Induratio penis plastica
Peyronie disease is the most common cause of painful penile induration. Fibrous tissue plaques form within the penile tunica albuginea, causing painful deformity and shortening of the penis. Though clinical diagnosis is usually accurate, the role of imaging is to evaluate extension of plaques, whether the penile septum is involved, and to examine the relationship between the plaques and the penile vasculature.
Epidemiology
Symptomatic Peyronie disease incidence has been estimated at ~1% of erectile dysfunction cases ,but the incidence has been rising due to increasing use of pharmacologic treatment for erectile dysfunction. Its age of onset is around 50-60 years of age. Some reports suggest prevalence in the general adult population at around 3 and 9% (although uncertain if this includes asymptomatic cases).
Associations
Peyronie disease is associated with fibromatoses including plantar fibromatosis and Dupuytren contractures. It is also associated with:
- penile trauma
- diabetes mellitus
- beta-blockers
- Paget disease of bone
- phenytoin
Clinical presentation
- curved/bent penis*
- penile plaque
- decreased penile length
- less rigidity of penis
- penile numbness
- erectile dysfunction
- painful erection
* congenital curvature of penis is a different condition, seen in children and young adults, and does not cause any problem
Radiographic features
Ultrasound
During pharmacologically-induced erection, Peyronie plaques are identified as localized/diffuse thickening of the tunica albuginea. Echogenic plaques are usually seen on the dorsal aspect of the penis, however they may also be seen on the ventral aspect. Calcifications are also frequently seen.
Ultrasound can detect the relationship of plaques to surrounding structures. For instance, involvement of the neurovascular bundle is important, which can be seen as plaque embedded within the dorsal arteries. Cavernosal artery encasement may be seen in cases of septal plaques. This arterial encasement can lead to erectile dysfunction (arteriogenic).
CT
CT is not employed in the investigation of Peyronie disease. If CT is performed for other reasons, plaques may be seen (especially if they exhibit calcification).
MRI
Plaques appear as thickened and hypointense signal areas on T1 and T2 weighted images, in and around the tunica albuginea. They are usually best seen on T2 weighted images . Albugineal calcifications are difficult to recognize on MRI.
Contrast enhancement may or may not be seen in active inflammation. The use of contrast enhancement for diagnosis is controversial .
Treatment and prognosis
Indications for surgical correction include severe bending or shortening of the penis causing sexual difficulty. Procedures available for surgical correction are
- shortening operations
- plaque excision or incision with grafting
- prosthesis implantation
A penile shortening procedure provides excellent preservation of erectile function, however this procedures causes loss of penile length. Excision of plaque conversely, carries a risk of post-operative erectile dysfunction. Prosthesis implant may be considered in severe Peyronie disease with erectile dysfunction.
History and etymology
It is named after François Gigot de Peyronie, a French surgeon who described the condition in 1743.
Differential diagnosis
- sclerosing lymphangitis of the penis: a superficial 'rope-like' lesion usually located at the coronal sulcus, and on examination, seen as a thrombosed vein
- congenital curvature of the penis
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