Tunical plication in the management of penile curvature due La Peyronie’s disease. Our experience on 47 cases
© Iacono et al; licensee BioMed Central Ltd. 2012
Published: 15 November 2012
Skip to main content
© Iacono et al; licensee BioMed Central Ltd. 2012
Published: 15 November 2012
Peyronie’s disease is an acquired connective tissue disorder of the penile tunica albuginea with fibrosis and inflammation. The disease produces palpable plaques, penile curvature and pain during erections. Patients report negative effects in four major domains: physical appearance and self-image, sexual function and performance. These changes damage sexual life and compromise the quality of life. Our objective is to review the patient's sexual life after penile tunical plicature using the International Index of Erectile Function (IIEF) and the Sexual Encounter Profile (SEP) questionnaires.
A total of 47 patients with Peyronie's disease (PD) were enrolled at our urology department and they underwent correction of penile deviation between February 2009 and March 2010. Mean patient age was 56 years and mean follow-up was 24 months. Patients with painless PD plaque with no progression in angulation for at least 12 months were chosen for surgery. They underwent a penile tunical plication.
IIEF and SEP questionnaire were administered to all patients.
Of all treated patients, 94% were able to insert their penis in the partner's vagina (p<0.01; SEP question 2), compared with 62% preoperatively and 90% of them was satisfied overall with the sexual intercourse (p<0.01; SEP question 5) .Patients had a significantly higher endpoint and a greater change from baseline for the remaining SEP questions related to achievement of an erection, satisfaction of erection hardness (SEP questions 1 and 4; p < 0:001).
We reported a significant improvement in the IIEF scores (from a baseline total score of 25.2 +/- 3.2 to a final score of 38.3 +/- 5.2; P<0.01). It resulted in significantly higher endpoint IIEF scores across all five IIEF domains: Erectile Function, Intercourse Satisfaction, Orgasmic Function, Sexual Desire and Overall Satisfaction. The main complaint was penile shortening (28 patients, 60%), feeling of the suture during flaccidity and tumescence (37 patients, 80%).
Patient quality of life improved after surgery thanks to the improvement of their sexual life. The complications are unimportant and few bother symptoms are reported. The significant improvement in erectile function was also supported by IIEF and SEP questionnaire data. Nowadays tunical plication is a safe, advantageous and useful technique to treat patients suffering of Peyronie’s disease.
Peyronie's disease (PD) is a poorly understood connective tissue disorder most commonly attributed to repetitive micro-vascular injury or trauma during intercourse and it is characterized by an inflammatory response beneath the tunica albuginea with fibroblast proliferation where the normal elastic tissue of the tunica is replaced by scar tissue  forming a thickened fibrous plaque. The penile plaque, or scar tissue in this condition, is not elastic but hard and will not stretch with erection. The side that does not stretch results in penile curvature on the side of the scar .
The prevalence of PD ranges between 3 and 9% of adult men with the most common age of presentation in the fifth decade [3, 4]. Recent studies have documented that in 10-15% of men with PD, the condition will resolve spontaneously over 1 year after the diagnosis is made, with 40% remaining the same and approximately 45% progressing [5, 6]. Despite progress in the understanding of PD on several fronts, it remains a physically and psychologically devastating condition for the affected patient and partner and it can often lead to an erectile dysfunction . The psychological aspect of both patient and partner are underrepresented in literature; data extracted from select Internet websites have better established PD effects on psyche and relationships . In the presence of severe curvatures, the deformity of the penis interferes with penile penetration, resulting in difficult coitus. Patients with this condition frequently report shame, embarrassment and interpersonal difficulties . Diagnosis is based on medical and sexual histories, which are sufficient to establish the diagnosis. Physical examination includes assessment of palpable nodules and penile length . Curvature is best documented by a self-photograph or pharmacologically induced erection. Prevalence approaches 5%, while less than 20% of men report spontaneous resolution of deformity . Conservative treatment for PD is associated with poor outcomes and surgery is indicated when PD is stable for at least 3-6 months . So far, there have been three basic categories to the surgical approach: shortening procedures on the convex side of the tunica albuginea using tunical excision or plication (Nesbit and its modifications, dot-plication and Yachia procedures); lengthening procedures on the concave side of the tunica albuginea using a graft (with or without plaque incision/excision) are preferred in more severe curvatures or in complex deformities ; or implantation of penile prosthesis combined with auxiliary procedures . Essed-Schroeder plication is an established operative technique to correct congenital and acquired penile deviation. However, a third of all patients complain about discomfort from the suture material used . We prospectively evaluated patient satisfaction, quality of life and erectile function after Essed-Schroeder plication by using IIEF and SEP questionnaire.
A total of 47 patients with PD were enrolled at our urology department and they underwent correction of penile deviation between February 2009 and March 2010. Mean patient age was 56 years +/- 21 and mean follow-up was 24 months. Patients with painless PD plaque with no progression in angulations for at least 12 months were chosen for surgery. Preoperatively penile curvature was greater than 30 degrees in all patients, as documented by auto-photography using the Kelami technique . Several self-administered patient questionnaires assist in the evaluation of sexual function. One instrument in wide use is the International Index of Erectile Function (IIEF) . A 15-item questionnaire, the IIEF addresses the 5 relevant domains of male sexual function: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction. The IIEF has been reported to be brief and reliable, psychometrically sound, and easy to administer in both research and clinical settings. It is available (and cross-culturally validated) in 10 languages and demonstrates adequate sensitivity and specificity for detecting treatment-related changes in erectile function . Patients also recorded efficacy information after each sexual encounter by answering 5 yes/no questions in their Sexual Encounter Profile (SEP) diaries. Of primary interest for this study were responses to SEP Question 2: ‘‘Were you able to insert your penis into your partner’s vagina?’’ and SEP Question 3: ‘‘Did your erection last long enough for you to have successful intercourse?’’. Detailed information on possible postoperative discomfort or pain from suture knots, initial irregularities of the penile shaft and penile shortening was provided to the patients preoperatively. Surgery was performed with the patient under epidural anesthesia. The surgical procedure started a coronal incision to 0.5-1cm from the gland line would allow to let intact an adequate amount of reflection of skin (prepuce) bound of preputial skin reflection , maintaining good vascularity and it was completed with a circumcision to prevent foreskin necrosis, phimosis or paraphimosis. A tourniquet was set at the base of the penis. Artificial erection was induced by injection of sterile saline solution into the corpora cavernosa through a 19 gauge butterfly needle to determine the degree of deviation. The careful degloving with preparatory isolation of the dissection plan between dartos and Buck's fascia reduced vascular trauma of the fascia, minimizing bleeding and ensuring tissue vitality. The effect of tunical plication was simulated using Allis clamps with care taken to protect the dorsal neurovascular bundle and its branches. Essed-Schroeder tunical plication using the inverted stitch technique was performed according to Knispel et al. . A 3-zero Polypropylen suture was used for 6 (3 + 3) inverted plication sutures applied contralateral to the maximum point of curvature to straighten the deviation. For ventral curvature the same procedure was performed by subtle isolation and careful lifting of the neurovascular bundles. Artificial erection was then repeated to confirm adequate repair. Buck's fascia is approximated in the midline with interrupted 3-zero quick absorption sutures and skin was closed with interrupted 4-zero quick absorption sutures. Moreover we think that the execution of only two hydraulics erections, after degloving and correction, may cause a minimal tissue stress. At the end a circular dressing with light pressure was applied for 24 hours and a catheter was applied and removed the following day. Patients were advised to have no sexual activity for at least for 6 weeks.
IIEF scores before and after surgery. P value <0.01
Patients N° 47
IIEF Total score
21.2 +/ 3.2
4.2 +/- 0.4
5.3 +/- 0.8
4.5 +/- 1.2
4.7 +/- 1.2
2.3 +/- 0.8
38.3 +/- 5.2
10.8 +/- 2.0
5.6 +/- 0.9
6.5 +/- 1.4
9.2 +/- 2.0
6.2 +/- 1.8
17.1 +/- 2.0
6.6 +/- 1.2
0.3 +/- 0.1
2.0 +/- 1.0
4.5 +/- 0.8
3.9 +/- 1.0
SEP scores before and after surgery. P value <0.01
Patients (pts) N° 47
N° patients ''yes'' response to SEP 2
N° patients ''yes'' response to SEP 3
N° patients ''yes'' response to SEP 5
28 pts (62%)
20 pts (43%)
12 pts (25%)
44 pts (94%)
30 pts (64%)
42 pts (90%)
16 pts (16%)
10 pts ( 21%)
30 pts (75%)
Patient quality of life was increased after surgery thanks to the improvement of their sexual life. Complications are few and the few bother symptoms regard the penile shortening and suture feeling under penile skin. For the all domains of IIEF, erectile function, intercourse satisfaction, orgasmic function, sexual desire, and overall satisfaction, treated patients had a significantly higher endpoint and a greater change from baseline across all domains compared to results before surgery. The significant improvement in erectile function was also supported by other efficacy measures. Increases in the proportion of positive responses of IIEF and SEP questions concerning patients’ improvement in erections, ability to penetrate their partner, and ability to maintain erection to successful completion of intercourse were significantly higher for treated patients after surgery. Furthermore, based on the SEP questions related to satisfaction of erection hardness and overall satisfaction with the sexual experience in this study, treated patients had a significantly higher endpoint and a greater change from baseline after surgery. So we think that tunical plication is a safe, advantageous and useful technique to treat patients suffering of PD.
International Index of Erectile Function
Sexual Encounter Profile.
This article has been published as part of BMC Surgery Volume 12 Supplement 1, 2012: Selected articles from the XXV National Congress of the Italian Society of Geriatric Surgery. The full contents of the supplement are available online at http://www.biomedcentral.com/bmcsurg/supplements/12/S1.
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.