Peyronie’s Disease

Peyronie’s disease is a medical condition characterized by the development of a lump on the shaft of the penis. This lump is a scar (plaque) that forms on the lining (tunica albuginea) of the penile erectile body (corpus cavernosum). It is believed to be the result of direct injury to the penis. Early on following the trauma, an inflammatory reaction occurs, often bringing a man’s attention to the problem because of pain associated with his erection. With time, the inflammation progresses, and a scar develops.

The time to develop this scar and the degree to which it occurs varies from patient to patient. Often the process heals itself over the first 12 months. In some cases, however, the scar formation is severe. In these cases, the scar becomes progressively harder and more obvious, causing the penis to curve during erection. While the scar is benign (non-cancerous), the resulting curvature may lead to the inability to have sexual intercourse. This may also interfere with one’s ability to get and maintain an erection.

Originally, the incidence of Peyronie’s disease was estimated to be approximately 1-3%. More recent research suggests that the incidence is far higher, at approximately 8.9%. This same research estimates that roughly one third of patients do not even know they have this condition.

Risk Factors

Peyronie’s disease occurs in about 10 percent of middle-aged men; however, younger and older men can also be affected. In some cases, men who are related tend to develop the disease, which means the disease may be inherited.

The cause of Peyronie’s disease isn’t completely understood, but a number of factors appear to be involved. It’s thought Peyronie’s disease generally results from repeated injury to the penis. For example, the penis might be damaged during sex, athletic activity or as the result of an accident. However, most often, no specific trauma to the penis is recalled.

During the healing process, scar tissue forms in a disorganized manner, which might then lead to a nodule that you can feel or development of curvature. Each side of the penis contains a sponge-like tube (corpus cavernosum) that contains many tiny blood vessels. Each of the corpora cavernosa is encased in a sheath of elastic tissue called the tunica albuginea, which stretches during an erection. When you become sexually aroused, blood flow to these chambers increases. As the chambers fill with blood, the penis expands, straightens and stiffens into an erection.

In Peyronie’s disease, when the penis becomes erect, the region with the scar tissue doesn’t stretch, and the penis bends or becomes disfigured and possibly painful.

While trauma is believed to be the initial event, many theories have been proposed for the pathogenesis of Peyronie’s disease, including: auto-immune factors, excess production of chemicals (known as cytokines) in the tissue of the penis, and abnormalities of cell behavior. Peyronie’s disease appears to be more common in certain ethnic groups, particularly northern European Caucasians; it is uncommon in African-American men and rare in Asian men.

Risks of Peyronie’s Disease include advanced age, diabetes, and erectile dysfunction. It is also believed that there is an association between Peyronie’s disease and Dupuytren’s disease (aka Dupuytren’s contracture). Dupuytren’s disease is a scarring (fibromatosis) of the hand leading to hand deformities. Between 10-20% of men with Peyronie’s disease will also have Dupuytren’s disease.

Having prostate cancer surgery is also a risk factor for developing Peyronie’s disease. As many as 16% of men undergoing surgery for prostate cancer may develop Peyronie’s disease within 3 years of having surgery.

Symptoms

The plaques of Peyronie’s disease most commonly develop on the upper (dorsal) side of the penis. Plaques reduce the elasticity of the tunica albuginea and may cause the penis to bend upwards during the process of erection. Although Peyronie’s plaques are most commonly located on the top of the penis, they may also occur on the bottom (ventral) or side (lateral) of the penis, causing a downward or sideways bend, respectively. Some men have more than one plaque, which may cause complex curvatures.

In some men, an extensive plaque that goes all the way around the penis may develop. These plaques typically do not cause curvature but may cause a “waisting” or “bottleneck” deformity of the penile shaft. In other severe cases, the plaque may accumulate calcium and become very hard, almost like a bone. In addition to penile curvature, many patients also report shrinkage or shortening of their penis.

Since there is great variability in this condition, men with Peyronie’s disease may complain of a variety of symptoms. Penile curvature, lumps in the penis, painful erections, soft erections, and difficulty with penile penetration due to curvature are common concerns that bring men with Peyronie’s disease to see their doctors.

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.

Evaluation and Diagnosis

A physical examination by an experienced physician is usually sufficient to diagnose Peyronie’s disease. The hard plaques can usually be felt with or without an erection. It may be necessary to induce an erection in the clinic for proper evaluation of the penile curvature; this is usually done by direct injection of a medication that causes penile 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.

Treatment

Urologists often opt to treat the disease without surgery while Peyronie’s disease is in the early, or active phase. Men with small plaques, not much curvature, no pain, and no problems with sex may not require treatment at all.

If your symptoms are severe or are worsening over time, your doctor might recommend medication or surgery.

Oral Medications

Unfortunately, no oral treatments have been proven to work better than a sugar pill for Peyronie’s.

Oral treatments that have been proven not to work include:

• Oral vitamin E
• Oral tamoxifen
• Oral procarbazine
• Oral omega-3 fatty acids
• Oral vitamin E with L-carnitine

There are other oral treatments that need more study to see if they work. They include:

• Oral colchicine
• Oral pentoxifylline
• Oral potassium aminobenzoate (“Potaba”)
• Oral co-enzyme Q10

Penile Injections

Injecting a drug into the plaque brings higher doses of the drug directly to the problem. An injection is an option for men with acute disease who aren’t sure that they want surgery.

These injections have been shown to help some men:

• Collagenase injections are used to break down certain tissues. A new drug, (Xiaflex), is now approved in the U.S. for men with a dorsal (upward) curvature more than 30 degrees.
• Verapamil injections are mostly used to treat high blood pressure. Some studies show that it may be a good, low-cost option for penile pain and curvature.
• Interferon injections are used to help control scarring. It can slow down the rate that scar tissue builds and make an enzyme that breaks down the scar tissue.

Surgery

Surgery is an option for men with severe penile curvature that find it difficult to have sex. Most providers want to wait before considering surgery. It’s an option after the plaque and curvature stop getting worse and stop causing pain.

There are three surgeries used to help men with Peyronie’s Disease:

Penile Plication Procedures — This group of procedures generally involves performing a tuck procedure on the side opposite to the scar (plaque). Its advantages include its simplicity, excellent preservation of preoperative erection ability, and high patient satisfaction. The disadvantages include loss of penile length, which in the medical literature is reported to occur in 46-100% of patients. Patients who are considered excellent candidates for this procedure include those with ample penile length who have a simple curvature without any other associated deformity (i.e. hour-glass).

Plaque Incision/Excision and Grafting — This group of procedures involves the complete or partial excision of the plaque, or its incision with the placement of a graft into the space left by the excision/incision technique. Multiple graft materials have been used, including dermis, cadaveric fascia, cadaveric pericardium, saphenous vein, and intestinal submucosa. The advantage of this approach is that it is typically not associated with loss of penile length. Its disadvantages include the development of postoperative erectile dysfunction in men with poor erectile function preoperatively, and prolonged loss of penile sensation in approximately 10% of men. Ideal candidates for this approach are men with complex penile curvatures who have normal erectile function preoperatively. Men who present with hour-glass deformity are also best served by plaque incision and grafting.

Penile Prosthesis Surgery — The placement of a penile implant allows immediate correction of the penile curvature as well as permitting fully rigid erections. It is associated with excellent postoperative patient satisfaction rates. It is reserved for men with combined erectile dysfunction and penile curvature.

Other Treatments

Penile traction, iontophoresis, extracorporeal shockwave therapy (ESWT), and radiation therapy are other treatment approaches to Peyronie’s disease (PD), but none have been shown to be conclusively effective in randomized trials. Well-designed studies are needed to document a treatment effect, should it exist, prior to widespread use.