PEYRONIE DISEASE,
PRIAPISM, THROMBOSIS
Peyronie
disease (PD), also known as induratio penis plastica, is a benign, poorly
understood condition that is associated with penile deformity. It occurs mainly
in men 50 to 60 years of age, although it can occur at any age. The condition
includes penile curvature or a plaque, penile pain, and erectile dysfunction.
Among these, penile curvature is the most common deformity. Interestingly, PD
is also associated with Dupuytren contracture of the palma fascia of the hand.
The penis
may bend in any direction, although an upward bend is most common. Usually, the
deformity is only evident during erection. Less commonly, a “waist” or
“hourglass” defect may exist in which one segment of the penis is narrower than
the surrounding areas. Importantly, PD is a separate entity from chordee, which
is a congenital penile curvature observed in newborns and is not associated
with plaques or pain. A firm, flat, benign nodule or plaque may be felt on the
penis and may contribute to curvature. The plaque is located within the tunica
albuginea, the tough fibrous covering of the corpora cavernosal bodies. The
plaque may accumulate calcium and become bone-like. Associated penile pain is
most severe during erection but may be present at rest. Pain is often the first
sign and occurs before noticeable bending. Bending occurs toward the side with
the plaque. In most cases, the pain will resolve with time although plaques and
curvature may persist. About 50% of men who present with PD also have erectile
dysfunction.
The
process by which penile plaques develop is unknown. The leading theory is that
minor trauma (often unnoticed) from penile buckling during sex shears layers of
the tunica albuginea and disrupts small blood vessels. Bleeding and trauma
induce the release of proinflammatory agents such as transforming growth factor-β (TGF-beta) and fibrin. The inability to drain these
inflammatory mediators away from the injury leads to prolonged inflammation and
fibrosis. In 15% of patients, PD will resolve with time. In persistent cases,
empirical medical treatments include antioxidants, anti-inflammatory agents, and
penile stretching devices. Surgical cures are routine with either penile
plication (straightening) procedures or plaque excision and grafting procedures
and may involve penile pros-thesis implantation.
PRIAPISM
Priapism
is a prolonged and often painful penile erection lasting more than 4 hours and
not related to sexual desire or stimulation. The word is derived from the Roman
god Priapus, a deity renowned for his erect penis. Priapism can affect boys and
men at any age.
There are
two types of priapism, ischemic and nonischemic. Ischemic, low-flow, or
venoocclusive priapism occurs when there is no penile blood flow. With
obstruction to flow, trapped blood increases pressure and the penile shaft
becomes very hard and painful. Nonischemic priapism, also known as high flow priapism, is rare
and occurs with excessive blood flow through the penis as a result of arterial
rupture within the erectile tissue, most commonly from blunt injury to the
groin or pelvis. In nonischemic priapism, the penis is enlarged but not as
rigid as a normal erection and there is usually less pain. It is critical to
distinguish these two forms of priapism, as ischemic priapism is a medical emergency
that can permanently injure the penis and lead to erectile dysfunction. This
generally occurs after 48 hours of unwanted erection as thrombosis within the
cavernous spaces causes fibrosis and permanent loss of function.
Priapism
can be idiopathic or secondary in nature. Drugs associated with priapism include
papaverine, phentolamine, prostaglandin (when given for erectile dysfunction),
trazodone, propranolol, hydralazine, thioridazine, antidepressants, and
cocaine. Medical conditions
associated with priapism include spinal cord injury, leukemia, gout, sickle
cell anemia, and advanced pelvic and metastatic cancer. Treatment is directed
at relieving the erection with corporal irrigation to remove blood clots,
intracorporal injection of α-agonist
drugs to contract arteries, and occasionally surgical shunts to restore venous
outflow. It is also important to find and treat the root cause of ischemic
priapism with intra venous
fluids, pain
medication, oxygen, radiation, or chemotherapy.
