What is Peyronie's Disease?
Peyronie-Peyronie's Disease is the formation of a cartilaginous-fibrotic plaque in the penis shaft-main body, in the tissues outside the erectile bodies, under the sheaths around the penis, causing bending and angulation in the erect penis. It is called . In other words, the penis bends to one side during erection. It is a chronic condition that affects approximately 3-9% of adult men and impairs their psychological and physical well-being and quality of life. Since the cause of its formation is not fully known, its treatment is limited. Evaluation, treatment and follow-up of these patients should be done in certain order. Although it was first described by Fallopius and Vesalinus in 1561, it was described by Francois Gigot de za Peyronie in 1743 as the subcutaneous accumulation of fibrotic and calcified-calcific plaques in the penis.
Peyronie's disease, also called calcification of the penis, was described by former US president It is famous as Bill Clinton's disease. Distribution by age; It was found to be 1.5% at the age of 30-39, 3% at the age of 40-49 and 50-59, 4% at the age of 60-69, and 6.5% at the age of over 70. This rate was found to be 8.9% in men with prostate cancer. It is thought that the frequency is higher because it is estimated that some of the cases do not consult a doctor because they are embarrassed. Although it can be seen between the ages of 15-80, 65% of the patients are between the ages of 40-60.
Causes of Peyronie's Disease
The cause and form of occurrence are not clearly known. However, genetic predisposition and/or autoimmunity (a large group of diseases in which the person's immune system attacks the immune cells), trauma and inflammation are blamed. .
Trauma: The most long-held cause of Peyronie's disease (PD) is minor trauma that occurs during sexuality. It is suggested that in these traumas, small vessel ruptures turn into scar tissues. It is suggested that the disease begins in the branches that spread into the tissue from the tissue called tunica albuginea, which is the thick solid tissue around the penis. Bleeding into the tunica albuginea causes fibrinogen activation, which causes inflammatory cells such as macrophages, neutrophils and mast cells to enter the trauma area. It causes the migration of cells and platelets. Intermediary substances such as cytokines, autocoids, vasoactive factors, serotonin, platelet-derived growth factor, which play a role in inflammation, are released into the environment and scarring (fibrosis) develops. The avascular structure of the tunica albuginea causes such intermediary substances to not be removed from the environment. It is thought that the increase or decrease in the functions of metalloproteinases, which are enzymes that play a role in shaping the proteins of the extracellular environment, also play a role in Peyronie's Disease. Most patients with Peyronie's Disease do not give a history of sexual trauma. Therefore, a hereditary (genetically inherited) predisposition is suspected with trauma.
Genetic Predisposition: Genetic predisposition is thought to play a role in the development of Peyronie's Disease. In 2% of patients, other men in the family also have the same disorder. Peyronie's Disease is also present in 16-20% of those with Dupuytren's disease, which progresses with increased scar tissue in the hand. Paget's disease of the bones is related to Peyronie's Disease. Autoimmune causes involving cellular type immunity are also suspected. In short, trauma and impaired immune response are thought to be among the causes.
Atherosclerosis: Vasculitis seen in the early stages of atherosclerosis is thought to be related to Peyronie's Disease. Premature aging of vascular connective tissues is thought to increase vulnerability to minor trauma. Diabetes was observed in 26% of men with Peyronie's Disease, high cholesterol in 24%, high blood pressure in 18%, high blood fat levels in 12% and ischemic heart disease in 8.5%. All of these diseases are risk factors for systemic vascular disease.
Symptoms
Patients may experience a hard plaque or area on the shaft of the penis, deformity of the penis both during erection and non-erectile periods, and erectile dysfunction during erection. They usually apply with complaints of pain in the penis, shortening of the penis length with or without erection, and erectile dysfunction
Physical Examination: In Peyronie's Disease, a hard area or plaque is palpable on the penis in all cases, but 38-62% of patients are unaware of this. Most of the plaques are on the surface of the penis facing the body, and the curvature is upward. Patients with a curvature of 45 degrees can often have sexual intercourse. It is less common for plaques to be on the side or lower part of the penis, and it is more difficult for patients to have intercourse because they cause curvature outside the natural erection angle. In patients with plaques on opposite sides of the penis, although the curvature is not very pronounced, the shortening in penis length is more obvious.
Plaque calcification is seen in 20-25% of those with Peyronie's Disease. It indicates that the disease has become chronic. Nonsurgical treatments are considered unsuccessful in these patients. Some studies suggest that the plaque size of 1-2 cm should be taken into consideration for surgery. Plaque calcification does not increase the degree of curvature, but it does cause more painful erections. There may be pain in the acute, inflammatory phase of the disease, but it is not severe, it only occurs during erection, and may affect sexual functions. Some patients experience pain during night erections. The pain disappears after the inflammation period or after 18 months at the latest.
The erectile dysfunction caused by Peyronie's Disease is not yet fully understood. It is seen in 58% of patients. Factors affecting erectile dysfunction in Peyronie's Disease are psychological factors, penile deformities and scar tissue formation (fibrosis), accompanying vascular diseases and venous insufficiency of the penis. Decreased compliance of the plaque's tunica albuginea during erection reduces the pressure applied to the penile veins and causes venous leakage.
Current-Clinical Course
If left untreated, the disease progresses in 48% of patients. Generally, Peyronie's Disease has 2 periods. An active first period and a quiet second period. During the active phase, erections are generally painful and the shape of the penis changes. This period lasts 6-18 months and resolves spontaneously in 10-15% of patients. In the second silent period, there is no progression of the deformity, and painful erections, if any, improve. One third of the patients develop a sudden painless deformity.
Diagnosis
p>Diagnosis is made by the patient's history and penis examination. The key point in the history is when the findings started, penis deformity, pain during intercourse, if any, and erectile dysfunction should be investigated. During penis examination, the location of the plaque or hard tissue and the degree of hardness should be recorded. The ideal thing is to evaluate the curvature of the penis during erection; if necessary, the use of devices such as drugs or vacuum pumps that provide erection may be required. As another method, the patient can take a photo of his erect penis at home. Stretched penis size should be measured. Penile length is shortened in almost all patients with Peyronie's Disease. Erectile dysfunction is common in patients with Peyronie's Disease, and to evaluate vascular predisposition, a detailed history should be taken and ready-made questions called International Erectile Function Questionnaire (IIEF) should be answered by the patients. If patients have erectile dysfunction, penile vascular structures should be evaluated with penile doppler ultrasonography.
TREATMENT
The approach to Peyronie's Disease is limited since the cause is not fully known. Treatment varies depending on whether the disease is in the acute or chronic stage, the severity of the patient's complaints, and whether or not he has erectile dysfunction. Oral drug treatments or minor interventional treatments are given to patients who are in the acute phase or have painful erections.
Oral medications for Peyronie's treatment: The aim is to prevent the progression of the disease and reduce pain by preserving erection capacity. Drugs such as vitamin E, Potaba (potassium para-aminobenzoate), colchicine, tamoxifen, pentoxifylline can be used in medical treatment.
ESWT (shock wave therapy on plaque): Especially applied in recent years. The purpose of this method is to remove free oxygen radicals by creating new blood vessels around the plaque.
Electromotive drug administration / Iontophoresis: It is the application of verapamil and verepamil + dexamethasone given to the skin by electrophoresis and electroosmosis with the help of high heat or current to increase the absorption from the skin. The treatment is applied 2-4 times a week for 2-3 months.
Surgical Methods: It should be considered in patients where severe deformities such as severe penile curvature and hourglass-shaped deformity impair sexual functions. Surgery should be considered for patients who do not benefit from minor invasive treatments, who continue to suffer from erectile dysfunction, and who want a solution in a short time. The aim of surgical treatment is to correct penis deformity, ensure or maintain erectile function, and preserve penis length and diameter. The surgical method may vary depending on the size and location of the hard tissue (plaque), the degree of penile curvature, and whether or not there is erectile function before treatment. Before the surgery, the patient's expectations from the surgery should be thoroughly explained and it should be said that a full return to the pre-disease period cannot be achieved. There are surgical methods such as shortening and lengthening the tunica albuginea, which is the tissue that surrounds the vascular tissue that provides erection in the penis and gives its shape to the penis, and placement of a penile prosthesis.
Shortening the tunica should be preferred if there is adequate erectile function with or without medication before the operation, if the penis length is sufficient, if the curvature is less than 60 degrees, if the curvature is at the tip, and if the shortening at the end of the operation will not exceed 20% of the penis length. In the operation, the curvature is corrected by shortening as much as the hard tissue does, right opposite the area where the hard tissue is.
Removing the hardened tissue and replacing it with a patch, or scratching and strengthening it with a patch, can be done with or without medication in patients with the presence of large plaques, in patients with a curvature degree greater than 60 degrees, in cases with hourglass-shaped deformities or in cases with short penis length. It is preferred if there is sufficient erectile function. The hard tissue on the side of the disease is removed and a patch (graft) is placed in its place. Complete removal of plaque is not recommended because it causes venous insufficiency and thus erectile dysfunction. Tissues obtained from the patient's own body can be used as patches, or patches obtained from another person or living creature can be used. Synthetic grafts are not preferred due to the risk of infection. After these interventions, patients are given penile stretching exercises or exercise.
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