CLINICAL SCENARIO
Setting: You are an ST3 registrar in a general urology/andrology OPD.
Mr Daniel Forsyth is a 52-year-old secondary school teacher referred by his GP with an 8-month history of progressive penile curvature causing painful erections and difficulty with intercourse. He noticed a 'lump' on the top of his penis approximately 10 months ago, and since then has developed a dorsal bend to his erect penis estimated at around 50–60 degrees. His erections were previously firm and reliable. He now reports softer erections, particularly towards the base, and that penetration has become difficult and intermittently painful for both himself and his partner.
PMH: Type 2 diabetes (HbA1c 58 mmol/mol, metformin), hypertension (amlodipine), no previous pelvic surgery. Smokes 10 cigarettes/day. No penile trauma. 15 units alcohol/week. No Dupuytren's contracture. Long-term relationship; partner supportive but both distressed.
Examination: Firm, non-tender dorsal plaque at mid-shaft, ~1.5cm length. No calcification. No ventral/lateral plaques. Testes normal. No Dupuytren's of palms. IIEF-5: 14 (mild-to-moderate ED).
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SECTION 1 — DIAGNOSIS, PATHOPHYSIOLOGY & EVALUATION
Q: Give me a concise overview of Peyronie's disease — what is it, who gets it, and what causes it?
Peyronie's disease (PD) is an acquired, benign condition of the tunica albuginea characterised by formation of a fibrous, inelastic plaque causing penile deformity, pain and — in many — ED.
Epidemiology: Prevalence ~3–9% in adult men; predominantly affects men aged 40–60. Higher prevalence in diabetes and pre-existing ED. Associated comorbidities: Dupuytren's contracture (~25%), plantar fasciitis, tympanosclerosis.
Pathophysiology: A wound healing disorder following repetitive penile microtrauma in genetically predisposed individuals. Microtrauma causes microvascular injury → inflammatory cascade → TGF-β driven fibroblast activation → excessive collagen deposition → inelastic plaque. The plaque prevents normal tunica expansion on that aspect, causing curvature towards the plaque on erection.
Disease phases:
Active phase (0–12 months): painful erections, changing deformity. Pain resolves spontaneously in ~90% within 12 months.
Quiescent/stable phase (>12 months): pain settles, deformity stabilises. Natural history: 40% progress, 47% stable, 13% improve.
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Q: How do you evaluate a patient with Peyronie's disease in clinic?
History: Duration and phase; degree and direction of curvature (patient photographs from 3 angles or clinic intracavernosal alprostadil injection); impact on penetration; erectile function (IIEF-5); hourglass/hinge deformity; penile shortening; psychosexual impact; risk factors (diabetes, smoking, Dupuytren's); medications causing ED.
Examination: Palpate plaque — location, size, tenderness, calcification. Assess erect curvature (photos). Hourglass/waist deformity. Palms for Dupuytren's. Testicular volume. Penile length. Circumcision status.
IIEF-5 scoring: 22–25 = no ED; 17–21 = mild; 12–16 = mild-moderate; 8–11 = moderate; 5–7 = severe.
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SECTION 2 — CONSERVATIVE & MEDICAL MANAGEMENT
Q: The patient asks about non-surgical options. What is the current phase and what would you offer?
This patient is still in the active phase (8 months, pain present, possible changing deformity). Surgery is contraindicated until disease has been stable for at least 12 months.
Conservative options:
• Watchful waiting — appropriate for mild deformity, minimal bother (~13% spontaneous improvement)
• Penile traction therapy (e.g., RestoreX®) — several hours/day; evidence emerging
• Vacuum erection device (e.g., SOMACorrect®) — 20 min/day for 3 months; improves curvature in ~2/3; also addresses ED
• ESWT — limited curvature reduction evidence but may reduce plaque-related pain
Intralesional: Collagenase Clostridium histolyticum (CCH / Xiapex®) — only licensed intralesional treatment. Cleaves collagen within the plaque. ~34% curvature improvement. Level 1 evidence (IMPRESS I and II). Best used in stable phase.
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SECTION 3 — SURGICAL MANAGEMENT
Q: Patient returns 14 months later. Pain resolved. Curvature stable at 55° dorsally. IIEF-5 now 13. Cannot achieve adequate penetration. Walk through your surgical algorithm.
The surgical algorithm depends on:
1. Degree of curvature (threshold ~60° for shortening vs lengthening procedures)
2. Quality of erectile function — can he penetrate with or without PDE5i?
Algorithm:
• Adequate EF, curvature <60°, adequate length → Nesbit/plication
• Adequate EF, curvature >60° / short penis / complex deformity → Plaque incision and grafting
• Poor EF / failed PDE5i / cavernosal fibrosis → Penile prosthesis
For this patient (IIEF-5 13, curvature 55°): First trial PDE5 inhibitors (minimum 6–8 attempts at maximum dose). If successful → Nesbit. If failed → penile prosthesis.
Nesbit procedure — technique: Circumglanular degloving incision. Artificial erection with saline. Mark ellipse on convex side (opposite plaque). Rule: 1mm excised per 10° of curvature. Close with PDS/Prolene. Re-inflate to confirm straightening.
Consent for Nesbit: Penile shortening (universal, ~1cm per 15° corrected); residual/recurrent deformity (~6–18%); new ED (1–5%); palpable sutures; bleeding/haematoma/infection; altered sensation.
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SECTION 4 — PENILE PROSTHESIS
Indications for primary prosthesis: Poor/absent EF failing medical therapy; cavernosal fibrosis; combined severe curvature AND poor EF.
Types: 3-piece IPP (cylinders + reservoir + pump; e.g., AMS 700™, Coloplast Titan®) — preferred for PD. 2-piece IPP. Malleable (semi-rigid) — rarely primary option in younger men.
Intraoperative PD considerations: Progressive dilation for cavernosal fibrosis. Assess residual curvature once inflated. Manual modelling (Mulcahy): firm lateral force over fulcrum for 90 seconds. If modelling fails: plaque incision with prosthesis inflated.
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SECTION 5 — ED PHARMACOLOGY & NHS PRESCRIBING
PDE5 inhibitor mechanism: Nitric oxide → sGC activation → cGMP → cavernosal smooth muscle relaxation. PDE5 degrades cGMP; PDE5i block this → sustained relaxation. Sexual stimulation still required.
Drugs:
• Sildenafil — t½ 3.7h; take 30–60 min before; avoid fatty meals
• Tadalafil — t½ 17.5h; up to 36h duration; not affected by food; daily 5mg also licensed for LUTS
• Vardenafil — t½ 3.9h; slight QT prolongation
• Avanafil — fastest onset ~15 min; fewer side effects
Side effects: Flushing, headache, nasal congestion, dyspepsia. Sildenafil/tadalafil: rare blue-tinged vision, back/myalgia.
Contraindications: Nitrates (absolute); recent MI/stroke; hypotension (<90/50); unstable angina; NAION; severe renal/hepatic failure.
NHS prescribing: PDE5i available on NHS FP10 for ED caused by specific medical conditions including diabetes, multiple sclerosis, Parkinson's, spina bifida, single gene neurological disease, renal failure, prostate cancer treatment, pelvic surgery, severe pelvic injury, and Peyronie's disease. Otherwise, 1 tablet per week on private prescription.
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SECTION 6 — ADVANCED QUESTIONS
Dupuytren's contracture in PD: Occurs in ~25% of PD patients. Shared TGF-β driven fibrotic pathway (systemic fibromatosis spectrum). Does not alter urological management but reinforces diagnosis. Refer to plastics if functionally significant.
Responding to partner's concerns: PD is not caused by a single event or lifestyle choice — genetic predisposition plus repeated microtrauma during normal intercourse. Not sexually transmitted. Not cancer. Diabetes and smoking are associated but not causative. Avoid blame. PD is treatable — manage hope and realistic expectations. Offer psychosexual counselling for both.
Post-Nesbit ED: Assess with IIEF-5, morning testosterone, penile duplex ultrasound (PDU) with ICI alprostadil. PSV <25 cm/s = arteriogenic; EDV >5 cm/s = venous leak. Management: PDE5i → ICI alprostadil → MUSE → VED → penile prosthesis. Also assess for psychosexual component.
Emerging therapies: PRP injections (early evidence, insufficient for routine use); stem cell therapy (experimental); Li-ESWT (growing evidence for ED, less consistent for curvature); hyaluronic acid injections (small case series); gene therapy (research only).