Peyronie's Flashcards
Pathophysiology of Peyronie’s
acquired inflammation disorder of tunica albuguinea
microvascular trauma to penile shaft associated with penile buckling, repetitive minor trauma, protein deposition, macrophage, collagen changes from 1→3
Symptoms of Peyronie’s
penile curvature
penile deformity
penile discomfort/pan
ED
usually a man in mid 50s with onset of curvature and pain
Describe active and stable Peyronie’s:
Active dz: changing sxs, pain/discomfort, induration, palpable plaque, deformity/curvature, shortening, indentation, hinge effect, narrowing, hourglass, distress
Stable dz: unchanged for at least 3 mo, plaque palpated or US, ED, penile deformity stable, no pain, distress
Don’t forget a questionnaire for ED/PD
Initial evaluation of patient with suspected Peyronie’s includes:
GUIDELINE STATEMENT 1
document signs and symptoms - characterize
history to assess deformity, interference with intercourse, pain, distress, frequency of sexual activity/changes
PE - for palpable nodules and curvature (often need to stretch), tenderness, DRE, scrotal exam, fibrosis/plaque
Clinicians should perform this procedure in office to assess for Peyronie’s:
GUIDELINE STATEMENT 2
ICI with or w/o duplex doppler US
Clinicians should evaluate and treat Peyronie’s only when:
GUIDELINE STATEMENT 3
he/she has expertise and diagnostic tools to appropriately evaluate, counsel, and treat the condition
Clinicians should discuss with patients regarding Peyronie’s dz:
GUIDELINE STATEMENT 4
the available treatment options and known benefits and risks/burdens associated with each tx
Clinicians may offer this for patients suffering from active PD?
GUIDELINE STATEMENT 5
NSAIDs
Clinicians SHOULD NOT offer these options for patients with PD?
GUIDELINE STATEMENT 6
oral vitamin E
tamoxifen
procarbazine
omega-3 fatty acids
or a combo of vitamin E and L-cartnitine
no efficacy
GUIDELINE STATEMENT 7
electromotive therapy with verapamil
GUIDELINE STATEMENT 16
radiotherapy
For patients with penile curvature >30 and <90 and intact ED, clinicians may administer what? How?
GUIDELINE STATEMENT 8
intralesional collagenase clostridium histolyticum
in COMBO with modeling
only when stable dz
Tx curvature NOT pain or ED
What should clinicians counsel patients of the risk of intralesional collagenase clostridium histolyticum of the risks?
GUIDELINE STATEMENT 9
penile ecchymosis
swelling
pain
corporal rupture
erythema
painful erections/ED
Besides intralesional collagenase, what else may be administered for PD?
GUIDELINE STATEMENT 10
intralesional interferon alpha-2b
improves curvature, plaque size, pain, ED
GUIDELINE STATEMENT 12
intralesional verapamil
active
pain, plaque, curvature
What should clinicians counsel as risk of alpha-2b intralesional treatments?
GUIDELINE STATEMENT 11
sinusitis
flu-like
minor penile swelling
ecchymosis
tx with OTC NSAIDs (last 48h)
What should clinicians counsel as risk of verapamil intralesional treatments?
GUIDELINE STATEMENT 13
penile bruising
dizziness
nausea
pain at injection site
Treatment with extracorporeal shock wave therapy (ESWT) for PD is indicated for:
GUIDELINE STATEMENT 14/15
for pain
NOT
reduction in curvature or plaque size
In the presence of stable PD, clinicians should assess patients as candidates for what?
GUIDELINE STATEMENT 17
surgical reconstruction
12-18m after onset, stable curvature 3-6 mo
in stable dz, pain only with erection
establish:
location (proximal, mid, distal)
direction of curvature (dorsal, lateral, ventral)
degree of curvature
presence of other deformities (indentation, hinge, narrowing, hourglass, shortening, uniplanar, biplanar)
presence, location, extent of plaque (calcification)
presence and extent of ED
interference with intercourse for patient/partner
degree of distress
What surgical options are appropriate for adequate rigidity (w or w/o meds and VED) for improving penile curvature?
GUIDELINE STATEMENT 18
tunical plication
GUIDELINE STATEMENT
plaque incision or excision and/or grafting
Risks and a/e of tunical plication surgery:
urethral laceration
urinary retention
UTI
superficial skin necrosis (minor/major)
hematoma (obs vs. re-operation)
wound infection
chest infection
painful/palpable suture
suture granuloma
phimosis
ED or penile pain (persistent)
What surgery may be offered to patients with PD and ED and/or significant penile deformity?
GUIDELINE STATEMENT 20
IPP
when deformity sufficient to impair coitus despite meds and/or VED
GUIDELINE STATEMENT 21
may perform adjunctive intra-operative procedures such as. modeling, plication, or incision/grafting when significant deformity persists after insertion of IPP
modeling/maneuvers when >30 after IPP
GUIDELINES STATEMENT 22
should use IPP
Grafting techniques are indicated when penile curvature is:
>60 degrees, hourglass deformity, or penile shortening
What type of grafts can be used in PD surgery?
autologous (vein, dermis, buccal) → increased morbidity
non-autologous (trend towards tissue engineered, pericardium, small intestine, or collagen fleece → no sutures required)
Peyronie’s Algorithm
How does intralesional interferon alpha-2b work?
cytokine thought to inhibit fibroblasts
works for curvature, pain, plaque
stable dz, curvature > 30 without calcified plaque
How does intralesional collagenase clostridium histolyticum in combination with modeling work?
stable curvature > 30 < 90
break down plaque and model to straighten
can improve 35-75%
(not for hourglass, calcified or ventral plaques or acute dz)
types of penile plication:
- excising and ellipse (Nesbit)
- vertical incision closed horizontally (Yachia)
- dot technique that imbricates tunica
- graft (incise/excise at point of m ax curvature), repair tunica with graft
Important questions to ask patient presenting with suspected PD?
direction of curvature
presence of UI
presence of pain w or w/o erection
current ability to have intercourse
degree of ED
stability curvature
presence of pain with intercourse for patient or partners
hx of intercourse injury
What are risks of IPP when done for PD?
pain
infection
need for ectopic placement of reservoir if after RP
adjacent organ injury
need for additional surgery
device erosion
device malfunction
residual curvature
decreased sensation
loss of penile length and girth
bleeding
Critical steps of modeling?
assure not injury to urethra or corpora
cycling device and repeating as necessary
applying force opposite the point of max curvature for 90 seconds
mark point of max curvature
protecting pump with rubber shods
completely inflating IPP prior to modeling
