Peyronie’s disease (PD) is characterized by scar tissue, also known as plaque, formation in the tough covering of the erectile cylinders in the penis.
It is thought to be caused by repetitive microtraumas that may lead to pain, worsening erections and penile deformities. Penile curvature or other more complex alterations, such as hour-glassing configurations, result from the scar being less elastic than the surrounding tissues during erection.
PD is typically split into two phases. The first phase is called the active phase, which usually lasts for about 9-12 months. The active phase is often marked by pain with erection and continued changes to the curvature. The second phase is called the stable phase, which is painless and characterized by curvature stability for at least 3 months.
Although difficult to assess precisely, the prevalence of PD is likely around 10% of men over 40 years old.
Causes and Risk Factors
Plaque formation is caused by changes in tissue characteristics around the erectile cylinders when healing from repetitive microtraumas. The microtraumas occur more frequently when engaging in sexually activity with reduced erections due to extra bending and compression. Some men are predisposed to plaque formation, including those men with a family history of PD and with a personal history of Dupuytren’s contracture in their hands.
When to Speak with a Urologist about Peyronie’s Disease
You should speak to a Urologist about Peyronie’s Disease if you are bothered by penile curvature, penile bump, or are having pain with erection.
What to Expect when Seeking Treatment
In addition to a history and physical examination, initial assessment includes laboratory testing to assess for low testosterone and early diabetes as well as penile ultrasound to check for plaque size and characteristics. Home photographs can be very helpful to better define the curvature and plan management. Sometimes an erection may be induced with injectable medication in the office to aid in measuring the exact curvature and determining erectile function.
The natural course of PD is variable. In terms of pain, 90% of men report resolution of pain after 12 months. In terms of curvature progression without treatment, 10% of men report resolution of curvature, 40% report worsening curvature and 50% report stable curvature at 12 months.
Observation may be appropriate your curvature is not bothersome, but if the deformity prevents you from having satisfactory sexual activity, then treatment should be pursued.
Ensuring maximum rigidity of erections for intercourse can be helpful in preventing further curvature. Oral medications such as Viagra or Cialis are important to maximize erection quality.
Limited therapies are available for men in the early, or active, phase of Peyronie’s disease while the curvature is still changing. Surgery is avoided in this phase because the curvature may continue progressing after straightening with surgery. This phase typically involves some pain with erections that can be managed with anti-inflammatory pain medications, such as ibuprofen.
No oral therapies or supplements have been FDA-approved to treat Peyronie’s disease. Some oral medications, such as pentoxifylline, are approved for other diseases and have been used to treat men in the active phase with small studies demonstrating a modest benefit.
Gentle penile modeling or penile physical therapy can be beneficial to men in the active phase. Modeling may include apply gentle pressure in the opposite direction of curvature during spontaneous erections. Sometimes, a vacuum-erection device is used for 30-60 seconds daily to physically stretch the penis and slowly decrease curvature. Traction devices (such as Restorex, SizeGenetics, Veromax) can also be used for 30 minutes daily instead of modeling.
Once your curvature is stable and has not changed for at least three months, more definitive treatments with injectable medications or surgery are possible. This typically happens around 12 months after your symptoms first start.
Xiaflex (collagenase from Clostridium histolyticum) is a medication designed to be injected into the scar tissue and dissolve it. Xiaflex is FDA-approved for men with stable curvature between 30 and 90 degrees, and is not approved for men with complex deformities, calcified scar or scar on the underside of the penis. Xiaflex involves up to 8 injections over 24 weeks and requires the patient to participate in modeling at home. Sexual activity must be avoided for 4 weeks following each injection. Trials have demonstrated 30% curvature improvement with average curve reduction by 18 degrees. About 80% of patients have significant penile bruising and swelling following injection and 1% of patients experienced penile fracture or serious disruption of the erectile cylinders.
Surgical procedures can provide immediate curvature resolution without the need for hospitalization. Penile plication is typically used for curvature less than 60-90 degrees and plaque incision and grafting is typically used for curvature over 90 degrees.
Penile plication tightens the side of the penis opposite the plaque to straighten the penis. Over 40 studies report between 90 to 100% improvement in curvature with penile plication. Few patients report changes to erectile function or penile sensation. The stitches may be palpable underneath the skin permanently. About 80% of patients have less than 1.5 cm decrease in stretched penile length while 20% experienced more than 1.5 cm decrease in penile length. Another study reports an average loss of length of 0.36 cm. Typically this is not an issue because patients are more easily able to engage in sexual activity with a straightened penis.
Plaque incision and grafting involves cutting into the scar tissue to release it and then patching the opened area. The vast majority of studies report curvature improvement over 90%. This procedure though risks changes to penile sensation (reports range from 0 to 25%) and erectile function (reports vary widely from decrease in erections to improvement).
In the event of poor erectile function in combination with bothersome curvature, implantation of an inflatable penile prosthesis may be your best option to correct both ED and PD at the same time with resolution of curvature in 85 to 100% of patients.