Men's health · SBA · Tutor mode
A 52-year-old accountant attends your private GP clinic, clearly embarrassed, about a change in the shape of his penis. Fourteen months ago he noticed discomfort on erection and a bending beginning to develop. The discomfort settled about six months ago and the bend has not changed at all since then. Intercourse is still possible and satisfactory for both him and his wife, although he dislikes the appearance and is anxious that it will progress. He achieves and maintains firm erections without difficulty. He has no diabetes, is a non-smoker and takes no regular medication. On examination, with a chaperone present, the flaccid penis looks normal and the meatus and foreskin are healthy. You palpate a firm, discrete, non-tender plaque about 1.5 cm long on the dorsal aspect of the mid-shaft, at the point where a photograph he has brought shows the penis curving upwards through roughly 20 degrees on erection. There is no hourglass narrowing, no shortening preventing penetration and no skin change or ulceration. You also notice a firm, painless cord in the palmar fascia of his right hand. He asks what treatment he should now have.
What is the MOST appropriate initial management?
- ARefer for penile plication surgery now
- BInject the plaque with intralesional triamcinolone
- CReassure, explain the natural history and review
- DPrescribe daily tadalafil 5 mg for six months
- EArrange urgent penile Doppler ultrasonography
Correct — Explanation
Stem context
A middle-aged man has an acquired dorsal penile curvature of about 20 degrees with a firm, non-tender dorsal plaque. The painful phase has passed, the deformity has been stable for six months, intercourse remains possible and satisfactory, and erectile function is normal. He also has a palmar fascial cord.
Question rationale
The question tests the distinction between disease that warrants intervention and disease that warrants explanation, and the avoidance of a treatment that is specifically not recommended. Peyronie disease is a fibrotic process of the tunica albuginea, sometimes associated with Dupuytren contracture, which typically affects men between 45 and 60 years and may follow minor trauma during sexual activity. It classically has an active phase, with pain on erection and progressive curvature, followed by a stable phase in which the deformity settles; the problem often increases over the first few months, then remains static and may improve over one to two years.
It is distinguished from congenital chordee, which is present from infancy, has no plaque and is often associated with hypospadias, and from a penile fracture, which is acute. Assessment centres on duration, whether the curvature is still progressing, whether erectile function is preserved and, most importantly, whether the deformity prevents satisfactory intercourse. Men with a mild curve that does not cause pain may simply be reassured. Surgical treatment, usually penile plication or, for severe deformity, incision and grafting or an implant, is reserved for stable disease causing ongoing distress, pain or sexual dysfunction. Intralesional steroid injections are not recommended.
Answer explanation
Reassurance with an explanation of the natural history and planned review is the correct initial management. His disease is in the stable phase, the curvature is mild and not progressing, erectile function is intact and intercourse is satisfactory, so none of the indications for intervention is met.
Explain that the plaque is scar tissue, that it is a recognised and benign condition often linked with the Dupuytren cord in his hand, that the painful phase has already passed, and that the deformity commonly remains static and may soften over one to two years. Address the psychological impact, which is often the dominant problem, and include his wife in the discussion if he wishes. Review in about six months, and refer to urology if the curvature progresses, if pain returns, if erectile dysfunction develops or if intercourse becomes difficult or impossible.
Why the other answer options are not acceptable
Refer for penile plication surgery now: Plication is a valid treatment, but only for stable disease that causes significant deformity, ongoing discomfort or sexual dysfunction. Operating on a man whose intercourse is satisfactory exposes him to penile shortening, altered sensation and erectile dysfunction for a problem that is essentially cosmetic and may improve on its own.
Inject the plaque with intralesional triamcinolone: Intralesional steroid injection is specifically not recommended in Peyronie disease. It lacks convincing benefit and carries risks of local tissue atrophy and further distortion.
Prescribe daily tadalafil 5 mg for six months: A phosphodiesterase-5 inhibitor treats erectile dysfunction, which he does not have, since his erections are firm and reliable. It does not correct the curvature or dissolve the plaque, and prescribing it here treats a problem that is not present.
Arrange urgent penile Doppler ultrasonography: Duplex ultrasound has a role in the assessment of erectile dysfunction and in surgical planning for severe deformity, and in a different context in distinguishing ischaemic from non-ischaemic priapism. In stable, mild Peyronie disease with normal erections it will not change management and would inappropriately medicalise a benign, stable curve.
Learning points
- Peyronie disease presents with acquired curvature, a firm non-tender plaque and, in the active phase, pain on erection; it is commonest between 45 and 60 years.
- It is associated with Dupuytren contracture and may follow minor trauma during intercourse.
- Distinguish it from congenital chordee, which is present from infancy, has no plaque and is often associated with hypospadias.
- The natural history is an active progressive phase followed by a stable phase, with the deformity often remaining static and sometimes improving over one to two years.
- Mild, painless, stable curvature that permits intercourse is managed with explanation, reassurance and review.
- Refer to urology when the deformity is severe or progressive, pain persists, erectile function is impaired or intercourse is not possible; options include plication, incision and grafting, or an implant.
- AKT trap: recommending routine intralesional steroid injection, which is not recommended, or operating on a curve that is not causing functional difficulty.
References
- Chapter 104: Disorders of the penis - Murtagh’s General Practice, 9th Edition, McGraw Hill
- Peyronie’s disease fact sheet - Healthy Male, Andrology Australia, 2023