Peyronie’s Disease

Peyronie’s disease is caused by the formation of fibrous scar tissue within the penis. This is thought to occur most commonly as the result of repetitive trauma to penis, likely through intercourse. Some cases may be due to autoimmune phenomena. An inherited or genetic predisposition to the condition has also been suggested. The scar tissue formation arises within the wall of the erectile bodies of the penis, the paired corpora cavernosa. This can result in a palpable area of firmness within the penile shaft. This discoid shaped mass of variable size is the typical Peyronie’s plaque that characterizes the disease. The Peyronie’s plaque prevents distension of the corpora cavernosa during erection and may cause the penis to bend or curve in the direction of the plaque. In the early phase of Peyronie’s disease the plaque may be painful. In the later phases of the disease pain is not typical, however, some degree of curvature may persist long term. Mild degrees of penile curvature usually require no intervention. More severe degrees of curvature can make penetrating intercourse physically difficult or even impossible. Erectile dysfunction may result if the plaque compromises penile blood flow. Peyronie’s disease sometimes goes away on its own. But in most cases, it will remain stable or sometimes worsen over time. Treatment might be needed if the curvature is severe enough that it prevents successful sexual intercourse.

Symptoms

Peyronie’s disease signs and symptoms might develop gradually or arise suddenly. Early and late phases of the disease are recognized. The early or acute phase can be expected to last 6 months or so. Plaque formation and penile curvature will be present as they are in the chronic phase of the disease. Hallmarks of the acute phase include penile pain likely due to the inflammatory response within the penis responsible for inciting plaque formation. Secondly penile modeling, which refers to the changing degree and direction of penile curvature, is typical of the acute phase of Peyronie’s disease. As the disease enters the late or chronic phase the inflammatory response subsides. Pain typically dissipates and the degree and direction of penile curvature becomes fixed and unchanging. Erectile dysfunction and penile shortening can result long term from the scar tissue of Peyronie’s disease

Causes

The cause of Peyronie’s disease isn’t completely understood, but a number of factors appear to be involved. Repeated subtle injury to the penis is the generally accepted mechanism for the development of Peyronie’s disease. For example the penis might be damaged during sex, athletic activity, or as the result of an accident. However, in most cases no specific trauma to the penis is recalled. During the healing process scar tissue forms in a disorganized manner which leads to a palpable plaque, and, penile curvature.

Penile trauma does not always result in Peyronie’s disease. It is thought that certain patient specific characteristics may contribute to the formation of Peyronie’s plaques in any given individual:

Heredity. Peyronie’s disease can be hereditary. If a first degree relative has it, you are at increased risk of developing Peyronie’s disease

Connective tissue disorders. Dupuytren’s contracture, a form of connective tissue disorder leading to fibrous scar deposition in the palmar surface of the hands, is associated with a higher than normal incidence of Peyronie’s disease.

Age. Peyronie’s disease increases with age, especially in men over 55.

Smoking. May contribute to development of Peyronie’s disease.

Prostate Surgery. May contribute to development of Peyronie’s disease

Sequelae of Peyronie’s Disease

Penile curvature

Erectile dysfunction

Cosmetic concerns regarding penile curvature

Anxiety and/or stress about sexual performance, penile appearance

Difficulty with, or inability to perform, sexual intercourse

Infertility issues

Diagnosis

The diagnosis of Peyronie’s disease is generally made with a simple history and physical exam. Except in rare cases, when other disease processes are being considered, are any diagnostic tests necessary. While the diagnosis can often be made without diagnostic testing, of paramount importance in determining appropriate therapy is assessing the degree penile curvature, and, the location and amount of scar tissue in any individual patient. This may require nothing more than providing your physician with a photograph of your erect penis from the side and from above. If this is not possible or is inadequate, an injection into the shaft of the penis to cause it to become erect may be advised.

Treatment

Most cases of Peyronie’s disease do not require treatment. Intervention either medical or surgical may be indicated when Peyronie’s disease is associated with any of the following:

Penile curvature that limits or prevents sexual relations

The presence of erectile dysfunction

Moderate to severe penile curvature that is troubling to you

Medication

Collagenase. The only FDA-approved medication for Peyronie’s disease is collagenase clostridium histolyticum (Xiaflex). This medicine has been approved for use in adult men with moderate to severe penile curvature (defined as curvature > 30 degrees) and a palpable plaque. Xiaflex has been shown to improve curvature and bother associated with Peyronie’s disease. Administered by direct injection into the plaque, this treatment works by breaking down the scar tissue responsible for penile curvature. Up to 8 separate injections given over a period of several months may be necessary to achieve penile straightening. Xiaflex appears to be most effective when used in conjunction with daily penile “modeling,” which is the forcible bending of the penis in the opposite direction of the bend.

While other pharmacologic agents are sometimes used for treating Peyronie’s disease (verapamil, interferon, pentoxifylline, vitamin E, potassium ash, L-carnitine), none have been shown in randomized trials to be more effective than placebo in correcting penile curvature from Peyronie’s disease.

Surgery

Surgery may be an option if the deformity of your penis is severe, sufficiently bothersome, or prevents you from having sex. Surgery usually isn’t recommended until the condition has progressed to the chronic phase which may take up to a year or more after the onset of symptoms. The goals of surgery are to correct penile curvature, and, preserve or correct any erectile dysfunction. Common surgical methods include:

Plication. This refers to the placement of plicating sutures in the shaft of the penis opposite the side of the scar or plaque. This has the net effect of bending the penis back to a straight position, however, does so with the caveat of simultaneously shortening the side of the penis that receives the sutures. Penile shortening is a side effect that patients must understand and consent to if they are undergoing a plication procedure.

Plaque incision, or, excision and grafting. With this type of surgery, the surgeon makes one or more cuts in the scar tissue allowing the sheath to stretch out and the penis to straighten (plaque incision). Alternatively, plaque may need to be excised and a graft placed over the resulting defect (excision and grafting). In both cases, penile shortening is avoided. These procedures are generally reserved for severe penile curvature. Incisional and excisional procedures carry a significant risk of erectile dysfunction and may require simultaneous placement of inflatable penile prosthesis.