Editing Peyronie's Disease (section)

== Diagnosis and Evaluation ==

=== UrologySchool.com Summary ===

* '''<span style="color:#ff0000">AUA:</span>'''
** '''<span style="color:#ff0000">Mandatory (1): history and physical exam</span>'''
** '''<span style="color:#ff0000">Recommended (1): detailed examination of erection (photograph or in-office ICI testing) prior to invasive intervention</span>'''
* '''<span style="color:#ff0000">CUA:</span>'''
** '''<span style="color:#ff0000">Mandatory (1): history and physical exam</span>'''
** '''<span style="color:#ff0000">Recommended (1): detailed examination of erection (photograph or in-office ICI testing) prior to invasive intervention</span>'''

=== History and Physical exam ===

==== History ====
* '''Signs and Symptoms'''
**'''Onset''', duration, acquired vs. lifelong (to differentiate PD vs. congenial penile curvature), changes over time (deformity and erectile function)
** '''Penile characteristics:''' extent of penile '''deformity''', direction of '''curvature''', palpable plaque(s), presence of hourglass deformity, shortening, and presence of hinging, penile '''pain''' with and without erection. Penile sensation, ejaculatory function, and length/girth concerns should be documented. 
*** '''<span style="color:#ff0000">Pain, when present in the acute phase, can occur in the flaccid penis with palpation of the plaque, with erection, or during intercourse</span>'''
*** '''<span style="color:#ff0000">Once the disease process is stable, most pain will resolve</span>, but in some men the pain persists with a pulling sensation on the plaque when a strong erection occurs (torque pain)'''
* '''<span style="color:#ff0000">Risk factors</span>'''
**History of traumatic event
**Medical history inclusive of family presence of Peyronie disease, Dupuytren’s contracture, and other related conditions that may impact erectile and sexual function.
*'''<span style="color:#ff0000">Sexual function</span>''': erectile '''rigidity,''' '''interference with intercourse,''' ability to penetrate, ability to complete intercourse, and partner complaints and support should be documented. The use of the International Index of Erectile Function-5 (IIEF-5) or the Disease Questionnaire Peyronie’s (PDQ), which is a newer, 15-item, validated instrument specific to Peyronie disease may be of use.
* '''Psychologic impact: Many men with PD experience emotional distress, depressive symptoms, and relationship difficulties.''' PD can have a profound negative impact on men’s QoL.
** Based on bother/psychologic impact, consideration may be made for referral to a mental health professional with expertise in sexuality.
* Prior Peyronie disease and ED treatments should be documented.
*'''AUA Guidelines: “The recent onset of penile curvature and varying degrees of penile pain, without a palpable penile abnormality, in the non-erect state, may be considered diagnostic”'''
* '''<span style="color:#ff0000">A diagnosis of ED or failed first- and second-line ED treatments warrants ruling out Peyronie disease</span>'''

==== Physical exam ====
[[File:Peyronie's disease.jpg|alt=Patient with ventral penile curvature.|thumb|Patient with ventral penile curvature. Source: [[commons:File:Peyronie's_disease.jpg#/media/File:Peyronie's_disease.jpg|Wikipedia]]]]
* '''<span style="color:#ff0000">Penis</span>''' 
**'''<span style="color:#ff0000">Should be examined on stretch</span>'''
**'''Assess for palpable abnormalities'''
***'''<span style="color:#ff0000">Plaque(s) can be palpated or documented on ultrasound.</span>'''
*** '''Identify the location, size, number and tenderness of the plaque'''
**** '''<span style="color:#ff0000">Most common location of plaque is on the dorsal mid-shaft</span>'''
**** Measurement of size of the plaque with any modality, including imaging, has been found to be inaccurate
** '''<span style="color:#ff0000">Prior to any intervention, measurement of stretched penile length,</span> from the penopubic skin junction to the coronal sulcus or the tip is recommended to establish baseline penile length''' as penile length loss is a primary concern and contributor to distress for Peyronie disease patients
**Digital home photographic documentation may aid in objectively determining treatment effects, especially when non-surgical options are used

=== Laboratory ===

* '''Routine laboratory testing is not recommended'''
*Targeted bloodwork may be obtained in response to specific findings on history or physical examination (for example, signs/symptoms of hypogonadism)

=== Imaging ===

* '''Options'''
** '''Ultrasound'''
*** '''Benefits (4):'''
***# '''Identification and measurement of calcification during initial surveillance in the flaccid state'''
***#* Calcification may occur early after the onset of the scarring process, not necessarily only in chronic/mature disease.
***#* '''Men with extensive calcification are less likely to benefit from non-surgical treatment'''
***# Identification of corporeal fibrosis
***# Assessment of penile vascular flow parameters after intracavernosal injection of vasoactive agent
***# Observation of the erectile response to the vasoactive injection compared to the patient’s sexually induced erection; best opportunity to objectively assess deformity (curvature, girth irregularities, hinge effect)
*** '''CUA: colour duplex ultrasonography may be offered, but may not be readily available'''; combination of ultrasound with intracavernosal injection may also identify arterial insufficiency or veno-occlusive dysfunction, influencing choice of Peyronie disease management
*** Insert figure
** '''MRI''' 
***'''Excellent imaging modality for penile pathology,''' including PD
***'''Routine use in clinical practice is not supported'''
** CT and plain radiography do not have a role

=== Other ===

* '''<span style="color:#ff0000">Prior to any invasive intervention</span>''' (e.g., intralesional treatments or surgery) '''<span style="color:#ff0000">obtain accurate assessment of erection including (4):</span>'''
*#'''<span style="color:#ff0000">Erect penile length</span>'''
*#'''<span style="color:#ff0000">Degree of curvature</span>'''
*#'''<span style="color:#ff0000">Presence of hourglass deformities</span>'''
*#'''<span style="color:#ff0000">Rigidity of erection</span>'''
*'''<span style="color:#ff0000">Accurate assessment of erection can be obtained with</span>''' 
*#'''<span style="color:#ff0000">Digital photographs</span>'''
*#'''<span style="color:#ff0000">Examination after intracavernosal injection (ICI) of vasoactive agents, with or without duplex Doppler ultrasound (gold standard)</span>'''
*#* The ICI test enables assessment of penile deformity, plaque(s), and pain in the erect state.
*#* When the ICI test is combined with duplex ultrasound, additional measurements of plaque size and/or density can be made, calcified and non-calcified plaques can be differentiated, and information on the vascular integrity of the penis can be obtained.
* '''<span style="color:#ff0000">AUA prefers in-office intracavernosal injection (ICI) test with or without duplex Doppler ultrasound</span> but describes that home photography of the erect penis with the use of a protractor during an erection in the office may be sufficient to document deformity from some cases.'''
* '''CUA describes both as options but describes the use of ICI as the most reliable method and that penile injection remains the gold standard, especially in patients reporting complex deformity (hourglass or bidirectional curvature) or ED'''