Peyronie’s Disease and Other Anatomical Disorders

Abstract

Disorders of penile anatomy comprise a variety of presentations that produce physical and psychological deficits in men. While congenital disorders like chordee and hypospadias contribute, the acquired condition Peyronie’s disease is by far the most commonly seen penile anatomical disorder. This chapter provides a contemporary review of the pathophysiology, diagnosis, and management of these conditions.

Appendices

Commentary: Peyronie’s Disease and Other Anatomical Disorders

• Christian J. Nelson Ph.D. 

1. Memorial Sloan Kettering Cancer Center, New York, NY, USA

   Christian J. Nelson Ph.D.

When considered superficially, Peyronie’s disease and other conditions that result in penile curvature or deformity may be considered “minor” issues in a man’s sexual health. After all, penile curvature is often imminently treatable, whether using medication or via a surgical approach, and minor penile curvature may not be so severe as to impact sexual function. Often, little consideration is given to the psychological ramifications of conditions that alter penile anatomy. This may be in part due to the private nature of these conditions and the reluctance of men to talk about them. One should also not overlook the fact that the physicians treating these conditions—urologists—often approach them from a physical perspective, seeking to address the condition directly with the assumption that this will result in cure.

In the preceding chapter, the organic etiologies and treatment approaches to penile deformities, in particular Peyronie’s disease, are laid out in detail. What most clinicians do not consider, however, is the significant psychological impact that Peyronie’s disease can have on affected men, with many of these men having depressive symptoms and relationship issues attributable to their penile deformity. The following commentary, however, outlines the current knowledge on the psychological impact of Peyronie’s disease, showing just how potently affected these men can be. Knowing that penile deformity can significantly alter a man’s psychological perspectives and deeply affect his relationships is worthwhile for the clinician and should prompt a discussion with the patient about these often overlooked aspects of these conditions. Only by understanding the global impact of penile deformity on the patient’s condition can appropriate, truly curative, treatment be implemented.

The Editors

Commentary

It should not be surprising that many men experience distress related to Peyronie’s disease (PD). Gelbard and colleagues were the first to characterize the psychological impact of PD in 1990 [1]. They conducted a survey of 97 men with PD that included an assessment of “psychological effects” and reported that 77 % indicated a psychological impact from their PD. Of these men, 36 % indicated that the psychological impact remained the same and did not improve with time, while 36 % said that is worsened [1]. Even of the men who had improvement in their PD symptoms, up to half indicated that they worried about the PD “frequently” or “all the time.”

A study by Smith and colleagues supports the results of the Gelbard study. Smith et al. discovered that over 80 % of men reported “emotional difficulties” related to their PD [2]. Importantly, 50 % of men endorsed relationship problems due to PD. Smith and colleagues also identified possible predictors of this distress. The presence of relationship problems and loss of penile length were significant and independent predictors of emotional problems due to PD. Likewise, emotional difficulties and the inability to have intercourse were independent predictors of relationship problems. To address these psychological problems, the authors suggested that physicians integrate a psychosocial evaluation early in the assessment phase of PD to facilitate referrals for appropriate mental health therapy [2].

Nelson and colleagues sought to specifically assess the level of depression that men with PD experience. In 92 patients with PD, 48 % of men reported clinically meaningful depression (26 % moderate; 21 % severe) [3]. Men who were single and self-reported greater loss of penile length were more likely to also report depressive symptoms. In support of the Gelbard study discussed above, the analyses showed that depression remained consistently high over time, regardless of length of time since diagnosis of PD. The authors argue that physicians should go beyond the role of treating the PD and facilitate proper evaluation and treatment of the emotional and relationship ramifications of the disease [3].

Rosen and colleagues conducted a qualitative study to better understand men’s experience with PD, highlighting important concerns among men with PD [4]. Men reported significant distress related to the physical appearance of their penis. Regardless of the severity of their PD, the psychological distress was consistently high for all affected men. Some men expressed that “even looking at or touching their penis was unpleasant.” Men with PD described feelings of shame and inadequacy and discussed how PD impacted their masculinity, stating that they felt like “less of a man” as a consequence of their penile deformity. Men reported a decreased sense of sexual attractiveness, sexual interest, and sexual confidence. As a result, patients were hesitant to initiate sexual relations with a partner, while single men avoided dating. The feelings of bother in men with PD were extreme and highly distressing [4].

All men reported a significant decrease in their sexual satisfaction since the onset of PD. Many reported that PD impacted other aspects of their sexuality as well and endorsed an increase in performance anxiety in addition to difficulties with erection, ejaculation, or other aspects of sexual function [4]. Practically all men with PD were afraid that they were not satisfying their partners sexually, although none had sought counseling together with their partners. Importantly, men reported a sense of social stigmatization and isolation. Many men with PD found it hard to discuss this condition with their health care professionals, their partners, or their friends, leaving them feeling chronically stigmatized and socially isolated over time.

Case Study

Bob was a 45-year-old man who developed PD. During a sexual encounter with his wife, he stated that he “injured his penis” followed by a significant amount of pain and bleeding. Following this penile injury, he reported about 30 degrees of curvature. He presented to a sexual medicine clinic for treatment of his PD, and at the time his wife strongly suggested he see a mental health professional. He and his wife reported that he was depressed as a result of the PD and that he was spending less time with his family, which included his wife and his two young children. Bob indicated that he did not enjoy playing with his children, that he felt “different” than other men, and that he could not talk about his PD with anyone because he was fearful of what they would say and who they might tell. He was started on intralesional verapamil injections to treat the PD, and during this time, he continued to report significant frustration related to his PD. He continued to feel isolated and felt like he had a “disease” that no one had heard about and the treatment for which was like some “medieval torture.”

He eventually agreed to see a psychologist to address his PD-related distress. Bob’s therapy focused on helping the patient reengage in sexual relations with his wife. He was afraid to attempt intercourse because he feared reinjuring his penis and was anxious that he would not be able to please his wife sexually or that his attempts would end in failure. His therapy also focused on helping him feel less isolated. He eventually identified one friend who he could confide in about his PD, providing an important sounding board in the recovery process. Eventually, Bob’s depression lifted during treatment, and he was able to see that there were many important and meaningful aspects of his life and that he could continue to have a meaningful sex life with his wife.

References

• 1. Gelbard MK, Dorey F, James K. The natural history of Peyronie’s disease. J Urol. 1990;144(6):1376–9.

• 2. Smith JF, et al. Risk factors for emotional and relationship problems in Peyronie’s disease. J Sex Med. 2008;5(9):2179–84.

• 3. Nelson CJ, et al. The chronology of depression and distress in men with Peyronie’s disease. J Sex Med. 2008;5(8):1985–90.

• 4. Rosen R, et al. Impact of Peyronie’s disease on sexual and psychosocial functioning: qualitative findings in patients and controls. J Sex Med. 2008;5(8):1977–84.