From 1966 to 1988, 98 of 108 patients with symptomatic Peyronie's disease received radiotherapy at our institution. In 11 of 61 patients (18%) who attended the clinic regularly for follow-up for longer than a year, new lesions distinct from the original lesions developed. This confirms that there is progression of the disease in a substantial number of cases after treatment. Long-term follow-up over an average of 111,5 months was achieved by means of a questionnaire in 47 of the 98 cases (48%). Forty-one of these patients (87,2%) had sexual intercourse after radiation. Twenty-eight of the 41 (68,3%) still have intercourse. Their average age at present is 59,6 years while the average age of the 13 patients (31,7%) not having intercourse is 70,9 years. The decline in sexual activity is thus age-related. Twenty-one of 25 patients (84%) experienced relief from pain, and angulation of the penis improved in 17 of 44 patients (38,6%) after radiotherapy. Radiotherapy may therefore be of benefit to patients with active Peyronie's disease and should be investigated in a randoIIlised controlled study

Doman, M. J.

Goedhals, L.

Viljoen, I. M.

English

AJOL - African Journals Online

------------------ ..J~Peyronie's disease - a perspective on the disease and thelong-term results of radiotherapyI. M. VILJOEN, L. GOEDHALS, M. J. DOMANAbstract FrOIIl 1966 to 1988, 98 of 108 patients with sYIIlP-to=atic Peyronie's disease received radiotherapyat our institution.In 11 of 61 patients (18%) who attended theclinic regularly for follow-up for longer than ayear, new lesions distinct frOIIl the original lesionsdeveloped. This confirms that there is progressionof the disease in a substantial nUIIlber of casesafter treatIIlent.Long-ter= follow-up over an average of 111,5IIlonths was achieved by IIleans of a questionnairein 47 of the 98 cases (48%). Forty-one of thesepatients (87,2%) had sexual intercourse afterradiation. Twenty-eight of the 41 (68,3%) still haveintercourse. Their average age at present is 59,6years while the average age of the 13 patients(31,7%) not having intercourse is 70,9 years. Thedecline in sexual activity is thus age-related.Twenty-one of2S patients (84%) experienced relieffrom pain, and angulation of the penis iInprovedin 17 of 44 patients (38,6%) after radiotherapy.Radiotherapy IIlay therefore be of benefit topatients with active Peyronie's disease and shouldbe investigated in a randoIIlised controlled study.S Air Med J 1993; 83: 19-20.Peyronie's disease, first described in 1743,1 hasbeen grouped with Dupuytren's contracture,aponeurotic plantar fibrosis and knuckle pads asone of the fibrosing diseases in which 'a burst of fibro-plasia' is the common denominator. 2 The aetiology isunknown. The increased density of the fibroblastsinhibits their capacity to produce type I collagen.' Thenonnal production ratio of type hype III collagen is dis-turbed and excessive amounts of type HI collagen aredeposited.3,4A dominant gene with high penetrance appears to beinvolved in these diseases as they are more prevalent inAnglo-Saxon populations.2,3In Peyronie's disease the lesion first appears as aplaque in the vascular areolar connective tissue sheaththat separates the corpus cavernosum from the tunicaalbuginea. I The plaque may extend into the corpuscavernosum.'The true incidence of Peyronie's disease is unknownbur it is not an uncommon disease.' The natural historyis vague",7 bur it is a self-limiting disease; the active stageapparently lasts from 12 to 18 months.' The plaque mayrecede spontaneously and even disappear in a fewinstances." Alternatively it regresses to an inelastic scar.;The extent and location of the lesion relative to theerectile tissue determine whether the patient is a sexualcripple or not. Sexual disability is the only indication fortreatment.The treatment options are varied and include medi-cal treatment with potassium para-aminobenzoateS andDeparttnents of Urology and Radiotherapy, University of theOrange Free State, Bloemfontein1. M. VILJOEN, M.SC., M. MED. (UROL.), F.c.s (SA)L. GOEDHALS, M. MED. (RJill. T.)M. J. DOMAN, B.SC. sel. NAT.Accepted 10 Feb 1992.vitamin E,' steroids,· ultrasound,!" radiation'·I!.I' andsurgery.5,13,14 Since 1966 orthovolrage radiotherapy hasbeen used at our instirution. Varying reponed successrates ',11,11 and the suspected risk of damage and furtherfibrosis as a result of radiotherapy!' have prompted us toevaluate our long-term results.Patients and methodsFrom 1966 to 1988, 108 patients with symptomaticPeyronie's disease were registered at our combinedurology and radiotherapy clinic. The mean patienr ageat registration was 53,7 years (range 19 - 79 years) withsymptoms present on average for 8,1 months (range 1 -24 months). Ten patients had had local steroid injec-tions before registration bur none had undergonesurgery. Virtually all the patients had raken an anti-inflammatory agent before they were seen by us. Twentypatients (18,3%) had Dupuytren's contracrure. Therewas no other associated abnonnality. All our patientswere white.Ninety-eight patienrs were irradiated. Forty-sevenreceived 2 500 cGy in 10 x 250 divided doses over a 12-day period. Forty-two patients had doses varying from1 500 to 3 500 cGy \vith an average of 2 363 cGy. Fivepatients had the initial dosage of 2 500 cGy supple-mented at a later stage by 1 000, 1 250, 1 400, 1 500and 2 000 cGy respectively. Four patients had 1 250,1 250, 1 250 and 2 100 cGy respectively added at a laterstage to an initial dosage of 1 500, 1 750, 2 250 and2 400 cGy respectively. Nine patients thus received fol-low-up radiotherapy re a maximum total dose of 4 500cGy.Radiation was applied by using a 250 KV unit with athoraeus filter and an RVI of 3 mm copper. The applieddose of the single field 250 KV beam was 250 cGy withthe standard fractionation being 10 x 250 cGy daily.Field sizes varied from 3 x 2 cm to 7 X 4 cm dependingon the extent of the Peyronie's disease palpated. Nonnaltissue was shielded by 3 mm lead shielding. The peniswas placed on a 3 mm lead sheer rhus shielding thedeeper-lying normal tissue, e.g. the testes and scrorumor suprapubic region depending on the position of thepenis during radiation. The field edges and size weredefined using a 3 mm lead cutout.To assess the long-tenn results of radiorherapy aquestionnaire was formulated in accordance with accep-ted guidelines. lo These were mailed re all the patients.To validate the reliabiliry of the questionnaire" °10patients, chosen at random, were telephoned approxi-mately 6 weeks arrer the receipt of the 30th completedquestionnaire; the questions were repeated to them. Thecorrelation between their answers and those in the ques-tionnaire satisfied us as to the questionnaire's test-retestreliability.ResultsOf the· 98 patients, 10 were lost to follow-up. Eightypatients attended the clinic regularly for an average of33 months (range 2 - 98 months) arrer treatment. Sixty-one attended for more than 12 months.Surprisingly, in 11 of 61 (18%) patients, new lesions,palpably distinct from the original lesion, developed. In20 SAMJVOL 83 JAN 19933 cases the lesions were associared wirh symptoms andthese patients were furrher irradiated. The doses respec-tively were 1 250 cGy added to the initial 2 250 cGy,2 000 cGy added to the initial 2 500 cGy and 1 000 cGyadded to the initial 2 500 cGy. Only the laner patientimproved after the second course of radiotherapy. Theremaining 8 patients did not have symptoms as a resultof rhe new lesions. In 5 patients the lesions remainedstatic and in 3 became smaller.Of the 98 questionnaires mailed to the patients, 53(54%) were rerurned. Forry-seven (88,3%) were ade-quately completed. Eight of the patients completing thequestionnaire did not attend the clinic after trearment.The period of follow-up was extended from an averageof 33 months to an average of 111,5 months (range 11 -273 months) by the questionnaire. The average age ofthese 47 patients was 55,1 years (range 27 - 70 years) atregistration and is at present 64,3 years (range 39 - 80years) .The subjective assessment of the quality of erectionafrer radiotherapy revealed that 17 of 43 patients(39,5%) thought it normal; 3 (7%) judged it to beimproved. It remained the same in 9 cases (20,9%) anddeteriorated in 14 (32,6%). Angulation of the penisimproved in 17 (38,6%) of 44 cases, remained the samein 16 (36,4%) and became worse in 11 (25%). A dra-matic reduction in pain occurred in 21 (84%) of 25cases. Pain levels remained the same in 3 patients (12%)and worse.pain was experienced by 1 patient (4%).DiscussionPeyronie's disease is a self-limiting disease with theactive stage lasting from 12 to 18 monrhs.5 The lesiondoes not cause symproms in the majority of cases. Itregresses spontaneously in about 50% of cases'· andmay even disappear completely." Altematively it formsan inelastic scar.5 The size of the scar, its position andthe extent of the involvement of the corpus cavemosumdetermine the degree of erectile disability.Three categories of patients are recognised:1. Those without symptoms. They have discoveredthe lesion by chance and many of them are afraid that itmay be cancer. They need reassurance only.2. Patients with active lesions producing symptoms.Their history is usually a year or less. They have painand/or bending of the penis with erection interfering tovarying degrees with sexual intercourse. This may havea psychological impact" and may lead to impotence.3. Patients with the end stage, the inelastic scar.Strictly speaking they do not have but have had the dis-ease and are left with mechanical disability.One in 1013 to 1 in 3 5 patients come to surgery.Three main surgical options exisr: (1) excision of thelesion followed by a replacement graft;5 (il) the Nesbitprocedure;13 and (iil) the insertion of a prosthesis.'· Theresults of these procedures are controversial.5.13,'-l,18Reasons for this include subjective assessment of theresults, lack of properly documented long-term resultsand the use in some instances of adjuvant trearment, forinstance vitamin E.15There is however general agreement5.13,.. that surgicalcorrection of the erectile deformity must be deferred forat least a year after diagnosis. Surgery is therefore, byimplication, reserved for caregory 3 patients. What mustbe done in the meantime? What is the preferred treat-ment for caregory 2 patients? It has been stated thatPeyronie's disease is fully manifested when the patient isfirst seen." We have found new lesions developing in 11of 61 (18%) patients. We accept this as confirmationthat there is progression of the disease in a substantialnumber of patients after they have first been seen. Theobjectives of treatment in category 2 patients musttherefore be, firstly, to arrest the progression and, sec-ondly, to alleviate the symptoms of the disease.Since it is a self-limiting disease, arrest of progressionwill be extremely difficult to prove. There is a naruraltendency for the symptoms to resolve.' The justificationfor treating patients in category 2 is that the relief ofsymptoms can be accelerated in a substantial number ofcases" especially when the symptomatology is of shortduration. The trearment selected must be effective witha low risk of complications. It must nor interfere v.>ithsubsequent surgical therapy should that become neces-sary. Radiation fibrosis has been considered by somel5 tohamper surgery while others have not found this so. '2 Incomparing the results of various repons on orrhovolragetherapy, differences in radiation dosage must be consid-ered. Our patients received an average dose of2 500 cGy in 10 fractions over a 12-day period. Tworecent reports mentioned 600 to 1 600 rad with an aver-age dose of 900 rad over a 10 - 90 day period" and asingle exposure dose of250 to 600 roentgens.'In our series, 21 of 25 patients (84%) experiencedpain relief. Bending of the penis improved in 17 of 44cases (38,6%). Forry-one of 47 patients (87,2%) hadsexual intercourse following radiotherapy and 28 ofthese (68,3%) srill have sexual intercourse 99,2 monthsafter trearment. Their average age is 59,6 years. Thedecline in sexual activity is age-related since 13 of 41(31,7%) patients who have ceased sexual activity are onaverage 70,9 years old and 129,9 months post-treat-ment.We conclude that the lack of randomised controlledstudies hampers treatment decisions in Peyronie'sdisease. The symptomatic patient with end-stagedisease clearly needs some form of surgery, be it theNesbit procedure, dermal graft inlay or the insertion of aprosthesis. We are concerned v.>ith the patient v.>ith theactive lesion. He deserves trearment and not only theadvice to persevere till the lesion has bumt itself out atwhich stage surgery may be contemplated! Our adviceto these patients is to have radiotherapy. It is a relativelyshort course of trearment done on an outpatient basis.More than 80% of our patients experienced relief frompain. Improvement of angulation was noted in about40% of early cases. In the long term, radiotherapy doesnot appear to affect the patient's erectile ability.REFERENCES1. Smith BH. Peyronie's disease. AmJ Clin Parho11966; 45: 670-677.2. Wooldridge WE. Four related fibrosing diseases. Postgrad Med1988; 84: 269-274.3. Murrell GAC, Hueston [f. Aetiology of Dupuytren's conrracture.AZlst NZJSlIrg 1990; 60: 247-251.4. Somers KD, Sismour EN, Wright GL, Devine CJ, Gilben DA,Honon CE. Isolation and characterization of collagen in Peyronie'sdisease.J Uro11989; 141: 629-631.5. Devine CJ, Honon CE. Peyronie's disease. Clin Plast SlIrg 1988;15: 405-409.6. Williams JL, Thomas GG. The natural history of Peyronie's ilis-ease.J Uro11970; 103: 75-76.7. Furlow WL, Swenson HE, Lee RE. Peyronie's ilisease: a study ofits natural history and rreaonent with orthovoltage railiotherapy. JUro11975; 114: 69-71.8. Zarafonetis CJD, Horrax TM. Treatment of Peyronie's iliseasewith potassium para-aminobenzoate (Potaba). J Urol 1959; 81:770-772.9. Desanctis PN, Furey CA. Steroid injection for Peyronie's disease: a10-year summary and review of 38 cases. J Uro11967; 97: 114-116.10. Frank IN, Scon WE. The ulrrasonic rreannent of Peyronie's ilis-ease. J Uro11971; 106: 883-885. .11. Mira JG. Is it worthwhile to treat Peyronie's disease' Urology 1980;16: 1-6.12. Carson CC, Coughlin PWF. Railiation therapy for Peyronie's ilis-ease: is there a place? J Uro11985; 134: 684-686.13. Bailey MJ, Yande S, Walmsley B, Pryor JP. Surgery fOt Peyronie'silisease. BrJ Uro11985; 57: 746-749.14. Cohen ES, Schmidt ID, Parsons CL. Peyronie's disease: surgicalexperience and presentation of a proximal approach. J Urol 1989;142: 740-742.15. Honon CE, Sadove RC, Devine Cr Peyronie's disease. Ann PlaslSZlrg 1987; 18: 122-127.16. Del Greco L, Walop W. Questionnaire development: I.Formulation. Call Med AssocJ 1987; 136: 583-585.17. Del Greco L, Walop W, McCanhy RH. Questionnaire develop-ment: 2. Validity and reliability. Can Med Assoc J 1987; 136: 699-700.18. Melman A, Holland TF. Evaluation of the dermal graft inlay tech-nique for the surgical treaonent of Peyronie's disease. J Urol 1978;120: 421-422.

Peyronie's disease - a perspective on the disease and the long-term results of radiotherapy

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Peyronie's disease - a perspective on the disease and the long-term results of radiotherapy

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