second stage of PD is characterized by a stabilization of the deformity. Pain with erections generally subsides. However, the majority of men may initially present with a painless deformity without experiencing painful erections.

The rigid plaque that is the cause of PD symptoms is found on the side of the corpus cavernosum to which the curvature is directed. Most often, the plaque develops on the dorsal side of the penis and causes the penis to curve upwards during erection. Plaques may also form on the ventral or lateral sides of the penis, causing it to curve downward during erection.

ED is often associated with PD. In fact, many patients initially present with ED as their major complaint. Although researchers have attempted to quantify rates of ED associated with PD, there appears to be a large psychological contribution to the ED, which makes it difficult to quantify objectively. In one large cohort of men with PD, the prevalence of ED was approximately 30% as assessed using the International Index of Erectile Function (IIEF).

About 80% of these patients reported that the disease was psychologically distressing, but the psychological stress is likely not the only cause of ED in these patients; physical factors of ED have also been identified. Hemodynamic changes in penile blood flow studies have been documented using both penile duplex Doppler ultrasonography and dynamic infusion cavernosometry/cavernosography (DICC). Kendirci and coworkers studied more than 500 men with ED using penile duplex Doppler ultrasonography after intracavernosal injection of a vasoactive agent and found a correlation between the type of penile deformity and hemodynamic changes.

Those patients with hourglass deformities were more likely to have arterial insufficiency, whereas those with ventral curvature were more likely to demonstrate veno-occlusive dysfunction. The presence of ED in these patients has a profound effect on the various treatment outcomes presented to the patient.