Penile Conditions

First described by Francois de la Peyronie in 1743, Peyronie’s disease affects up to 9% of men during their lifetime, and is sometimes linked to ‘vascular’ risk factors such as diabetes, high blood pressure and high cholesterol. Mr Rees is referred > 100 new patients a year with Peyronie’s disease, and all evidence-based treatment options are available via the clinic.

Peyronie’s is essentially abnormal scarring in the inner lining of the penis and may manifest itself by a lump, curvature on erection, erectile dysfunction, penile shortening or deformity. Its cause is unclear.

There is no established medical / tablet therapy that can reverse the process, and treatment essentially aims at alleviating symptoms, correcting the deformity and restoring sexual function.

Typically there is an initial painful, inflammatory phase which can be helped with tablet therapy such as Vitamin E or Pentoxyifylline, but while they improve pain, these treatments do not alter the natural history or progression of the disease or the extent of curvature.

There is emerging evidence for the benefit of vacuum therapy device exercises, and a trial is currently underway to study this in more detail. The initial results are promising, and if you would like to find out more then please do get in touch via the link above.

The use of collagenase is being investigated as a potential injectable treatment for Peyronie’s disease with some promising initial data, but this is not yet approved or in routine use.

The most effective treatment for penile curvature and Peyronie’s disease remains surgical treatment. The three main surgical options are listed below. All are carried out regularly by Mr Rees.

• Nesbit procedure: shortening the longer side to produce symmetry and a straight erection
  Incision.
• Grafting (Lue) procedure: to lengthen the scarred (shorter) side, using a piece of vein from the leg or synthetic material.
• Penile prosthesis: The best option for men with complex deformities or a combination of significant penile curvature and erectile dysfunction.

Surgery remains the mainstay of treatment for congenital and acquired forms of penile curvature. The type of operation depends mainly on the severity of the deformity, as well as the quality of erectile function. It is standard practice to allow the disease to stabilise for approximately a year before considering surgery.

One of the most important aspects of Peyronie’s disease is to have realistic expectations of what treatment can achieve. The psychological effects of a penile deformity must not be underestimated, and is important for patients to realise that the underlying disease process cannot be reversed or cured.

The three broad categories of surgery for Peyronie’s disease are:

• To shorten the long/healthy side eg Nesbit procedure
• To lengthen the short side – ie the Lue (or Incision and Grafting procedure)
• Penile prostheses – for patients with significant erectile dysfunction or complex deformities

Nesbit procedure

The Nesbit procedure is by far the most commonly performed procedure, where an elliptical area of tissue is removed from the healthy (longer) side of the penis to restore symmetry – thus straightening the erection.

A cut is made in the skin around the top of the penis, and occasionally a circumcision is also required. The skin is pulled back, and after an injection to create an artificial erection, the point of curvature as well as the area to be removed on the opposite side is marked out. This tissue layer, which contains blood during erection, is called the tunica albuginea, and is the layer that is affected by scarring in Peyronie’s disease. The width of tissue removed is proportional to the degree of penile curvature.

The defect is then closed with slowly-absorbing stitches, and the correction checked. The skin is then returned to position, and absorbable stitches placed in the skin.

The above procedure will take a little over an hour to carry out, and the vast majority of patients are day-cases. An anaesthetic block is injected at the end of the penis, and a dressing is placed around the penis that can be removed the next day. Patients can expect some minor bruising and swelling for a week or so, but there are usually no problems with urination or healing. Patients are reviewed at 6 weeks in the outpatients to ensure all is well.The success rate in terms of satisfaction and durability is high (~ 85% over 15 years1). One has to remember that Peyronie’s disease will progress in a small proportion of men, even if no operation is carried out.

The main drawback of the Nesbit procedure is that of penile shortening, though in 90% of patients this is 1cm or less. Some patients also experience a reduction in sensation, which may be temporary, and others are aware of being able to feel the stitches. However, due to the type of slowly-absorbing sutures used, this problem tends to resolve with time. If a circumcision is not carried out, a small proportion may develop tightening of the foreskin subsequently.

Approximately 10% of men undergoing Nesbit procedure will subsequently report weaker erections and may go on to require medication such as Viagra / Cialis / Levitra. Again, it should be bourne in mind that even without surgery, a proportion of men will develop such problems with time – either as a function of ageing, or as a consequence of the Peyronie’s disease process.

Incision and Grafting – The Lue procedure

The incision is similar to that of the Nesbit procedure, but in this operation, the nerves and blood vessels are carefully moved away from the scarred area of penile tissue, and a cut made into the scarred layer (tunica albuginea). The penis is then straightened and a gap therefore created. A graft is then stitched into this gap to allow lengthening of the scarred side of the penis. The commonest graft type is a piece of vein from the groin (saphenous vein), but artificial materials can also be used.

Satisfaction rates are again high 2, and erectile dysfunction is the main complication (up to 20%). Therefore good pre-operative erectile function is required to undergo this procedure. It is indicated where the penile curvature is greater than 60 degrees and is popular with men anxious about their penile length.

The procedure can also sometimes be used to treat other deformities of the penis due to scarring, such as indentations or areas of instability.

Penile Prostheses

When a penile curvature is associated with difficulties in maintaining an erection, then penile straightening surgery alone may not restore sexual function.

If drugs such as Viagra / Cialis / Levitra are effective, it may be possible carry out a Nesbit procedure and use these medications post-operatively. However where these drugs are not helping, it may be advisable to consider a penile prosthesis from the outset. This device (see penile prosthesis section) will treat both the erectile dysfunction and the curvature. In a large study of American men, 90% of patients with severe Peyronie’s disease undergoing penile prosthesis insertion were successfully using their prostheses 3 years later 3.

References

1. Ralph DJ, al-Akraa M, Pryor JP. The Nesbit operation for Peyronie’s disease: 16-year experience. J Urol. 1995 Oct;154(4):1362-3.
2. El-Sakka AI, Rashwan HM, Lue TF. Venous patch graft for Peyronie’s disease. Part II: outcome analysis. J Urol. 1998 Dec;160(6 Pt 1):2050-3.
3. Wilson SK, Delk JR 2nd. A new treatment for Peyronie’s disease: modeling the penis over an inflatable penile prosthesis. J Urol. 1994 Oct;152(4):1121-3.

Abnormalities of the skin of the head or shaft of the penis are common, and most often are due to infection or inflammation. Very rarely, they may represent cancerous or pre-cancerous changes.

Infections of the penis can be fungal or bacterial, and your GP may be able to start you on the necessary treatment, often cream-based. If there is tightening of the foreskin (phimosis), infections of the head of the penis (balanitis) may be recurrent and difficult to clear. In which case, discussion about a circumcision may be necessary.

A fairly common cause of redness, pain +/- white scarring of the penis is lichen sclerosus (or Balanitis Xerotica Obliterans – BXO). This is not an infection, and the cause is not well understood. However, it is commoner in diabetic and overweight men.

BXO may start as a red or painful area of the foreskin or head of penis (glans), which does not respond to antibiotic or anti-fungal creams. It can progress to white scarring or pale areas on the head of the penis, eventually causing tightness of the foreskin. In the early phase of the problem, a short course of steroid cream may be useful in reversing the inflammatory changes, but once scar tissue has formed, creams are less useful.

The vast majority of men with foreskin problems associated with BXO are cured by a circumcision, but a small proportion will develop further scarring requiring more extensive surgery such as skin grafts. There is a very small risk of cancerous changes in men with untreated persistent / severe BXO, and it is therefore best to have it treated in the early phase.

Occasionally a penile lesion may have some suspicious features, such as aggressive-looking red areas, raised red areas, ulceration, hardness etc), and these may prompt the Urologist to advise a biopsy. If so, this can often be done with a local anaesthetic (injection), and the results will determine what happens next.

Thankfully penile cancer is very rare in the UK, but if there is an early type of penile cancer, a limited procedure to remove the skin of the head of the penis may be possible (glans resurfacing), and the skin replaced with a skin graft. In larger tumours, it may be necessary to remove part or all of the penis (penectomy), in which case the water-pipe (urethra) can be brought out to the surface beneath the scrotum (penineal urethrostomy). This necessitates passing urine in the sitting position.

Circumcision (surgical removal of the foreskin) is a common and usually straightforward operation that can be carried out under local or general anaesthetic.

The commonest reason for medical circumcision is a tight foreskin (phimosis), which may be causing pain, difficulty passing urine or difficulty with sexual intercourse. Other indications are recurrent infections, inflammatory conditions such as lichen sclerosus (also termed BXO – Balanitis Xerotica Obliterans), and more rarely – penile cancer or pre-cancer. It is also carried out for religious reasons.

The operation takes around 25 minutes and is carried out as a day case procedure using special cauterising scissors and dissolvable stitches. A small dressing is placed over the suture line, which can be removed later that day. A long-acting local anaesthetic is placed beneath the skin which minimises pain in the post-operative period.

General day-to-day activities can be resumed soon after circumcision, but you are advised to refrain from sexual activity for 4 weeks or so. It is common to get some swelling post-operatively, and uncommon complications include bleeding, infection, reduced sensation and cosmetic dissatisfaction.

For more detailed information about circumcision, please follow the link below to the patient information section of the British Association of Urological Surgeons website:

http://www.baus.org.uk/Resources/BAUS/Documents/PDF%20Documents/Patient%20information/Circumcision.pdf

Frenuloplasty

Occasionally the band of skin linking the underneath of the head of the penis to the penile skin (frenulum) is tight or becomes tight after tearing / injury, and the remainder of the foreskin is unaffected and normal. In this case, it may be reasonable to cut the frenulum under a local or general anaesthetic and stitch it in such a way as to elongate it and get rid of the tightness. This appeals to many as it avoids removal of the foreskin, but in approximately 50% of patients undergoing frenuloplasty, there are further problems with the foreskin requiring subsequent circumcision.