Peyronies DiseaseRetno Widayanti, drg

Lecturer: Ricky Adriansjah, dr., SpU

DefinitionDescribed by Francois Gigot de la Peyronie in 1743Also known as induratio penis plasticaFibrotic induration of the penis with concurrent curvature

The symptomatic incidence 1%.In white men the average age at onset : 53 years. The asymptomatic prevalence : 0.4% - 1.0%.In a study of 100 men without known Peyronies disease autopsy 22 had fibrotic lesions of the tunica albuginea compatible with Peyronies disease

EtiologyFibrosing condition of the tunica albuginea Repetative microtrauma is most probably the inciting eventDupuytrans contracture has been associated with PDAlways examine the handsPossible genetic aetiology

Tunica albugineabilaminar throughout most of its circumference.composed of an outer longitudinal layer & an inner circular layer.varies in thickness : 1.5 - 3.0 mm, depending on the position on the circumference.

Most patients with Peyronies disease demonstrate lesions dorsally.Peyronies disease most likely begins with buckling trauma injury to the septal insertion of the tunica albuginea

Buckling trauma of the penis, usually occurring during intercourse TGF- has been found to be related to the disordered healing process that leads to the scarring of the Peyronies plaque. failure of downregulation of a number of antifibrotic factors

Basic science research into the etiology of Peyronies disease is limited by the failure, to date, to develop a true animal model of Peyronies disease.

Natural history of Peyroniesdisease 2 phases1. active phasenot uncommonly is associated with painful erections & changing deformity of the penis.2. a quiescent secondary phase- characterized by stabilization of the deformity, painful erections (-) & in general, stability of the process. - > 1/3 patients, present with sudden development of painless deformity.

SYMPTOMSpenile pain with erection; Penile deformity, both flaccid and erect;shortening with and without an erection;plaque or indurated areas in the penis; Difficult intercourse ; and, in many patients, erectile dysfunction.

EVALUATION OF THE PATIENT1. Medical & sexual history (duration of the disease, penile pain, change of penile deformity, difficulty in vaginal intromission due to deformity, and erectile dysfunction)2. Routine genitourinary assessment3. Hand & feet detecting possible Dupuytrens contracture or Ledderhose scarring of the plantar fascia . 4. Penile examination a palpable node or plaque Plaque size measured in the erect penis

5. Assess Erectile function may impact on the treatment strategy 6. Ultrasound (US) measurement of the plaques size (inaccurate & operator dependent)7. Doppler US may be required for the assessment of vascular parameters 8. Plain x-ray

7. objective assessment of penile curvature with an erection a home (self) photograph of a natural erection (preferably) or using a vacuum-assisted erection test or an intracavernosal injection using vasoactive agents

Clinical presentation

Most cases is self limitingDevided into acute and chronic phaseIn the acute phasePainWorsening of the deformityEnlargement of the plaque12 to 18 months durationChronic phaseNo painStable deformity

MANAGEMENT

Medical ManagementUsually during the acute phase

Reserved for patients with PD for at least 12 months (chronic phase) and a stable deformity for at least 3 months3 groups of surgeryPenile shorteningPenile lengtheningPenile prostesis

Surgical Management

Penile Shortening (Nesbit Plication)

Penile Lengthening entail an incision in the short (concave) side of the tunica to increase the length of this side, creating a tunical defect, which is covered by a graft.Devine and Horton introduced dermal grafting in 1974. Since then, a variety of grafting materials and techniques have been reported Unfortunately, the ideal material for grafting has yet to be identified

Penile prostesis

ORAL MUCOSAL GRAFT 1ST discovered by Humby in 1941 for urethral reconstruction (dog model)Re-introduction by Burger in 1990s oral mucosa graft widespread use in - urethral reconstruction of long segment anterior urethral strictures, - hypospadias, - epispadias - bladder exstrophy

Oral mucosal graftconstant availability,favourable immunological properties, easy harvesting, excellent tissue characteristics; Easy handling properties, minimal contracture formation andadaptation to a moist environment

Oral Mucosal Graft Buccal mucosa : oral mucosa overlying the inner cheek of the oral cavity Labial mucosa : alveolar mucosa of the inner lower lipLingual mucosa : the mucosa overlying the tongue

Histology of Buccal Mucosa

Graft Biology IMBIBITION : diffusion of nutrients between donor & recipient site 1st 48hrsINOSCULATION: microsirculation reestablished 2-4daysREVASCULARIZE

Principles of ideal mucosal graftWell vascularized recipient siteRapid and efficient imbibitionRapid and efficient inosculationImmobilization of graft and recipient site as neovascularization and healing take place

Oral mucosa harvest from the lower lipOral mucosa harvest from the lingual site

Complications of harvestHemorrhageInfectionPainSwellingDamage to Stensons duct (parotid)Perioral or cheek numbness

ConclusionPeyronies disease presents as a variety of deformities of the penis. The symptomatic incidence has been estimated at 1most patients do not require surgery. Most do require reassurance and education. Surgery for Peyronies disease is considered palliation for the mechanical effects of the disease.Buccal mucosa is confirmed to be a very attractive and potentially ideal substitute for tunica albuginea.

THANK YOU

ED+-Penile ProstesisNormal length< 30 degreesShort penis> 45 degreesPenile shortening procedurePenile lengtheningprocedureNesbitGraft

RecomendationsLeave 1cm from labial commisureStay 1cm away from Stensens ductAvoid cautery and using sponges (compression) for hemostasisLeave donor site open however if thingking of reharvesting close