Reproductive · Urology
The facts most likely to be tested
Peyronie disease is characterized by the formation of a fibrous inelastic plaque within the tunica albuginea of the penis.
Patients typically present with penile curvature, painful erections, and a palpable penile nodule.
The underlying pathophysiology involves aberrant wound healing and collagen deposition following repetitive microtrauma to the erect penis.
The condition is frequently associated with Dupuytren contracture, suggesting a shared fibroproliferative genetic predisposition.
Diagnosis is primarily clinical, based on the history of penile deformity and the presence of a hard plaque on physical examination.
Initial management for the acute phase involves conservative observation and NSAIDs for pain, as the condition may stabilize or resolve spontaneously.
Intralesional collagenase clostridium histolyticum injections are the primary FDA-approved pharmacologic therapy for patients with significant penile curvature.
Vignette unlocked
A 52-year-old male presents to the clinic complaining of a progressive change in the shape of his penis during erections over the past 6 months. He reports that his penis now curves significantly to the left, which has made intercourse difficult and occasionally painful. Physical examination reveals a discrete, firm, non-tender plaque palpable on the dorsal aspect of the penile shaft. He has no history of recent trauma but notes a family history of palmar fibromatosis. He is otherwise healthy and denies any urinary symptoms.
What is the most likely diagnosis?
Peyronie disease
The patient's presentation of a palpable penile plaque, penile curvature, and association with Dupuytren-like contractures is classic for Peyronie disease, which is tested via its clinical diagnostic criteria.
Full handout
High yield triage
Etiology / Epidemiology
Acquired connective tissue disorder of the tunica albuginea. Middle-aged men with diabetes or Dupuytren contracture are at highest risk.
Clinical Manifestations
Presents with Peyronie's plaque and penile curvature during erection. Classic triad: pain, curvature, and erectile dysfunction.
Diagnosis
Clinical diagnosis based on history and physical exam. Penile duplex ultrasound is the gold standard to assess plaque and vascular flow.
Treatment
Acute phase: Pentoxifylline or NSAIDs. Chronic phase: Collagenase clostridium histolyticum injections. Avoid surgery until stable.
Prognosis
Spontaneous resolution is rare (<15%). Surgical correction is reserved for severe cases causing inability to achieve penetration.
Full handout
Epidemiology & Etiology
Occurs most frequently in men aged 40–70. Strong association with Dupuytren contracture and Ledderhose disease suggests a genetic predisposition to fibrotic disorders. Diabetes mellitus and smoking are significant independent risk factors.
Pertinent Anatomy
The disease involves the tunica albuginea, the fibrous sheath surrounding the corpora cavernosa. Fibrosis here prevents normal expansion during tumescence, leading to mechanical deviation.
Pathophysiology
Repetitive microtrauma to the erect penis triggers an aberrant wound-healing response. This leads to excessive collagen deposition and formation of a non-elastic fibrous plaque. The resulting inelasticity causes the characteristic curvature toward the side of the lesion.
Clinical Manifestations
Patients report a palpable penile plaque and painful, curved erections. Red flags include rapid progression or associated penile mass suspicious for malignancy. Peyronie's deformity often leads to significant psychological distress and secondary erectile dysfunction.
Diagnosis
Diagnosis is primarily clinical via palpation of the plaque. Penile duplex ultrasound is the gold standard to map plaque size, calcification, and assess for underlying vascular insufficiency. No specific laboratory markers exist.
Treatment
Early inflammatory phase management includes Pentoxifylline to inhibit collagen synthesis. Collagenase clostridium histolyticum is the only FDA-approved intralesional therapy for stable disease. Contraindicated in active infection or bleeding disorders. Surgical intervention is reserved for patients with severe, stable deformity preventing intercourse.
Prognosis
The disease is typically progressive or stable; spontaneous improvement is uncommon. Key complications include permanent deformity, loss of penile length, and severe erectile dysfunction. Patients require monitoring for disease stabilization before considering invasive procedures.
Differential Diagnosis
Congenital penile curvature: present since puberty without plaque
Penile fracture: acute onset with audible 'pop' and hematoma
Penile cancer: firm, non-tender mass, often ulcerated
Lichen sclerosus: skin-based, white, atrophic plaques
Chordee: ventral curvature associated with hypospadias