Peyronie's Disease Treated with Oral Weekly Dexamethasone and Continuous Low-dose Cyclophosphamide

Sir,

Peyronie's disease, an acquired fibrotic inelastic scar of the tunica albuginea of the penis, causes different degrees of bending, narrowing, curvature, or shortening of the penis.[1] Clinically, it presents as a palpable penile scar in the flaccid condition, which is associated with penile pain, angulation, and erectile dysfunction. A myriad of medical therapies like pentoxifyllin,[2] colchicine, potassium amino benzoate, vitamin E, tamoxifen, and acetyl-L-carnitine systemically;[3] verapamil, clostridial collagenase, interferon-α-2b, corticosteroids, and hyaluronidase intralesionally,[4] and verapamil gel topically[5] have been used with variable success. We report a case of peyronie's disease treated by oral weekly dexamethsone (5 mg) two consecutive days weekly and cyclophosphamide (50 mg) daily orally.

A 53-year-old man presented with complains of painful erection with bending of penis for the past 1 month.

There was a single firm plaque with tenderness measuring 1 × 1 cm on the dorsal left side of the penis. There was penile angulation with basal bending of about 60% and coronal bending of 45%. Rest of the genitalia was normal.

A radiograph of the penis showed calcification in the posterior part of the penis, while penile urethrogram was normal.

Dexamethasone (5 mg) for two consecutive days weekly orally was started. The condition improved in the first 6 months with reduction in basal bending to 10% and coronal bending to 15%, but the condition became static thereafter during the next 2 months. At this juncture, cyclophosphamide (50 mg) daily was added, which lead to complete clearance of the angulations back to normal in 8 months along with complete resolution of the plaque. Radiograph of the penis showed no calcification. During the next 4 years of follow-up, there was no recurrence of any plaque or angulations of the penis.

François Gigot de Peyronie was the first to describe penile curvature in year 1743. Over the years, various medical and surgical therapies have been used to treat this condition with variable success.[2,3,4,5]

Our case of Peyronie's disease, cleared with dexamethasone (5 mg) given on two consecutive days weekly, orally over 14 months period along with cyclophosphamide (50 mg) daily, orally for 8 months period. There was no recurrence on follow-up after 4 years.

The present regimen includes oral mini pulse, as used by Pasricha and Khaitan,[6] for vitiligo, where betamethasone/dexamethasone (5 mg) is used for two consecutive days weekly. Subsequently, Radakovic et al.[7] used dexamethasone at the same dose for vitiligo. In the present study, dexamethasone was used in similar dose along with cyclophosphamide in later stage when no improvement was seen.

Pathophysiologically, peyronie's disease has been thought to result from vascular trauma to the penis, which triggers the release of cytokines that activate fibroblast proliferation and collagen production, the main matrix component of a Peyronie's plaque within the tunica albuginea.[8] The aetiology remains enigmatic. It has been reported in association with Dupuytren contracture. Its association with scleroderma and diabetes mellitus[9] point toward an autoimmune basis. This could probably explain the effectiveness of oral weekly dexamethasone with continuous cyclophosphamide therapy in this report.