Postgrad Med J: first published as 10.1136/pgmj.56.661.773 on 1 November 1980. Downloaded from http://pmj.bmj.com/ on November 27, 2019 by guest.

Postgraduate Medical Journal (November 1980) 56, 773-776

Peyronie's disease in a district general hospital

VICTOR 0. N. ODIASE ROBERT H. WHITAKER
F.R.C.S.(Ed), F.R.C.S.(Eng) M.Chir., F.R.C.S.
Department of Urology, Addenbrooke's Hospital, Cambridge

Summary (2) lump in the penis;

Peyronie's disease can cause severe physical and (3) pain in the penis on erection;
psychological distress. Of 31 cases in this retrospective (4) difficulty in performing sexual intercourse;
study, 12 underwent spontaneous improvement in their (5) proximal distension and distal laxity of the
symptoms which makes the assessment of active erect penis.
treatment in other patients difficult. The indications The past illnesses which could be significant and
and limitations of operative approach are discussed. any factors which might have a predisposing in-
fluence were recorded. The diagnosis was confirmed
Introduction by feeling the typical fibrous plaque. The authors

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The 17th century French periodical 'Les found that the plaque was easiest to feel with the
Ephemerides des Animaux de la Nature' is alleged fingers on the 2 lateral sides of the penis and indeed
to have mentioned the condition which is now may not be detectable in the antero-posterior plane.
recognized as Peyronie's disease (Merle, 1899; An X-ray of the penis was taken in one of the severe
Fogh-Anderson, 1957; Chesney, 1975). However, cases; histological examination was available in the
it was not until Franqois de la Peyronie (1743) 3 patients who underwent operation.
published his article on 'some obstacles opposing the
natural ejaculation of semen' that the clinical entity Management
gained recognition and became known by his name. All patients were reassured that the illness from
He described 3 patients who had pain and associated which they suffered was not malignant and that
curvature of the penis on erection and were found on there was a tendency for the condition to improve
examination to have thickened fibrous areas in the spontaneously. The more severe cases, and those
shaft of the penis. The work of Smith (1966) has who insisted on treatment even though their disease
resulted in the recognition of an early phase of the was mild, were treated with potassium para-amino-
disease characterized by aggregation of lymphocytes benzoate (Zarafonetis and Horrax, 1959). Three
and plasma cells around the vessels in the connective patients have had an operation and 2 more are
tissue between the tunica albuginea and corpora awaiting it. The criteria for surgery were a very large
cavernosa and a later phase when these chronic fibrous plaque producing severe deformity and a
inflammatory changes are replaced by a fibrous plaque which, though not necessarily large, resulted
plaque. There are very few lymphocytes or plasma in laxity of the distal part of the erect penis.
cells seen in the later phase and the fibrous plaque Numerous types of operation have been described
may become ossified. The aetiology and satisfactory for Peyronie's disease but the authors preferred the
management of this disease remain contentious. technique of Devine and Horton (1974) of excising
Thirty-one cases seen in the clinic of one of the the plaque of fibrous tissue and repairing the tunica
authors over a 5-year period are retrospectively albuginea with a free dermal graft. The only modi-
studied. fication made was to obtain the skin graft from the
anterior aspect of the thigh rather than the ab-
Patients and methods dominal wall. The skin, as Devine and Horton
Diagnosis and investigations suggested, was denuded of its epidermis and under-
Thirty-one patients referred by their general lying fat.
practitioners were diagnosed as suffering from
Peyronie's disease. There were 5 main symptoms of Results
which the patients complained and these were The ages of the thirty-one patients with Peyronie's
(1) deformity of the penis on erection; disease ranged from 20 to 72 years and the age
0032-5473/80/1100-0773 $02.00 (¢ 1980 The Fellowship of Postgraduate Medicine
 Postgrad Med J: first published as 10.1136/pgmj.56.661.773 on 1 November 1980. Downloaded from http://pmj.bmj.com/ on November 27, 2019 by guest.
774 V. 0. N. Odiase and R. H. Whitaker
distribution is illustrated in Fig. 1. In this retro- 10_
spective study only 24 patients timed the onset of
symptoms precisely (Fig. 2). The patients' com-
plaints are summarized in Table 1. The past ill-
8-
nesses which could be significant were recorded:
mumps, one case; ankylosing spondylitis, one case;
osteoarthritis, 2 cases; severe disc lesion, 2 cases;
urinary tract infection, 2 cases; prostatism, 2 cases;
trauma, 2 cases. 0

One of the patients timed the onset of his disease

with an episode of trauma during forceful sexual nn
intercourse while another patient related it to the E4
z
time his wife began using a ring pessary to correct a
retroverted uterus. The only penis that was X-rayed,
a severe case, revealed calcification of the plaque. 2-
Histological examination of the plaques removed
from the 3 patients treated surgically showed thick
fibrous tissue between the tunica albuginea and
corpora cavernosa with minimal cellular reaction. 0 12 24
H 36
H
48
I60
Months after first attendance

12- FIG 2. Duration of symptoms at first attendance.

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The results of the management were categorized
10- as 'Improved', 'Worse' and 'No change' (Table 2).
The classification was based on a consideration of
the patients' symptoms and physical findings at
8- follow-up attendances. The patients who improved
accepted that pain was less and sexual intercourse
ar
had improved but rarely admitted improvement in
w the deformity of the penis. Complications from the
tn
a treatment are noted in Table 2.
U

Discussion
Peyronie's disease is a disease of middle age as
shown in Fig. 1 with an average age of onset of 47
D 20 4 6
years in this series. Others have found a similar age
0 0
w~~~~~~~Aei er
incidence of 49 years (Morales and Bruce, 1975)
and 48 years (Raz, Dekernion and Kaufman,
1977). The disease does not appear to cause acute
symptoms in many patients and this results in an
average delay of 8 months before consultation.
This is similar to the average of 9 months in the
series of Winter and Khanna (1975). While de-
formity of the penis was the most common complaint
FIG. 1 Age distribution of patients with Peyronie's disease. (80%) in this series, proximal distension and distal

TABLE 1. Complaints of patients

Deformity of penis Difficulty with Pain in penis Lump in penis Proximal distension
on erection sexual intercourse on erection and distal flaccidity
of penis
Number complaining
of symptom out of
31 (%) 25 (80) 16 (51) 14 (45) 7 (22) 3 (10)
 Postgrad Med J: first published as 10.1136/pgmj.56.661.773 on 1 November 1980. Downloaded from http://pmj.bmj.com/ on November 27, 2019 by guest.
Peyronie's disease 775
TABLE 2. Summary of management
Outcome of
Treatment Number treatment Complication of treatment
No active treatment 19 Improved (12)
No change (3)
Worse (4)
Potassium para-amino benzoate 8 Improved (5) (1) One patient developed gout every time he
No change (2) took the drug
Worse (1) (2) One patient developed severe rash
following the drug
Surgery 3 Improved (2) The penile skin of one patient sloughed.
No change (1) Scrotal skin graft applied
Worse (0)
Awaiting surgery (one transferred from the
para-amino benzoate group) 2 No change

laxity of the erect penis (10 %) formed one of the stronger erection of the penis. One of these cases
major indications for offering surgery to the patient. had a protracted recovery as the skin of the penis
The authors felt that the fibrous plaque was causing sloughed and needed a scrotal skin graft. The third
a constriction of the corpora cavernosa and this was patient was not improved by surgery.

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best dealt with by excision. No hard and fast rule can be formulated for the
The aetiology of Peyronie's disease remains management of Peyronie's disease. Each case has to
obscure. It has been found to occur in association be assessed on its merit and when non-operative
with urethritis (Smith, 1969), Dupuytren's contrac- treatment is decided upon potassium para-amino-
ture (Morales and Bruce, 1975; Chesney, 1975) and benzoate may offer some help. Surgery should not
osteoarthritis (Furlow, Swenson and Lee, 1975). be undertaken lightly but, when indicated, excision
Although trauma has been suggested, the plasma and of the fibrous plaque and free patch skin graft can
lymphocyte infiltration found around the vessels in restore the anatomy of the corpora cavernosa to pro-
the early stage of the disease has led to the specula- duce an acceptably good result. Alternatively the
tion that it is more likely to be an auto-immune deformity can be corrected by excising one or more
disease. In this series, 2 patients have firmly related pieces from the tunica albuginea opposite to the de-
the onset of their symptoms with trauma. In others formity (Pryor and Fitzpatrick, 1979). Surgery is
arthritis and urinary infection have also been de- probably best reserved for those who find sexual
tected. The authors are, however, unable to attach intercourse impossible and whose degree of defor-
any aetiological significance to them. mity has become stable.
A satisfactory management of Peyronie's disease
remains as elusive as its aetiology. Numerous forms
of treatment have been suggested and each has had References
success claimed for it. As the untreated disease has a CHESNEY, J. (1975) Peyronie's disease. British Journal of
tendency to improve over approximately 4 years Urology, 49, 209.
DEVINE Jr, C.J. & HORTON, C.E. (1974) Surgical treatment of
(Williams and Thomas, 1970) it is difficult to judge Peyronie's disease with a dermal graft. Journal of Urology,
the efficacy of any form of treatment. This series 111, 44.
has clearly shown that most of the untreated patients FOGH-ANDERSON, P. (1957) Treatment of plastic induration
can improve spontaneously (Table 2). It should of the penis (Peyronie's disease). Acta chirugica scandin-
avica, 113, 45.
however be remembered that the patients in this FURLOW, W., SWENSON, H.E. & LEE, R.E. (1975). Peyronie's
group were those whose disease was considered disease: study of its natural history and treatment with
mild. The severer forms of the disease automatically orthovoltage radiotherapy. Journal of Urology, 114, 69.
qualified the patients for treatment. A few patients MERLE, N. M. (1899) Contribution a l',6tude des corps caverneux
et des os penis. These de Toulouse.
whose disease was mild but who insisted on treat- MORALES, A. & BRUCE, A.W. (1975) Treatment of Peyronie's
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s'opposent a 1'ejaculation naturelle de la semence. Mem-
suffered severe drug reaction. Two of the 3 patients oires de l'Academie de chirurgie, p. 425.
who have had surgery have recovered straight and PRYOR, J.P. & FITZPATRICK, J.M. (1979) A new approach to
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776 V. 0. N. Odiase and R. H. Whitaker
the correction of the penile deformity in Peyronie's disease. WILLIAMS, J.L. & THOMAS, G.G. (1970) The natural history
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RAZ, S., DEKERNION, J.B. & KAUFMAN, J. (1977) Surgical WINTER, C.C. & KHANNA, R. (1975) Peyronie's disease-
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