eMedicine Specialties > Urology > Common Problems of the Penis

Peyronie Disease: Workup

Author: Eli Lizza, MD, Clinical Instructor, Department of Urology, Weill Medical College of Cornell University
Contributor Information and Disclosures

Updated: Dec 7, 2009

Workup

Laboratory Studies

  • No specific blood test is available for Peyronie disease (PD). Although an association exists between PD and HLA-B7 surface antigen, it is not a specific marker for this disease. Also, identifying this marker in order to diagnose PD is not practical because the diagnosis should be obvious based on the history and physical examination findings.

Imaging Studies

  • The main objective of imaging studies in a patient with PD is to identify calcification of the plaque because this endpoint usually signifies maturity of the plaque, and, when it is present, further angulation should not occur. This can be accomplished in a variety of ways.
    • A simple radiograph of the penis can often help identify calcification within the plaque.
    • Alternatively, penile ultrasonography can be used to help delineate the plaque and to place the calcification within it by the characteristic echogenic shadowing.
    • Corpus cavernosography can be used to help delineate the plaque and any compression of the cavernosal space. This test is usually not necessary because the findings typically do not alter the course of treatment.
    • MRI of the penis has recently been used to image the plaque while it is still composed of fibrous tissue (see images below). Although this is not the preferred imaging technique because of cost and availability, it may prove helpful in questionable cases.

    • MRI of the penis in the axial plane (T1-weighted ...

      MRI of the penis in the axial plane (T1-weighted image). The penis is in the erect position with the corpus spongiosum located ventrally (upper part of the frame). The tunica albuginea can be seen as the dark band outlining the corpora cavernosa. The tunica albuginea appears irregular and heterogeneous dorsally, which is consistent with the presence of a fibrous plaque. The image on the left is without annotation. The image on the right is identical but with annotation. Courtesy of Evan H. Dillon, MD

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      MRI of the penis in the axial plane (T1-weighted ...

      MRI of the penis in the axial plane (T1-weighted image). The penis is in the erect position with the corpus spongiosum located ventrally (upper part of the frame). The tunica albuginea can be seen as the dark band outlining the corpora cavernosa. The tunica albuginea appears irregular and heterogeneous dorsally, which is consistent with the presence of a fibrous plaque. The image on the left is without annotation. The image on the right is identical but with annotation. Courtesy of Evan H. Dillon, MD


    • Precontrast MRI of the penis in the axial plane (...

      Precontrast MRI of the penis in the axial plane (T1-weighted image with fat saturation). Preaxial image demonstrates lack of definition of the tunica albuginea in the dorsal aspect of the penis. The image on the left is without annotation. The image on the right is identical but with annotation. Courtesy of Evan H. Dillon, MD.

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      Precontrast MRI of the penis in the axial plane (...

      Precontrast MRI of the penis in the axial plane (T1-weighted image with fat saturation). Preaxial image demonstrates lack of definition of the tunica albuginea in the dorsal aspect of the penis. The image on the left is without annotation. The image on the right is identical but with annotation. Courtesy of Evan H. Dillon, MD.


    • Postcontrast MRI of the penis in the axial plane ...

      Postcontrast MRI of the penis in the axial plane (T1-weighted image with fat saturation). Image obtained after the injection of gadolinium demonstrates enhancement of the tunica albuginea in the dorsal aspect of the penis. Enhancement reflects the presence of active inflammation in the region of the plaque. The image on the left is without annotation. The image on the right is identical but with annotation. Courtesy of Evan H. Dillon, MD.

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      Postcontrast MRI of the penis in the axial plane ...

      Postcontrast MRI of the penis in the axial plane (T1-weighted image with fat saturation). Image obtained after the injection of gadolinium demonstrates enhancement of the tunica albuginea in the dorsal aspect of the penis. Enhancement reflects the presence of active inflammation in the region of the plaque. The image on the left is without annotation. The image on the right is identical but with annotation. Courtesy of Evan H. Dillon, MD.

    • Recently, investigators have used imaging studies to attempt to distinguish unstable evolving PD from stable PD. Erdogru et al used penile scintigraphy with technetium Tc 99m human immunoglobulin G in a prospective study.17 These authors found Tc 99m human immunoglobulin G at the plaque site in 10 of 11 patients with unstable plaques, compared with only 2 of 14 patients with stable plaques and 0 of 7 control patients. Although this technique requires some refinement and the data must be confirmed, it nevertheless presents a measurable parameter to help distinguish unstable PD, which is best treated medically, from stable PD, which may require surgical intervention.

Other Tests

If ED is associated with the PD, then duplex ultrasonography with intracavernous injections of a vasoactive agent, such as alprostadil, and/or dynamic infusion cavernosometry and cavernosography may be indicated to help identify associated arteriogenic ED or corporeal veno-occlusive dysfunction.

Diagnostic Procedures

Duplex ultrasonography with intracavernous injection has become popular in helping to delineate the extent of the Peyronie plaque, to evaluate for any hour-glass deformity in the shaft, and to quantify the extent and direction of penile angulation. If a full erection is achieved during the test, the clinician should document the angle of shaft deflection. It is important that this be performed in a fashion that the patient can observe and agree with the estimation of the penile angulation. The results of this measurement should be documented in the patient's chart.

The surgeon can also approximate the appearance of the penis after repair by bending the shaft until straight. Bacal et al (2009) assessed the difference between patients' estimates of penile curvature and objectively measured findings in men with PD.18 In their study, the authors prospectively investigated 81 men with PD, asking them to give their best estimate of their degree of penile curvature. The actual curvature was then measured from a standardized photograph with a protractor. The author found that 54% of men overestimated their degree of curvature, while 26% underestimated it. Only 20% were able to accurately estimate the curvature to within 5°. The authors emphasized the need for objective measurement of penile angulation in order to accurately counsel patients regarding disease severity and appropriate therapy and to objectively assess treatment outcome.

It is also important to measure the length of the penis before intervention. The stretched length of the flaccid penis from the base to the tip should be measured. This measurement should be repeated after an erection is achieved. These data help the physician to present a realistic picture as to what can be achieved by intervention. They also help to afford the patient with an accurate portrayal of the degree of his problem before treatment. This time is well spent to help ensure patient satisfaction after treatment and to minimize an inaccurate conclusion that treatment could have caused further loss of penile length.

If the penis does not achieve full erection during the test, then the physician has also documented associated ED, and the recommended treatment can be appropriately adjusted to address both problems.

Histologic Findings

Normal histology of the tunica albuginea reveals 2 layers of elastic fibers interposed with collagen—an outer longitudinal layer and an inner circular layer. Tissue taken from a Peyronie plaque has abnormal deposition of the elastic fibers around a disordered and excessive array of collagen. Devine et al also identified fibrin deposition in the extravascular material in these plaques.11 The result of these changes is that the tissue in the plaque loses its normal ability to stretch with tumescence. This leads to the characteristic curvature of the shaft around the area of the plaque as the opposite side stretches and enlarges. The location and orientation of the plaque determines the direction of the angulation. For example, if the distal penis curves upwards and to the right, then the plaque is found on the right side of the dorsal penile shaft.

More on Peyronie Disease

Overview: Peyronie Disease
Workup: Peyronie Disease
Treatment: Peyronie Disease
Follow-up: Peyronie Disease
Multimedia: Peyronie Disease
References
Further Reading
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Further Reading

For further information, see Medscape’s Erectile Dysfunction Resource Center.

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Keywords

Peyronie's disease, Peyronie disease, PD, penile fibrosis, penile curvature, induratio penis plastica, erectile dysfunction, ED, Dupuytren contracture, vascular trauma, penile trauma, penis trauma, Peyronie plaque, Peyronie’s plaque, penile pain, penile angulation, decreased erectile function, penile buckling, impotence, curvature of the penis, HLA-B7

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Contributor Information and Disclosures

Author

Eli Lizza, MD, Clinical Instructor, Department of Urology, Weill Medical College of Cornell University
Eli Lizza, MD is a member of the following medical societies: American Medical Association, American Society for Reproductive Medicine, American Urological Association, and International Society for Sexual Medicine
Disclosure: Nothing to disclose.

Medical Editor

Leonard Gabriel Gomella, MD, FACS, The Bernard W Godwin Professor of Prostate Cancer Chairman, Department of Urology, Associate Director of Clinical Affairs, Kimmel Cancer Center, Thomas Jefferson University
Leonard Gabriel Gomella, MD, FACS is a member of the following medical societies: American Association for Cancer Research, American College of Surgeons, American Medical Association, American Society for Laser Medicine and Surgery, American Urological Association, Sigma Xi, Society for Basic Urologic Research, Society of University Urologists, and Society of Urologic Oncology
Disclosure: GSK Consulting fee Consulting; Astra Zeneca Honoraria Speaking and teaching; Watson Pharmaceuticals Consulting fee Consulting

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

J Stuart Wolf Jr, MD, FACS, David A Bloom Professor of Urology, Director of Division of Minimally Invasive Urology, Department of Urology, University of Michigan
J Stuart Wolf Jr, MD, FACS is a member of the following medical societies: American College of Surgeons, American Urological Association, Catholic Medical Association, Endourological Society, Society for Urology and Engineering, Society of Laparoendoscopic Surgeons, Society of University Urologists, and Society of Urologic Oncology
Disclosure: Terumo Corporation Consulting fee Consulting; Gyrus-ACMI Honoraria Speaking and teaching

Chief Editor

Edward David Kim, MD, FACS, Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center
Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association, and Tennessee Medical Association
Disclosure: Lilly Consulting fee Consulting; Astellas Consulting fee Speaking and teaching; Indevus Consulting fee Speaking and teaching

 
 
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