Michael J. Metro, MD, Fox Chase-Temple Urologic Institute Provider, discusses history, presentation and assessment of Peyronie’s Disease.
Hi everybody, my name is Michael Metro, and I'm an associate professor of urology here at Temple University, Lewis Katz School of Medicine, I'm the director of traumatic and reconstructive urology here at Temple and I'm going to talk briefly about Cronies disease today uh with an update on the history, a little bit of the ideology, the epidemiology and some um presentation and assessment. So prone these diseases is not a new disease. It's been around for a long time. It actually carries the name of Francois de la Peroni from 1743 who was french barber surgeon who described uh disfiguring knobs in durations and bends in the penis and and coined the term indoor Otto penis plastic to which is actually still a cpt code, believe it or not. Um Cronies disease is a disease of the covering of the erectile bodies of the penis. So the development of an elastic scar of the tunica al Virginia that covers the erectile bodies. When the penis is flaccid, it presents as a palpable lump or a palpable scar that the patient or a partner can feel and when the patient has an erection, this in elastic scar can limit the expansion of that side of the penis and cause curvature. It can cause a functional buckling or a hinging of the penis during sexual activity. It can cause narrowing or wasting deformity of the penis. Um Most men describe shortening of their erections due to this and elastic scar and the acute phase of the disease is marked by painful erections. Now this disease is, as you can imagine, psychologically devastating and physically devastating for many men and their partners. And for many years it was a dilemma with treatment because they're really, it wasn't very good treatments, at least medical treatments for this disease. Until recently, the FDA development FDA approval of a medicine for um, the medical treatment of ponies disease. Before that, it was um treatment for erectile dysfunction and surgical treatment. Yeah. Now the history of Peroni is diseases that detailed sexual history is important. And classically it was thought to be some due to some sort of deviant sexual behavior in the mail that caused trauma to the penis. Now we know that that's not particularly true right now, really, it does require sexual activity to cause um, the damage or the trauma to the penis to incite cronies disease. Uh, but it's not necessarily deviant. Um, it's often caused by a forceful penetrative event where there might be some a miss mount during sexual activity, um, where the patient will remember that event uh, that triggered it. But more commonly, it's secondary to uh, small repetitive micro traumas to uh, to the penis that causes this. And it's, it really is only present in guys that are sexually active patients that don't use their penis for sexual activity, dont get cronies disease. And I say jokingly in the office that catholic priests and monks don't get cronies disease and they shouldn't, uh, it's a disorder of wound healing. And um, after the trauma, there's a a parent or abnormal healing of that area of trauma to the penis and it's kind of comparable to the formation of hypertrophic scars or colloids in patients that are more superficial that they can see. So after this injury to the penis during sexual activity, uh, there's an acute phase of healing. Like any injury, there's uh, can be um, some internal bleeding. So there's homeostasis and inflammation at the site of the trauma. So the buckling that occurred during the sexual activity and induces a form of, or a site of local trauma that has to be stabilized by the body. And if you think of playing basketball in a sprained ankle, your body has to stabilize that area of ligament that was strained to prevent it from rupturing. So there's inflammation, there's development of scar tissue formation and the same thing happens in the penis with Speroni's disease. There's a proliferated phase of wound healing that causes fibroblasts and epithelial growth at the site. And then the third phase is the abnormal phase and cronies disease, where We get remodeling, where we get collagen breakdown. The normal penis erectile bodies are covered with a protein called Collagen one and Collagen one is a very cool protein because it's super strong. Um, but it's um, it's only two thick. So if there's a damage in your body has to regenerate or reorganize In peronist disease, which is 10% of all men. The reorganization is that the laying down of collagen three fibers in college in three is equally as strong as college in one. But it's in elastic and it doesn't stretch which now gives us the palpable placket gives us the and elasticity and the curvature and the dent and the divots that occur with penises of guys with veronese disease. So in the acute phase of wound healing, we have a response to the disruption of this tissue damage. There's platelets and uh coagulation, cascade aggregation and activation. There's deposition of fiber in which is a connective tissue and scar tissue. And then there's a response to this. And then the proliferation phase of this wound healing Is similar to any injury in the body. There's 4-12 days after the injury. There's the development of initial scar formation in college in three deposition. And oftentimes this is when there's pain involved and the patient will recall an event and then the subsequent um injury with pain and then the subsequent curvature divot with the remodeling phase. This occurs during the proliferation phase. And the final product is this a small potentially contracted area of scarring of college in three that does the things that cronies disease causes the homework of the disease which is curvature shortening palpable lump and the problem is there's the balance between the normal college and once protein and the college in three. And the M. M. P. S. And fiber blasts that are recruited into the area. The balance gets thrown out of wax. So you get more scar and less normal tissue. So after discussing uh the ideology of Cronies disease. Let's talk a little bit about the epidemiology Germany's disease. Now initially the data was limited and very inconsistent. In fact the first report was in 1928 it was a 550 paid patient of Clinical report and established kind of a historical prevalence of about 1% of all sexually active men in 1991. And the attempt was done to kind of elucidate or illustrate how much and how common prone diseases. But they used records from hospitals which this is an acute event that causes a A state or a visit to the hospital. So it was grossly underrepresented. Underrepresented and it was less than .5% prevalence and they estimated that there were in 1991 only 423,000 men in the us with Veronese disease. With 32,000 new cases annually. Now what we know now is that the incidents um is about 10% of all men. So if you do the math of what percent of men in the U. S. Sapa Ronis disease, It's astronomically higher than the 423 that was reported in 1991. So it is a much more common disease now that it's kind of brought out of the closet and it's talked about a little more and and why has that been the case? Well, I mentioned earlier in the talk that there was a development of an FDA approved treatment for this and this company trying to make a buck from the money they spent with the development of the drug and the clinical trials has done some direct to consumer advertising of first the disease state of proteins disease and then more commonly and more recently, the actual drug itself. And this has brought a lot of men who are watching the ESPN and listening to ESPN radio when they hear about Peronist disease, they now know that is a real thing and it's more common than they thought and it brought it's brought them out of the woodwork to get treatment and to tell their physicians about. So what we know is that The mean age of diagnosis is in the 50s, the higher highest incidences between 50 and 59 and one of the reasons why the prevalence rates were falsely low is that patients were unwilling to report something that was, you know, only present in their sexual life. So, um if they had a growth on their forehead, it would be much more prevalent because they would everyone would see it and they would go tell their doctors about it. But if it's inside their pants and it's only visible in the bedroom that's a little more easy to hide and not tell anybody about it. Well, now we know that uh, even though it was thought to be a disease of men in the 50s and 60s, it can be seen as early as the age of 18. Um, more and more patients are presenting under the age of 40 with less people with uh, you know, concomitant erectile dysfunction. Now these men that are under 40 without significant erectile dysfunction, I had mentioned that the traumatic event for sexual uh, for the incidents of, for the onset of cronies disease is a city is either a significant traumatic event or a repetitive micro traumatic traumatic event. So guys that have no erectile dysfunction are more likely to have the, I remember we were on vacation and had a couple of bottles of wine and we had a traumatic sexual activity and I heard a buckle and um, but nothing broke and I kept going and the next morning they wake up with this or penis that has a curve to it. Uh, these younger men with less erectile dysfunction are more likely to present in the early phase of disease. Um, there are more likely to have more plaques and complicated curvature tres um, they present with pain with erections. So this is the active or acute phase of Peroni disease. Uh, now, once the acute phase or an active phase of peroni disease goes away and that happens between 12 and 18 months after the onset of the disease, a spontaneous improvement in pain occurs as the inflammation resolves and in the past. Urologist used to tell patients to come back in a year after they presented with this disease. Not because it would get better in a year because there was nothing to do and it would stabilize the patient's would leave the office and say, oh doc said it would go away in a year. Well That's not really the case. It certainly stabilizes and the pain goes away, but the disfigurement of the Penis does not go away. And in the first year of presentation, 50% worsen over that first year, 40% stay about the same and 10% get a little better. So what they present with is a pinot deformity. When you're placid, they can feel a lump or they can feel a plaque and certainly with an erection, they have short in curvature and dents and divots. Um um They have these integrated areas in their penis that they're wondering what it's all about or their partner's wondering what's all about and most curvature Zwick proteins disease are upwards or dorsal. Um but they can be left. They can be right. They can be down. So when someone presents to the Urologist office with Speroni's disease, we want to do in a further complete assessment of their medical history. Try to figure out if there's any concomitant erectile dysfunction that can be present, which is commonly seen with veronese disease about 60% of men with bronies disease have some either untreated or undertreated erectile dysfunction. Um We want to try to classify things in their medical history that might give them a higher incidence of erectile dysfunction. So high blood pressure, smoking diabetes, history of pelvic surgery like prostatectomy. So we want to figure out the time of the onset and to try to see when our clock should be set between the development of acute and stable disease, which I said before was about 12 months. We want to um to further evaluate any external trauma. We want to know if they've had any um pelvic surgery, like their prostate removed. We want to see if they've been doing any medicines for erectile dysfunction like injection therapy into their penis, which can lead to some ponies disease if they have any more systemic um scar tissue diseases like five fiber moto sis or um there's a disease in the hand called do patrons contracture, which is actually a college in three disorder of the hand, which allows patients or prevents patients from straightening one of their fingers. Um and we want to illustrate and tease out any risk factors for erectile dysfunction. We want to do a detailed psycho sexual history, including an assessment of their funk sexual function. And we use uh something in the urologists use a shim which is called a short a sexual health inventory for men. It's a five question questionnaire from 0 to 5 to a perfect score is 25. It's a way of, of kind of categorizing and classifying what type of erectile function is present at the time of presentation. We certainly want to do an examination of flaccid penis. So we examine the penis on stretch, which allows us to feel the plaque. We want to measure the penis, the stretch, penile length we want to measure and mark which were the plaques are present. And then eventually we want to do some assessments of the of the erect penis. Now that's either done with home photographs at home. But before any other definitive therapy, I do an assessment in the office where I did them Aviso active agent by shot and I induce an erection and I measure everything in the office. So I have an objective measurement of their curve at the time of presentation. And then sometimes imaging is important. Uh, some um, some physicians are more interested in this than others. Uh, some patients that have concomitant erectile dysfunction are always curious why they're having trouble getting an erection. So, a penile blood flow study done with Doppler ultrasound can measure the inflow of the penis. We call that arterial um inflow. So they can have a reclusive disease of their arteries or they can have vino inclusive disease. So they have trouble trapping the blood in their penis. And some guys want to know why they're having trouble getting erections. And this study allows them to illustrated, you can quantify this, but we also induce an erection during this study and we can measure our curve and identify our plaques by sonogram. So uh this is a study that was done in 2009 using a sonogram for patients with cronies disease. And then it was It was referenced in 2010 by one of the leaders and cronies disease. Tom Lou in San Francisco who I did some training with. This was 78 men with cronies disease. They were able to localize localize to nickel lesions or plaques and 60% of them. Um um They followed. Um And it's in the subsequent study in 2010 and 518 patients. They did a more detailed study with medical history, health-related behaviors, other characteristics of Pepperoni disease. And they measured by sonogram these abnormalities that were present. Um When when sub to tickle calcifications were present on the study, they found that there was a 75% increase of progressing to surgical innovation, intervention and calcification might be an indicator of stable or or chronic phase of perennials disease rather than the acute or active phase. So back in 2000 and 81 of the leaders um in new york city john Mulhall tried to do a 46 question instrument through the au a where he Evaluated patients urologists for their treatment of cronies disease. And he used if you can imagine taking a 46 question and questionnaire as a urologist and you know, not many urologists are going to spend the time to do that type of Instrument. And there really was no au a guidelines for this disease back in 2008. Um but what he was able to find is that 640 Urologists were did return this uh about a third or an academic practice and about two thirds or three quarters said that they were trained in residency and how to fix these patients surgically. So these urologists about 66% saw about 10 patients a month which I would consider a lot of peroni is disease. And the treatment recommended Worse. recommended observation. 59% were given medical management and only 3% were referred to sub specialist. So this is what we know about ponies disease back in 2008. Uh since that time with the development of some drugs for the injection therapy into Peron's plaques. Um This again has changed our ability to treat this disease. And has allowed uh you know more patients that come out of the woodwork to be treated. And there has been since a U. A. Guidelines published for the disease management of this entity. And we can discuss uh some medical management and some surgical assessment and surgical management on a subsequent talk in this forum. I hope this was informative to the viewers. And um thank you for attending
