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The Clinical and Psychosocial Impact of Peyronie's Disease
Laurence A. Levine, MD, FACS

The Clinical and Psychosocial Impact of Peyronie's Disease

Laurence A. Levine, MD, FACS
Peyronie’s disease (PD) is characterized by the formation of palpable fibrotic tissue in the tunica albuginea of the penis. It is thought to manifest in response to recurrent microtrauma during erection in those with risk factors that may include wound-healing disorders. The initial stage of PD is thought to last from 6 to 18 months, and it is characterized by an inflammatory period with pain in approximately one-third of men. This initial phase is followed by a chronic phase when pain typically resolves and the deformity stabilizes with no additional plaque development. PD has been reported to develop in up to 9% of adult males according to published literature, but the incidence may be even higher. The most frequently affected age group is men between 50 and 59 years. Because of the associated penile deformity and effect on sexual relations, psychosocial distress is very common in those with PD. It has been reported to negatively affect self-image, sexual activity, intimacy, and mood, and it is often associated with depression and erectile dysfunction (ED). At this time, nonsurgical treatments are unreliable and have variable efficacy, and surgical treatments are reserved for those with disabling disfigurement. Moreover, surgery may result in loss of penile length and ED, and there are only a few physicians in the United States that perform such surgeries. There is a great need to increase awareness of PD in patients and general practitioners, to elucidate the pathogenesis of PD, and for the development of novel treatments for this disfiguring disease.

(Am J Manag Care. 2013;19(4 suppl):S55-S61)
Peyronie’s Disease

Peyronie’s disease (PD) is a disorder of the penis characterized by irregular, dense plaques of fibrous scars that are located in the tunica albuginea.1,2 In the erect penis, the scars associated with PD are known to cause a variety of deformities such as curvature, shortening, narrowing, and the hinge effect (ie, buckling of the penis due to a narrowed segment in the penis shaft).2,3 During the early phase of the disorder, about one-third of patients may experience pain caused by an inflammatory component, but pain typically resolves spontaneously within 12 to 18 months of onset in the majority of patients and deformities stabilize. Patients with PD often develop erectile dysfunction (ED).2,4-6 Following the increasing usage of phosphodiesterase inhibitor therapy to treat ED, an increasing number of patients have been presenting to the physician’s office with PD. At this time, there remains no cure for PD and surgical treatment is only recommended to those who are sexually disabled and are willing to undertake risk.7,8

PD is defined clinically as a wound-healing disorder that is thought to be initiated by trauma in genetically susceptible individuals.2,9 Clinical outcomes in PD are difficult to predict. Although pain typically subsides within the first several months of onset, PD progresses in 48% of men who do not receive treatment, resulting in increased curvature and decreased penile length.4 Based on the unpredictable course of disease and the effects of PD on quality of life and sexual function, PD has been associated with significant psychological distress, including anxiety and depression. The psychological impact of PD may be one reason why patients delay their presentation to a physician or fail to discuss their condition with a healthcare provider.10 Moreover, the lack of knowledge about PD, among patients and physicians, may delay diagnosis.

Prevalence of PD

PD is not an uncommon disorder; the prevalence of PD has been reported to be approximately 3% to 9% in men studied.2,11 In 1 German study of the general population, palpable penile plaques were reported in approximately 3% of men (aged 30-80 years).11 Validated questionnaires were mailed to 8000 men and those who did not respond received second and third questionnaires. According to the results, 142 men (3.2% of the respondents; mean age, 57.4 years) reported having a palpable plaque. Only 1.5% of those aged 30 to 39 years reported an induration, with the prevalence of PD increasing as age increased. This study found that the most common age group of men reporting palpable plaques was greater than 70 years (Table 1).11 However, other studies have reported the most common age at presentation is between 50 to 60 years (Table 2).12,13

Results from a larger study, this time in the US general population, suggested that the rates of penile deformities or plaques were substantially higher. The US study was conducted to define the rate of PD using Internet-based technology in 16,000 randomly selected men over the age of 18 years who were asked to self-report the symptoms, diagnosis, or treatment of PD.14 Compared with results from the German study, the response rate in the US study was much higher at 71% (n = 11,420; mean age, 52.7 years); and, of those patients responding, 13.1% reported having symptoms of PD such as a penile deformity or plaque, although only 0.5% to 0.8% of respondents claimed to have been formally diagnosed with PD or to have received treatment for PD.

PD can also occur in teenagers. These patients report a high level of distress, often present to physicians earlier than adults, and have an increased number of plaques.15 Using more objective measures to identify PD, another study estimated the prevalence of PD by physical examination of the penis to detect palpable plaques or curvatures in 1440 patients with ED and found that the rate of PD was 7.9%.16 In this study, patients were significantly more likely to have PD if they had diabetes, dyslipidemia, or a psychological disorder (P <.05 for each). Similarly, a study conducted a year earlier evaluated the incidence of PD in 1133 patients with diabetes who were also screened for ED.17 The rate of PD in the diabetic population was 8.1%, and PD was significantly associated with ED (P <.001) and the duration of ED (P <.05) but not the severity of ED.

It is important to note that the prevalence rates of PD vary according to the population studied (ie, the presence of certain concomitant health conditions that may increase the probability of acquiring PD), the definition of PD, and the study design (ie, studies that use self-reported techniques to estimate the prevalence of PD may not yield results as accurate as those studies which use more objective measures of PD). It is worthwhile to note that the rates of PD from self-reported studies may be higher than published, as men with PD may be reluctant to discuss the signs and symptoms of this embarrassing disorder.

The Etiology of PD

The penis is a cylindrical organ consisting of 3 separate chambers that include 2 corpora cavernosa and a single corpus spongiosum, which is located below the corpora cavernosa (Figure 1).18 Surrounding the corpora cavernosa is a tough elastic layer of connective tissue called the tunica albuginea whose 3-dimensional structure affords flexibility, rigidity, and strength to the penis.18-20 The chambers of the penis contain highly specialized, sponge-like erectile tissue that fills with blood during an erection, causing the corpora cavernosa to balloon and push against the tunica albuginea. The collagen and elastic fibers of the tunica albuginea are key structures that permit an increase in girth and length during erection. While the penis hardens and stretches, the skin and connective tissue of the penis remain loose and elastic to accommodate the changes. However, in men with PD, plaque formations interfere with the elasticity of the tunica albuginea and cause variable penile deformities. Changes in elastic fibers and collagen types can also contribute to the formation of penile deformities.20

Although the exact etiology of PD has yet to be clarified, research suggests there are a number of factors that may predispose men to develop PD. The most widely accepted etiology is thought to involve a repetitive minor trauma to the tunica albuginea during erection with subsequent abnormal wound healing. More specifically, during penetrative sexual relations, torqueing stresses are believed to result in a delamination of the tunical fibers, causing microhemorrhage with resultant inflammation that eventually leads to scar formation in the tunica albuginea. Approximately 20% to 30% of patients may distinctly recall a particular traumatic episode.5,21 In response to trauma, the pathogenesis of PD plaques is thought to occur via a number of potential contributors (Figure 2).21 These include an inappropriate fibrotic response via an overproduction of collagen and alterations in the type of collagen deposited in the tunica, an overproduction of cytokines that induce fibrosis, alterations in T-cell-mediated immunity and human leukocyte antigen system associations, or failure to degrade and clear fibrin from the tunica albuginea.2,21,22 The exact cascade of events leading to PD remains unclear.

In addition to trauma, other risk factors that have been associated with PD include diabetes, obesity, hypertension, hyperlipidemia, smoking, and pelvic surgery (Table 3), although it remains unclear how any of these factors specifically contribute to the pathophysiology of PD.2 Epidemiological studies of PD have also named certain medications (eg, thiazides and propranolol), Dupuytren’s contracture, and low androgen levels as risk factors for PD.23-25 However, the association between medications such as thiazides or propranolol and PD is most likely simply an indication that cardiovascular disorders are more common in men with PD compared with controls.24

Originally, PD was regarded as a spontaneously resolving phenomenon,26 but more recent studies have indicated that only 12% of patients experience disease resolution, with 40% maintaining stable disease, and 48% developing worsening disease.4,27 The initial phase is said to last from 6 to 18 months, with pain and inflammation occurring during this acute phase followed by a chronic phase when the penile deformity stabilizes.5,28 Importantly, results suggest that the psychological effects associated with PD do not improve or resolve over time in the majority of patients.27

Sexuality and Well-being in Patients With PD

The treatment of such a personal and embarrassing disorder as PD requires careful consideration of the psychosocial effects. Men with PD experience a variety of related psychological effects, including a reduced quality of life due to PD-related pain and discomfort, depression, low self-esteem due to physical appearance and self-image, and emotional distress. In turn, these factors have been reported to alter the quality and frequency of sexual relationships, restrict intimacy, and cause social isolation and stigmatization.

Results from a recent study in 92 men with PD suggested that men with PD should be routinely screened for long-term psychological effects including depression.29 Using validated measures to identify depression in men with PD, the study found that almost half of all participants (~48%) had depression and that depression rates generally increased as the duration of PD increased; 38% of men with PD lasting less than 6 months were depressed compared with 56% of those with PD for greater than 18 months. Aside from the effects of PD on intimacy and comfort, men with PD have described the condition as a “freakish” one, which they did not know existed until diagnosis.

 
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