Dr. Williams' Urology Resource

A Guide to Men's Health, Reproductive Medicine, and Microsurgery

Peyronie's Disease

The following information is adapted from www.urologyhealth.org:

What is Peyronie's disease?

Peyronie's disease is an acquired inflammatory condition that leads to penile curvature. In some cases, hard plaques (scar tissue) form underneath the skin in the erectile tissue of the penis leading to penile curvature and/or pain.

What are the symptoms of Peyronie's disease?

There is great variability in this condition. Symptoms may include penile curvature, lumps in the penis, painful erections, soft erections, and difficulty with penile penetration due to curvature. The most common curvature is upward (dorsal) but may also be downward (ventral) or to the side (lateral). Some men have more than one plaque, which may cause complex curvatures. Some men have plaques that goes all the way around the penis that may cause a "waisting" or "bottleneck" deformity of the penile shaft. Patients often report shrinkage or shortening of their penis.

How common is Peyronie's disease?

It is reported that nearly 10% of men between the ages of 40 and 70 suffer from Peyronie's disease, however, the actual prevalence may be much higher due to patient embarrassment and limited reporting by physicians. Peyronie's disease can be a serious quality-of-life issue. Studies have shown that over 75% of men with Peyronie's disease have stress related to the condition. Unfortunately, many men with Peyronie's disease are embarrassed about the condition and choose to suffer in silence rather than speaking with their health care provider about it.

What causes Peyronie's disease?

The process by which Peyronie's disease occurs is still not entirely understood, but most experts believe that Peyronie's disease is likely the consequence of a minor penile trauma. The most common source of this type of penile trauma is thought to be vigorous sexual activity (e.g., bending of the penis during penetration, pressure from a partner's pubic bone, etc.) although injuries from sports or accidents may also play a role.

Injury to the tunica albuginea may trigger a cascade of inflammatory and cellular events resulting in a process called fibrosis, a medical term for formation of excessive scar tissue. This abnormal scar tissue in turn forms the plaque of Peyronie's disease.

Not all men who suffer occasional mild trauma to the penis develop Peyronie's disease. For this reason, most researchers believe that there must be genetic or environmental factors that contribute to the formation of Peyronie's disease plaques. Men with certain connective tissue disorders (such as Dupuytren's contractures or tympanosclerosis) and men who have a close relative with Peyronie's disease have a greater risk of developing the condition. Certain health conditions such as diabetes, tobacco use, or a history of pelvic trauma may also lead to abnormal wound healing and may contribute to the development of Peyronie's disease.

Peyronie's disease is in essence a derangement of normal wound healing. Because it is related to normal wound healing, Peyronie's disease is a very dynamic process early on but over time, the inflammatory changes may decrease. In fact, this disease is usually divided into two distinct stages. The first phase is the acute phase; this portion of the disease persists for six to 18 months and is usually characterized by pain, worsening penile curvature and formation of penile plaques. The second phase is the chronic phase where the deformity remains in a stable state. As in the first stage the deformity may interfere with sexual activity and there may be associated erectile dysfunction. Pain with erection has typically resolved during this phase.

How is Peyronie's disease diagnosed?

A physical examination is usually sufficient to diagnose Peyronie's disease. The hard plaques can usually be felt with or without erection. Pictures of the erect penis may also be useful in the evaluation of penile curvature. In some cases an ultrasound examination of the penis is used to characterize the plaque and check for the presence of calcification.

Medical and Non-surgical Treatment of Peyronie's Disease

In about 13% of cases, Peyronie's disease goes away without treatment. Many physicians recommend conservative (non-surgical) treatment for at least the first 12 months after symptoms present.

Men with small plaques, minimal penile curvature, no pain, and satisfactory sexual function do not require treatment.

Men with active phase disease who do have one or more of the above problems may benefit from medical therapy.

Oral Medications -- Historically, these include vitamin E, potassium amino-benzoate, tamoxifen, colchicine, and carnitine. Unfortunately, very few well designed clinical trials of medications for Peyronie's disease have been performed and therefore the true effectiveness of many of these treatments is unclear. Recently, pentoxifylline (Trental) has been shown in some studies to reduce plaque size in animal models.

Penile Injections -- Injecting a drug directly into the plaque of Peyronie's disease allows for higher doses of the medication and more local effects. A local anesthetic is given prior to the injection. Because plaque injection is a minimally invasive approach, it is a popular option amongst men with active phase disease and men who are reluctant to have surgery. Verapamil is a calcium channel blocker usually used in the treatment of high blood pressure but has also been shown to disrupt collagen production. Several uncontrolled studies have suggested that verapamil injection is an effective treatment for penile pain and curvature; unfortunately, there are no large scale placebo controlled trials of this treatment. Verapamil appears to be a reasonable and affordable treatment option for Peyronie's disease, but further controlled studies are needed to verify the effectiveness of this treatment. Other injectable medications that are being invesitgated are interferon and collagenase.

Xiaflex (collagenase) was approved by the FDA in 2013 as a treatment option for Peyronie's disease with a palpable plaque and curvature of at least 30 degrees at the start of therapy. side effects can include penile hematoma, penile swelling, and penile pain. Corporal rupture occured in 0.5% of patients in clinical studies. It should not be used in patients on blood thinners (except for low-dose aspirini) or with coagulation disorders. A treatment cycle consists of 2 injections, separated by 1 to 3 days. After the second injection, a penile modeling procedure is performed. The treatment cycle is repeated at approximately 6-week intervals up to 3 additional times (total of 4 cycles--8 injections and 4 modeling procedures). Clinical studies have demonstrated an average change in curve of about 33% with Xiaflex injections compared to about 20% without Xiaflex injections. Because of the risk of corporal rupture or other serious penile injury, providers must complete a Risk Evaluation and Mitigation Strategy (REMS) program.

Mechanical Stretching -- Both vacuum erection device therapy and external penile traction therapy have demonstrated measured improvements in girth, length and curvature after 6 months of daily stretch therapy. This treatment is often used incombination with oral medications and penile injections. An example of a traction device can be found at www.usphysiomed.com (D-316).

Surgical Treatment of Peyronie's Disease

Surgery is reserved for men with severe, disabling penile deformities that prevent satisfactory sexual intercourse. Most urologists recommend avoiding surgery until the plaque and deformity have been stable and the patient pain-free for at least six months. An evaluation of the penile blood supply using injection of erection producing medications is often done prior to any surgery. A penile ultrasound may be performed at the same time. These two tests permit assessment of whether or not the man has significant ED and may also provide important anatomical information that will help guide the choice of surgical procedure.

There are three general approaches to surgical correction of Peyronie's disease:

I. Procedures that shorten the side of the penis opposite the plaque/curvature (i.e. tunicaplication) -- These procedures are generally safe, technically easy, and carry a low risk of complications such as bleeding or worsening erectile function. One particular disadvantage of these approaches is that they tend to be associated with some loss of penile length. For this reason shortening procedures are generally preferred in men with mild or no ED, mild to moderate curvatures, and long penises.

II. Procedures that lengthen the side of the penis that is curved (i.e. incision/excision and grafting) -- These procedures are indicated when the curvature severe or there is significant indentation causing a hinge-effect or buckling of the penis due to the narrowed segment in the penile shaft. In these cases, the surgeon incises (cuts) the plaque to release tension. In some cases a segment of the plaque may be removed. After the plaque has been incised, the resulting hole in the tunica must be filled with a graft. These procedures can correct severe curvatures, in most cases without significant shortening of the penis. Unfortunately, this type of procedure is technically challenging and carries a risk of worsening erectile function. Therefore, lengthening/grafting procedures are typically not recommended except in cases of severe deformity in men with adequate erectile function at baseline.

III. Placement of penile prosthetic devices -- Placement of an inflatable penile pump or malleable silicone rods inside the corpora is the preferred treatment option for men with Peyronie's disease and moderate to severe erectile dysfunction. In most cases, implanting such a device alone will straighten the penis, correcting its rigidity. When device placement alone does not sufficiently straighten the penis, the urological surgeon may further straighten the penis by cracking the plaque against the rigid prosthesis or by incising the plaque and subsequently covering the incision with a graft material.

What can be expected after surgery for Peyronie's disease?

A light pressure dressing is typically left on the penis for 24 to 72 hours after the surgery to prevent bleeding and hold the repair in place. In some cases, patients will wake up with a catheter in the bladder but this is usually removed in the recovery room. Most patients are discharged later the same day or the following morning. The patient is also often given several days of antibiotics to reduce the risk of infection and inflammation and a pain medication for discomfort. In most cases surgeons recommend not engaging in sexual activity for at least 4-6 weeks after surgery, longer in some cases of complex repairs.

What are the most important things to know about Peyronie's disease?

Peyronie's disease is a poorly understood urological condition characterized by penile deformity and pain. Treatment for this condition needs to be individualized to each patient based on the timing and severity of the disease. The objective of any treatment should be to reduce pain, normalize penile anatomy so that intercourse is comfortable, and restore erectile function in patients who suffer from concomitant erectile dysfunction. The early phase of the disease is treated with either oral medications and/or plaque injections approaches. Vacuum and traction therapy is emerging as a potential valuable non-surgical treatment. The late phase of the disease is usually managed with surgery if penile deformity is preventing a man from enjoying sex. As medical researchers continue to develop basic and clinical research for a better understanding of this disease, more therapies and targets for intervention will become available.

Watch Dr. Williams perform surgery for Peyronie's Disease

Watch Dr. Williams perform placement of a 3-piece inflatable penile prosthesis

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