Shahin T. Chandrasoma1 and Martin K. Gelbard2
(1)
Skyline Urology, 2601 W Alameda Ave, Los Angeles, CA, USA
(2)
Clinical Faculty, Skyline Urology, University of California, Los Angeles, 2601 West Alameda Avenue, Burbank, CA 91505, USA
Martin K. Gelbard
Email: mgelbard@uamg.net
Keywords
Peyronie’s diseasePenile anatomical disordersPenile anatomyPathophysiologyDiagnosisManagement
10.1 Introduction
Disorders of penile anatomy can result in a variety of problems with sexual function, ranging from purely physical issues with regard to size, shape, or rigidity to psychologic impairment—embarrassment, loss of confidence, alteration in body image, and depression. There are three clinical conditions that comprise this group: Peyronie’s disease, congenital penile curvature or chordee, and hypospadias. The prime focus of this chapter will be on Peyronie’s disease (PD) , as it is the most common of the three. Congenital curvature and hypospadias are present throughout life and unless particularly severe are not often regarded as abnormal unless commented on by a partner. Peyronie’s disease, however, is an acquired condition that alters baseline sexual function and can result in severe psychological effects.
Peyronie’s disease is named after Francois Gigot de la Peyronie, physician and battlefield surgeon to the court of Louis XV. He was credited with the first medical article describing a “ram’s horn” curvature of the penis associated with palpable subcutaneous nodules, though written descriptions of a similar observation date to the sixteenth century and earlier.
Peyronie’s disease can cause painful erection, difficulty maintaining an erection, curvature, indentation, or twisting of the penis, and loss of penile length and girth. Congenital curvature, comparatively, is associated with an otherwise normal penis that curves laterally, ventrally, or dorsally. Dorsal or upward curvature is the most common presentation of PD and the least common congenital deformity. Hypospadias , a congenital condition wherein the urethra variably exits the penis proximally and ventrally to the tip of the glans, can be associated with ventral or downward bending as well. All three conditions can cause sexual dysfunction via physical or psychological effects on the patient and/or his partner.
10.2 Prevalence and Genetic Patterns
Though it has been identified in all races, PD is most common in men of Northern European ancestry. The prevalence of PD varies considerably, depending on the cohort studied: from 0.39 % based on diagnoses within Rochester County, Minnesota [1], to 20.3 % based on cases identified in diabetic men with erectile dysfunction [2]. Another study showed 7.9 % prevalence among patients with erectile dysfunction [3]. A large general Internet-based survey of 11,420 subjects found a 0.5 % prevalence [4], while a different general survey of 4432 men measured prevalence at 3.2 % [5]. A survey of 647 men between 50 and 70 showed a 7.1 % prevalence [6], and another study of 534 men over 40 being screened for prostate cancer identified 8.9 % with the diagnosis [7].
10.3 Natural History and Pathology
Of the disorders covered in this chapter, only PD is acquired; as such, its development tends to follow a predictable pattern or so-called natural history. In some cases it follows an obvious coital injury, which can range from pain and/or a cracking, popping sensation during intercourse up to frank penile fracture with detumescence and appearance of a hematoma. In those cases of penile fracture, whether treated surgically or by observation, alteration of penile shape and palpable penile induration are usually apparent soon after the event. By comparison, presentation may be delayed for a year or more after less violent injuries.
Although trauma is a known inciting event, the clinical fact is that most patients present without any history of penile injury. Roughly only half of affected patients complain of penile pain or a history of painful erections, though in some cases a period of painful erections precedes the appearance of bending or palpable nodules. In other cases penile curvature is reported as coming “out of the blue,” with patients describing the surprise they experience when they notice that their morning erection has suddenly taken a turn in a new direction.
Most cases of PD evolve over a period of 12–18 months before stabilizing. Since most cases follow this progression, there is a clinical distinction between early and late PD. Pain, if present, is usually associated only with this early formative phase and in most cases tends to resolve spontaneously with the passage of time. Following the cessation of pain and/or stabilization of evolving deformity, most patients will experience relatively little change in their condition. As will be described in more detail below, this late phase is characterized by the presence of stable, mature scarring of the penile tunica albuginea, the dense collagenous wall of the corpus cavernosum. Significant variation in this pattern has been recognized, however. In 217 men followed for a mean of 14.5 months, Mulhall et al. found that curvature worsened in 48 %, improved in 12 %, and stabilized in 40 % [8]. Similarly, some patients will continue to experience erectile pain for several years into the course of the disorder, though this is rare.
Congenital curvature is generally first noted at puberty. Most cases will exhibit little change over subsequent years, though occasionally the bend will increase slightly over time, perhaps due to the mild trauma experienced on the concave side from straightening the penis during intercourse. Many patients with hypospadias severe enough to cause downward curvature will have had corrective surgery by the time they reach puberty. This experience carries its own unique psychological effects, though some authors feel that surgical correction prior to puberty in general decreases emotional strain relative to the condition.
PD has been characterized as a wound healing disorder of the tunica albuginea [9]. The earliest histologic changes observed are fibrin deposition within the tunica and a round cell inflammatory infiltrate in the areolar layer just deep to it. These findings are thought to represent the initial subclinical trauma and the consequent inflammatory response and are consistent with the usual early, transient painful phase, mediated by inflammatory cytokines. For unknown reasons, the wound healing response engendered by these events is not properly regulated, persisting and causing an inappropriate amount of scarring. The net result is that most patients with PD will develop permanently scarred regions of the tunica. By producing firm areas, or plaques, the normal pliancy of the tunica albuginea is limited. Peyronie’s plaque can range from areas of reversible inflammation (early PD) to permanently scarred tissue (late PD). Regardless of their composition, plaques alter the shape of the erect corpora cavernosa. Like cellophane tape on the wall of a balloon, they prevent symmetrical inflation and result in a bent, shortened, indented, or otherwise misshapen erection.
All sexually active men experience some degree of wear and tear on vulnerable areas of the erectile mechanism. Both the structural arrangement of the corpora and the inherent elasticity of its connective tissues counteract the mechanical stress imposed by intercourse. But by the time men reach the sixth decade of life, tunical elasticity is waning. The median age for the appearance of PD is 55. Fibrin deposition in the tunica, the earliest microscopic change associated with PD, is a common finding on autopsy studies in asymptomatic men. While many men develop areas of fibrin deposition, only a small percentage will experience progression to plaque formation. There is no generally accepted explanation as to what factors or situations stimulate this progression, though it is thought that some men are genetically susceptible, as PD can occur in families and is closely associated with Dupuytren’s contractures , a hereditary condition causing similar fascial scarring in the palm of the hand. PD has also been associated with the presence of the human leukocyte antigen DQ5 locus, Paget’s disease of bone, diabetes, hyperlipidemia, hypertension, heart disease, the use of beta blockers, smoking, low testosterone, penile instrumentation, radical prostatectomy, and penile injection therapy.
10.4 Presentation and Clinical Findings
Though identifiable by puberty, congenital curvature without hypospadias often will not become apparent until the patient becomes sexually active, if the bend is severe enough to interfere with intercourse. Hypospadias with or without curvature is usually identified at birth. Peyronie’s disease, however, most often presents in the fifth or sixth decade of life, though it occasionally occurs as early as the third decade. There appear to be two common modes of presentation: painful erections followed by the onset of penile bend and/or indent and the rather abrupt appearance of change in penile shape without antecedent pain. Only about 50 % of new PD patients complain of pain. Although many patients become aware of a hardened platelike or nodular region below the skin (“Peyronie’s plaque”), recognition of a plaque—which can be tender to touch—is not commonly the initial presentation. Some PD patients can recall a specific traumatic coital event that precipitated the problem, though in most cases there is no clear-cut history of such an event.
There are a variety of subjective responses seen in PD patients in addition to pain: erectile dysfunction, which can be psychogenic and/or organic via interference with passive venocclusion, embarrassment, anger, shame, loss of confidence, change in self-image, withdrawal, loss of intimacy, and depression. Recently, a statistically validated questionnaire was developed to identify and quantitate the subjective bother associated with PD. The disabling psychological effects of this condition are now recognized as particularly prevalent; one study showed clinically significant depression in 48 % of unselected men with this diagnosis [10].
Objective findings in Peyronie’s patients include bending, indentation, and or twisting of the erect penis, loss of length or girth, and the presence of lumps or plaques palpable when flaccid. Changes in girth can be unilateral (indentation), bilateral (“hourglass deformity”), or segmental (distal taper or diameter loss beyond a plaque). Areas of diameter loss compromise column rigidity of the shaft and can produce buckling or so-called “hinge” effects. Often, passive elasticity or the unrestricted ability to stretch the flaccid penis is impaired in PD.
10.5 Diagnosis
Hypospadias is readily diagnosed by finding that the urethral opening or meatus is located more proximally on the penis than the tip of the glans. Congenital penile curvature can be identified when curvature has been present since puberty and is not associated with penile plaque, pain, and loss of elasticity or girth. The diagnosis of Peyronie’s disease can be made clinically without the need for imaging or laboratory studies in most patients based on the history and physical findings noted above. Very rarely the diagnosis is in question, as penile phlebothromboses (Mondor’s syndrome) or malignant tumor infiltration of the corpora can also produce painful nodules in the penis. Mondor’s syndrome does not tend to cause curvature, while tumor infiltration will change the shape of the erection in addition to causing an atypical pattern of continual pain rather than erectile pain. In these cases MRI is helpful in differentiating the diagnosis. Despite the ability to diagnose most cases without such studies, imaging and measurement of objective findings in PD are essential for careful clinical management.
The first step in clinical management of PD is obtaining a detailed history, covering the patient’s perceptions of the various symptoms and findings noted above. To this should be added the disease duration, whether there was a history of preceding coital trauma, and whether there is a personal of family history of Dupuytren’s contractures of the hand or plantar fibromatoses (Ledderhose disease). Other conditions felt to contribute to PD include diabetes, beta-blocker use, and a history of urethral or prostate surgery. The Peyronie’s Disease Questionnaire (PDQ) is a statistically validated instrument for the documentation of psychologic bother and is a helpful adjunct to the screening history [11].
Detailed and directed physical examination should be performed and should include the stretched length of the flaccid penis, usually measured from the pubic symphysis to the penile corona. Plaque location and configuration likewise should be identified, though detailed measurement of plaque size is not clinically reliable or helpful in the management of these patients. We find it helpful to comment on the preservation or absence of passive stretch or extensibility. Complaints about sensory change are rare but if present can be evaluated with biothesiometry of vibratory thresholds.
There are a variety of ways to document penile deformity. This step is mandatory, as patients’ subjective estimation of their curvature is inaccurate. Photos submitted by patients can be helpful, and there is even a smartphone app for quantifying the degree of bending. Bending and other shape issues can be most reliably measured and documented following intracavernosal injection of vasoactive compounds such as prostaglandin E1 or Trimix. Goniometer measurement in this setting is sufficient in some cases, though most clinicians will do this as part of a penile duplex Doppler ultrasound examination. The value of this examination is that in addition to identifying the location of the primary plaque or the area most contributing to the deformity, it can determine whether the calcified plaque is present and whether there is any associated vasculogenic erectile dysfunction. A recent survey of 220 men with mean age 55 years showed 69.5 % had vasculogenic erectile dysfunction: 10 % with arterial insufficiency, 43.2 % with venocclusive dysfunction, and 16.3 % with both [12].
Plaque calcification can also be assessed with xeroradiography or low kilovoltage radiography (50 KV at 50MAs) utilizing film in a light tight paper jacket without an image intensification cassette. In those rare cases where other causes of penile induration are present, MRI imaging can be helpful. Laboratory testing is generally not necessary, though based on reports on the association of PD with low testosterone, some clinicians will obtain screening testosterone levels.
10.6 Treatment
There is no nonsurgical treatment for hypospadias or congenital curvature. While the management of hypospadias is beyond the scope of this article, surgery for congenital curvature involves surgical plication of the corpora, which is discussed below.
A variety of medications, surgery, and stretching devices have been used in the treatment of Peyronie’s disease. Even extracorporeal shock waves, as administered for kidney stones, have been tested. Until large multi-institutional international studies were recently completed, there was little consensus among urologists as to what constituted an optimal approach. Even with the robust data generated from those studies, there are still widely varying opinions on best practices. This is due in part to deficiencies of earlier studies and in part to the wide variation in presentation from one individual to another, ranging from the pain of early inflammation in some patients to later stage shrinkage or curvature in others.
To evaluate the efficacy of PD treatments, the evolution of the disease in the absence of therapy should be known. Erections can be painful during the first 6 months or early phase of the disorder, though about half of patients have minimal or no pain initially. Eventually, pain tends to resolve on its own as PD enters the second or chronic stable phase. Unfortunately, bending does not usually follow the same resolving course as pain—in the majority of men, angulation present in the latter stages of PD usually persists. Bending may worsen or progress after this point, and spontaneous resolution is rare. Factors associated with a tendency for bending to persist are the presence of Dupuytren’s contractures in the hand, the presence of plaque calcification, and severe penile angulation (>45°). Understanding this “natural history” provides a basis for comparison of outcomes from various treatment modalities. Despite the well-documented course of untreated PD, there exist a number of deficiencies in much of Peyronie’s clinical literature; the quality of evidence supporting nonsurgical treatment varies considerably.
10.7 Medications
Until recently, nonsurgical or “medical therapy” was thought to give best results during the early phase of PD, while correction of curvature associated with chronic second stage scarring required surgery. Traditionally, medications were employed early in the initial inflammatory stage with surgery indicated later where loss of sexual function accompanied persistent penile deformity.
This view was based on the mechanism of action of early medical therapy. Though never well characterized by exhaustive basic science, medical therapy was intended to reduce the inflammatory response or inhibit the deposition of new scar tissue. On the other hand, effective pharmacologic manipulation of established or chronic scar has been an elusive goal until recently. Data from clinical trials of collagenase clostridium histolyticum (CCH) have shown statistically meaningful improvement both in curvature and subjective function in men with stable chronic disease of >1 year duration. While starting treatment early is always a good principle, the use of CCH is changing the traditional timing of nonsurgical treatment. For the first time, men with long-standing deformity may expect improvement in many cases with nonsurgical therapy.
There are a number of medications and remedies that have been used off-label in the treatment of PD [13]. Some of the most commonly used agents are:
· Vitamin E : this antioxidant has been widely used in the treatment of PD since 1948, though evidence of its efficacy is lacking.
· Potassium para-aminobenzoate (POTABA) : related to B complex vitamins and can theoretically increase the supply of oxygen to inflamed tissues. There are no good randomized controlled trial data demonstrating efficacy in PD treatment, and the high doses frequently recommended may cause digestive upset.
· Colchicine : a medication used for many years in the treatment of gout, colchicine has anti-inflammatory properties and interferes with collagen (scar) synthesis. There is weak evidence for efficacy in PD in clinical trials, and it can cause diarrhea and should not be used in patients who are on statins (cholesterol-lowering drugs) due to the risk of muscle inflammation.
· Tamoxifen : a nonsteroidal antiestrogen that may inhibit scar-producing cells. Clinical evidence for the use in PD is weak—it was unable to outperform placebo.
· Acetyl carnitine : appears to reduce cellular damage due to inflammation. Clinical trials in PD patients have shown minimal effects.
· L-Arginine : an amino acid supplement that is a precursor to a nitric oxide, a neurotransmitter critical for erection, and thought to inhibit fibrosis or scarring.
· Pentoxifylline : a nonselective phosphodiesterase inhibitor that improves red blood cell circulation in vascular disorders and may help to locally reduce scarring following inflammation.
· Verapamil : blocks the delivery of scar tissue precursors into an area of wound healing. Penetration into penile plaque has not been proven when used as a topical ointment. Injection directly into the plaques has shown varying degrees of success—some clinical trials have shown benefit, while others found it did not outperform placebo.
· Interferon-α (IFN-α) : a signaling protein that plays a role in human immune responses by inhibiting cellular proliferation. IFN-α was the first anti-PD drug to be tested in a multi-institutional clinical trial, where comparison to placebo showed a small effect on curvature reduction. It has a tendency to produce systemic flu-like symptoms.
10.8 Biological Agents in Peyronie’s Disease
The only treatment specifically approved by the US Food and Drug Administration in the management of Peyronie’s disease is CCH, a proprietary combination of two enzymes found in cell-free filtrates from cultures of the bacterium Clostridium histolyticum . This mix of powerful enzymes is highly specific for collagen, the molecular constituent of scar tissue. It is capable of dissolving this scar tissue at normal body temperature and pH, reducing the curving or distorting effect scar creates in the penile corpora cavernosa. That it is highly specific for collagen and binds it tightly at the injection site without a tendency to spread through tissues contributes to its safety profile. It has been FDA approved for the treatment of Dupuytren’s contractures of the hand since 2011, and in December 2013 it was approved for the use in PD. This biologic agent (it is not technically a drug) is in a completely new class compared to the existing therapeutic agents discussed above. Because it is the first nonsurgical treatment to be tested extensively for safety and efficacy in international multi-institutional clinical trials, it is supported by evidence gathered under more stringent and exacting conditions than in any other study of PD treatment to date [14].
The quality of clinical trial data supporting the use of nonsurgical therapy for the treatment of curvature and subjective bother due to PD has been graded in a recent comprehensive survey [15]. The authors found that the highest level of evidence supporting this approach came from the use of either CCH or IFN-α.
10.9 Other Minimally Invasive Treatment Modalities
Traction therapy, conducted using mechanical stretching devices, is proposed to work by the induction of plaque remodeling via tensile stress. Studies have shown it can have a modest impact on penile curvature and length when used regularly, but can be uncomfortable and inconvenient. The mechanism of action whereby shock wave therapy can influence PD has not been defined, and meta-analyses of pooled clinical outcomes have failed to confirm efficacy.
10.10 Surgical Management of Peyronie’s Disease
In cases refractory to minimally invasive treatment, surgical intervention may be considered. The approach is dictated by the location, direction, and severity of curvature, the presence of plaque calcification, and the presence or absence of concurrent or underlying erectile dysfunction. Typically, surgical management is reserved for patients who are in the chronic stable phase of the disease, with curvature significant enough to preclude penetration during intercourse [16]. Based on results of CCH in chronic stable Peyronie’s disease, the indications for surgery can be modified to include chronic stable PD patients with heavy plaque calcification or those who have failed a course of CCH.
Lesser degrees of bending due to PD can be corrected surgically with simple plication opposite the point of bending (Fig. 10.1). This is also the preferred method for correcting congenital curvature regardless of severity. It is also indicated for the surgical correction of ventral PD, as grafting procedures for this condition often compromises erectile rigidity. These procedures can be done with either suture plication or removal of a small ellipse of tunica followed by closure. Plication procedures will shorten the penis and may cause indentation, sensory change, or reduced erectile rigidity.
Fig. 10.1
Nesbit plication . (a) Exposure of the ventral penis after artificial erection, followed by (b) clamping of penile tissue in the area of curvature to define the degree of plication needed. Suture is then placed to cinch the tissue and straighten the penis, contributing to (c) the final result
For more pronounced curvature or complex deformities involving indentation or diameter loss, incision of the contracture and grafting is more effective (Fig. 10.2). We have had good results using autologous temporalis fascia, though many other graft materials have been employed successfully as well. The plaque is incised and the contracture expanded, removing spicules of sub-tunical calcifications if they are present using relaxing incisions. Usually several grafts are required, which are sutured in place for a watertight closure. This procedure can also cause penile shortening, sensory change, and loss of erectile rigidity.
Fig. 10.2
Peyronie’s plaque incision and grafting. (a) Relaxing incision of a PD plaque with (b) placement of autologous temporalis fascia graft with watertight closure
Patients with underlying erectile dysfunction at baseline may elect graftless straightening at the time of inflatable penile prosthesis placement. In this procedure the PD plaque is incised with short staggered incisions that expand the contracture; much like is accomplished by meshing a split-thickness skin graft.
10.11 Conclusion
Peyronie’s disease is one of the most common disorders of penile anatomy in the adult population. Unlike hypospadias or congenital curvature, PD is acquired in adult life so it tends to have a powerful secondary psychological effect. Historically, medical management of PD left much to be desired; surgical management of Peyronie’s disease was considered the gold standard. With regulatory approval of CCH, we now have a reliable intermediate option, as CCH is highly effective at correction of mild to moderate bends without the shortening and other complications seen with surgery. Future directions of study will include a better understanding of wound healing and its disorders, while contemporary practice will continue to recognize the powerful psychologic and relational issues created by this challenging disorder.
Commentary: Peyronie’s Disease and Other Anatomical Disorders
Christian J. Nelson3
(3)
Memorial Sloan Kettering Cancer Center, New York, NY, USA
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.
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