A 34-year-old man comes to the office due to erectile dysfunction. For the past 2 months, he has had pain and penile curvature during erections, which has made vaginal penetration difficult and has started to adversely affect his self-esteem. The patient has had no urethral discharge or other symptoms. He smokes a pack of cigarettes daily and does not use alcohol or illicit drugs. The patient has had a total of 5 female sexual partners. Vital signs are within normal limits. Cardiopulmonary examination shows no abnormalities. The abdomen is soft and nontender with no masses. There is no inguinal lymphadenopathy. A palpable plaque is present on the dorsal side of the penis approximately half way between the glans and the pubis. The testes are normal with no scrotal erythema or skin ulceration. Which of the following is the most likely diagnosis?

Question

A 34-year-old man comes to the office due to erectile dysfunction.  For the past 2 months, he has had pain and penile curvature during erections, which has made vaginal penetration difficult and has started to adversely affect his self-esteem.  The patient has had no urethral discharge or other symptoms.  He smokes a pack of cigarettes daily and does not use alcohol or illicit drugs.  The patient has had a total of 5 female sexual partners.  Vital signs are within normal limits.  Cardiopulmonary examination shows no abnormalities.  The abdomen is soft and nontender with no masses.  There is no inguinal lymphadenopathy.  A palpable plaque is present on the dorsal side of the penis approximately half way between the glans and the pubis.  The testes are normal with no scrotal erythema or skin ulceration.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

This patient's dorsal penile plaque and pain/curvature with erection likely indicate Peyronie disease (PD), a common condition (affecting ~5% of men) that arises due to repetitive blunt trauma to the penis during sexual intercourse with subsequent aberrant wound healing. It is characterized by the formation of fibrous plaques (due to transforming growth factor-1 upregulation) in the tunica albuginea, which reduce tissue elasticity and expansion during erections. tunica albuginea Manifestations generally include penile pain, curvature, and dorsal nodules or plaques. Distortion of the penis during erection may make sexual intercourse difficult or impossible, leading to body image and relationship issues. Most cases are diagnosed based on clinical findings, but ultrasound is sometimes necessary. In many individuals, the pain and deformity resolve spontaneously over 1-2 years. However, those with active or progressive PD often require nonsteroidal anti-inflammatory drugs for pain; pentoxifylline to reduce fibrosis; and/or intralesional injections of collagenase. Surgery may be indicated in refractory cases. (Choice A) Genital warts (condyloma acuminata) typically present with clusters of small pink or skin-colored papules. Although plaques can occasionally occur, they are usually painless and do not result in erectile curvature. (Choice B) Bowen disease (cutaneous squamous cell carcinoma in situ) may develop on the penile shaft but typically presents as a painless, erythematous plaque. It may progress to penile cancer, which is most common in older men (age >60) and usually presents as a painless ulcer/nodule with inguinal adenopathy. (Choice D) Systemic sclerosis can cause skin induration and fibrosis, but it primarily affects the hands, fingers, and face. Vascular manifestations such as Raynaud phenomenon and telangiectasias are often prominent. (Choice E) Primary syphilis is associated with a painless genital ulcer. Tertiary syphilis may cause mucocutaneous plaques (gummas), but the lesions are typically painless and often ulcerate. Educational objective: Peyronie disease is an acquired disorder characterized by fibrosis of the tunica albuginea of the penis, which restricts tissue expansion and flexibility during erections. Manifestations often include penile pain, curvature, and/or dorsal nodules/plaques; distortion of the normal erectile shape of the penis may make sexual intercourse difficult. References: Peyronie's disease: a literature review on epidemiology, genetics, pathophysiology, diagnosis and work-up. (http://www.ncbi.nlm.nih.gov/pubmed/27298774)

A 34-Year-Old Man Comes to the Office Due to Erectile