Peyronie’s Disease
Peyronie’s disease is a common problem (approximately 5% of all men) seen mostly in middle age, though men of any age are susceptible. It is not to be confused with congenital penile curvatures that one might be born with, although both problems share the common trait of penile deformity that may require surgical correction. Men can also have curvature from actual penile fractures. Peyronie’s disease results from scarring of the tough tissue called the tunica albuginea that comprises the two erectile bodies of the penis, known as the corpora cavernosa. Dr. Engel describes the penis as a triple-barreled shotgun, with the top two barrels being the corpora cavernosum and the bottom one containing the urine channel or the urethra. The bottom one is called the corpus spongiosum and does supply blood to the head of the penis during erection. Normally, Peyronie’s disease affects only the top two bodies. Though a patient can sometimes recall an injury of some sort to the penis preceding the problem, usually during sexual activity, it most commonly forms spontaneously in men having less firm but still useful erections. It is theorized that small tears occur in the tunica albuginea during sex that the body heals by laying down scar. At times, this scarring can be part of a more global syndrome and is seen in patients with scarring of the tendons in their hands called Dupuytren’s contractures.
Symptoms of Peyronie’s Disease
A patient with Peyronie’s disease will first notice pain in the penis during erections, described as soreness that can, at times, be considerable. This is the inflammatory response that, usually within a few weeks or months of the pain starting, produces a scar that can be palpated in the flaccid penis. This scar is called a Peyronie’s plaque. Once the scar matures, the inflammation subsides, and the soreness usually resolves over time. As seen in the schematic shown, most plaques are located at the top of the penis and can usually be felt as a lump. Approximately 20% will eventually become calcified.
The hallmark of Peyronie’s disease is penile deformity. This is most commonly seen as a curvature of the erect penis produced as a result of the plaque not allowing expansion of the tunica albuginea at its location. However, this fixation can also cause waisting called hourglass deformity, shortening, indentation, or instability of the penis while erect. This instability is called hinging and can be particularly problematic in terms of performance. The deformity is dictated by the shape and location of the plaque, and as the plaque develops, the manifestation of the deformity can change. Peyronie’s disease rarely causes erectile dysfunction on its own unless severe but can amplify any degree of existing erectile dysfunction by replacing erectile tissue with a scar and thus disallowing free flow of blood throughout the entire corporal body, thus causing less rigidity. The problems of Peyronie’s disease and erectile dysfunction often go hand in hand, with the real issue being erectile dysfunction more so than what is often very mild Peyronie’s disease. Much focus is given during an initial office visit to determine which of the two makes the patient most unhappy. If erectile dysfunction exists, this becomes the main focus. Once addressed and the patient gets useful and reliable erections, often the significance of the actual Peyronie’s disease to the patient fades away.
It is important to understand that Peyronie’s disease often has as much or more of a psychological impact than a physical one. When first realizing the presence of Peyronie’s disease, many men panic, thinking that it will inevitably worsen, progress to images they have seen on the internet, and feel very insecure about the appearance of their erection. We have found that this psychological impact does not necessarily correlate to the actual degree of Peyronie’s disease. For this reason, we always ask for a photo of one’s best erection showing the most obvious deformity so that we can understand the severity of the physical problem before diving into the severity of the psychological problem.
Prognosis of Peyronie’s Disease
First and foremost, patients are reassured that the plaque is not a tumor and will not affect their lives negatively. In almost all cases, the pain resolves with time alone, and any curvature or deformity that exists does not progress to the point that it makes sexual activity difficult.
Once noticed, many patients seek advice from a Urologist, largely seeking reassurance. In almost all cases, the initial pain phase resolves with time, and any curvature or deformity that exists does not progress to the point that it makes intercourse difficult. It is the change to a man’s penis and the resulting fear that it will progress in severity to the rare worst-case scenario that often results in the most significant negative impact. Of all cases at presentation, approximately 20% will remodel and improve, 40% will remain stable, and 40% will worsen. But, even for those men that worsen, the minority will progress to the point where they need treatment to have fulfilling sexual activity. As you will read below, there are no easy, miraculous treatments besides surgery that will truly fix the deformity from Peyronie’s disease.
For this reason, we focus far more on offering ED treatments that improve erections than treatments for Peyronie’s disease. Again, once a man achieves a good erection, he typically no longer seeks help for penile scarring or deformity. Once a man can feel confident again in his erection, most get used to the usually mild curvature, and this just becomes their new normal. Of course, some don’t, or in some, the deformity makes the act of intercourse difficult. For these men, after erections are addressed, we move on to treatment.
Medications, Supplements, and Devices to Treat Peyronie’s Disease
It is anxiety, and not necessarily physical deformity, that tends to drive men to seek non-surgical treatment. Unfortunately, there are very little data to support using oral remedies for Peyronie’s disease. However, many men find the concept of accepting a minor curvature of the penis and not seeking some form of therapy unacceptable. A partial historical list of such remedies would include Potaba, colchicine, Vitamin E, marketed herbal remedies, Coenzyme Q, Pentoxifylline, and L-arginine. Dr. Engel does not discourage a man from trying these remedies as long as they are not overly expensive (Potaba) or cause side effects (colchicine). Pentoxifylline, an old anti-hypertensive named Trental, has the most recent literature with some scant data supporting its use. It must be taken several times a day. Vitamin E is the simplest remedy for a man to try, but again, it has little to support its use.
Also heavily marketed are traction devices with little data to support them. They are found on the internet and are often harmless to try. Traction is somewhat helpful but only in conjunction with injections (described below) that first soften the plaque, making it more susceptible to stretching. Again, if a patient is uncomfortable simply taking a wait-and-see approach, this is something a patient can try, but it is not encouraged in Dr. Engel’s practice due to poor efficacy. Shock wave lithotripsy to the penis is also an idea that is sometimes marketed but has been shown to be ineffective.
Dr. Engel believes that, in large part, only time and one’s body will determine if the plaque will worsen, remodel, stabilize, or calcify. Since, in most men, the problem is physically a minor one, we feel that de-emphasizing this rather than keeping the anxiety associated with it in the forefront by taking minimally effective meds several times a day, using a traction device or applying shock waves to no avail is the healthiest psychological approach.
Next Steps
After a typical six-month period of observation, which is often used to work on erections, the approach that Dr. Engel takes is to have the patient decide if their degree of deformity is getting in the way of sexual activity or not. A distinction is made between this physical problem and a situation where a man is suffering from the anxiety that can surround not knowing the future or a struggle with one’s body image. Once again, if the primary goal is to improve erections, we address this with ED treatments and not with Peyronie’s disease treatment.
However, there are times when more aggressive treatment for Peyronie’s disease is very reasonable. Generally, the first real steps include medicine injections directly into the plaque to soften the scar. This can be done to lessen curvature with a secondary hope of allowing for better blood flow distal to the plaque, which may improve erections. There are now three medicines with evidence of efficacy, and all are similar. Verapamil was the first to be shown to soften scar. It is an anti-hypertensive drug but can induce one’s scar cells, called fibroblasts, to remodel scar by producing collagenase, the body molecule that melts scar. These injections are inexpensive and generic and are Dr. Engel’s mainstay when no severe curvature exists. These are given as injections in the office every two weeks for a total of twelve injections. We look for efficacy after the sixth injection, and if the scar is softening, we proceed with the rest. Dr. Engel was among the first to use this in the DC area and has been using Verapamil for Peyronie’s since beginning practice in 1999.
Alpha-interferon injections have a similar effect. These are far less accessible and far less commonly performed than verapamil. More recently, an FDA-approved drug called Xiaflex was released and heavily marketed. This is a bacterial version of collagenase. To have this approved by insurance, specific parameters must be met in terms of curvature angle and duration of the problem. Dr. Engel will use this when approved but sees little advantage over verapamil after extensive experience with both. Xiaflex also carries with it some risk, including penile fractures and warnings that the patient is not to be sexually active during its use, which can be up to 24 weeks.
Patients must understand that with all injection therapy, in general, there is improvement just over 60% of the time and that improvement in curvature may not mean that the patient’s difficulty with intercourse is fully addressed. For instance, Xiaflex succeeded in showing that it can lessen curvature beyond the placebo. However, a typical success in their study may have been to reduce a 45-degree curvature to 40 degrees. Although this is an objective change, it is usually not the difference between a patient being happy or not, with happiness being the real goal. We institute a combined penile traction program with all injections, which has been shown to increase the success rate slightly. Also, injection therapy will not be successful if the plaque is calcified. The key to understand is that injections are often a good first step, but patients must understand that both verapamil and Xiaflex involve long 24 week treatment courses, do not actually make a penis straight and are certainly not one shot fixes as implied by advertising.
Surgery is far more efficacious than injection therapy, and the most common procedure offered due to its simplicity is called penile plication. Here, we expose the corporal bodies opposite the Peyronie’s plaque and place counterbalancing sutures to straighten the penis. It is a quick, outpatient procedure. Its downside is that the penis will be shortened to some degree based on the curvature. Thus, patients who choose this surgical option should have only mild to moderate curvature lest the shortening be significant. Most patients adjust to their slightly shorter length and are happy to have the problem solved.
For severe curvature, plication can still be performed. However, the degree of penile shortening here may be prohibitive. Here, there is a far more complex, highly specialized operation called incision and grafting, which Dr. Engel has performed many times. With incision and grafting, the plaque is exposed, incised, and lengthened. The defect is then patched with a graft material. Patients find this far more appealing but must understand that given the complexity, there are more risks involved, including a low but present risk of erectile dysfunction and penile numbness. Peyronie’s disease could also recur and cause further scarring. Dr Engel still does perform this surgery, but the general feeling is that this should be reserved for the most severe curvatures. Long-term follow-up in most experts’ hands shows that there still is often a contraction of the graft material such that the penis may still end up with a similar degree of shortening that would have been seen with a simpler plication procedure.
In large part, patients with severe Peyronie’s commonly also have severe erectile dysfunction. What has almost become the standard recommendation as a highly effective treatment that would correct the ED and the Peyronie’s simultaneously is the placement of a penile prosthesis. If the curvature is severe, this can also be combined with an incision and grafting procedure. If the curvature is less severe, plication can be performed during the penile prosthesis placement. Examples of these procedures can be found in our common procedures section of our site.
Dr. Engel is highly experienced in these approaches and would be happy to consult with you and find out which approach, if any, is right for you.
