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      Drugs & Diseases > Urology

      Peyronie Disease Workup

      Updated: Jan 28, 2023
      • Author: Eli Lizza, MD; Chief Editor: Edward David Kim, MD, FACS  more...
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      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 from the history and physical examination findings.

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      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, indicating that further angulation should not occur. The following imaging methods may be used:

      • A plain radiograph of the penis can often help identify calcification within the plaque.
      • 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 study is usually not necessary because the findings typically do not alter the course of treatment.
      • Magnetic resonance imaging (MRI)

      MRI of the penis has been used to image the plaque while it is still composed of fibrous tissue (see images below). Although MRI 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 i 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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      Precontrast MRI of the penis in the axial plane (T 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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      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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      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. [22] 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.

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      Diagnostic Procedures

      If erectile dysfunction (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.

      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. [23, 24]

      The surgeon can also approximate the appearance of the penis after repair by bending the shaft until straight. Bacal et al assessed the difference between patients' estimates of penile curvature and objectively measured findings in men with PD. [25] 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.

      Measuring the length of the penis before intervention is also important. The stretched length of the flaccid penis from the base to the tip should be recorded. This measurement should be repeated after an erection is achieved. Those 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.

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      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. [16]

      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.

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