Peyronie’s Disease often develops later in life and is distinct from other penile curvature conditions that are present from birth. Men often are shocked and embarrassed by the condition and do not seek treatment. Fortunately, this condition can be successfully managed and allow men to resume satisfying sexual intercourse.
The erectile mechanism of the penis consists of two long tubes called the corpora cavernosa that fill with blood during arousal. These tubes are covered by the tunica albuginea, a flexible but strong sheath that allows the penis to maintain its rigidity when erect. Penile curvature firms when part of the tunica albuginea becomes scarred and inflexible. This leads to an assymetry during an erection and a curvature in the direction of the scar of the tunica albuginea.
The most common curvature is upward, but men can experience curvature in any direction or even notice a point of their penis that is narrower than the rest, called an hour-glass deformity.
The amount of curvature, duration of the curvature and its impact on sexual intercourse are important considerations when deciding on treatment. The penis may appear to be normal when flacid so an examination of the penis while erect is often necessary. Photographs of the erect penis are helpful but many men will be examined after injection of an erectile agent into the penis to measure the curvature directly.
Phases of Peyronie’s Disease
There are generally considered two phases of Peyronie’s Disease, the immature and mature phases.
The Immature Phase generally occurs during the first year and is when the penis curvature is first noticed. This phase is characterized by inflammation and the degree of curvature can increase or resolve completely during this phase.
The classic ‘Peyronie’s Plaque’ can be felt as a thickening along the shaft of the penis and may be tender. Patients often report pain with erections.
The Mature Phase is considered to begin after the first year when the inflammation has subsided and the curvature is unlikely to change. There is usually no pain during this time and the plaque may be easier to feel. Surgical treatments are reserved for Peyronie’s disease that has entered the mature phase.
In addition to a thorough history and physical exam, an examination of the penis while erect and/or an ultrasound may be ordered during evaluation. In some cases labs will be ordered including a testosterone level.
Consists of several oral medications that are thought to help in reducing inflammation and leading to smaller, more flexible scar formation
Scientific evidence supportive of their use is limited and they are generally only used during the immature phase.
• Vitamin E (oral 1200u per day) is a widely used during the immature phase in the hopes of reducing the inflammation due to an anti-oxidant effect.
• Colchicine is a drug used to treat gout and may reduce inflammation by blocking the reproduction of inflammatory cells.
• Potaba (2 gm taken 6 times daily) is thought to help with the uptake of oxygen by the cells that form Peyronie’s plaque and reduce the amount of fibrosis (or scar tissue) that forms.
• Pentoxiphylline(400 mg three times/day) is a medication that is approved to reduce leg cramping due to blockage of the arteries to the leg but has been used by many physicians to improve the curvature in Peyronie’s patients during the immature phase.
Are used by many physicians as the first step in management during the mature phase. The following agents are injected directly into the Peyronie’s plaque. The injections occur directly through the skin, in the office after the penis is anesthetized. Most of the agents must be injected on several occasions over several weeks and is most effective when used with a penile straightening device.
• Verapamil is a calcium channel inhibitor used to treat hypertension. Injection into a Peyronie’s plaque is thought to alter the function of fibroblasts that are involved in the creation of scar tissue. Many patients will experience improvement in the degree of penile curvature after a course of verapamil injections. At North Austin Urology we generally recommend 12 injections performed every 10 days along with the use of a penile traction device. We will assist in securing insurance coverage as allowed for this treatment.
• Interferon can also be injected into a Peyronie’s plaque to achieve a similar response.
Is appropriate for those patients whose penile curvature is leading to pain for the patient or his partner, or is preventing complete penetration. The Plication and Grafting surgical procedures described below are only appropriate for men who are able to achieve a rigid erection. The erection can be obtained with pharmacological assistance but must be of sufficient rigidity to allow for penetration. For men that are unable to obtain an erection, an implantable penile prosthesis is a more appropriate treatment.
Plication is a surgical procedure appropriate for patients in the mature phase of a Peyronie’s curvature and involves placing sutures in the penis to ‘curve’ the penis straight. This method is generally considered fairly straightforward and easily tolerated. Upward curvatures are corrected by placing sutures on the bottom surface of the penis. Curvatures to the right or left are similarly treated with sutures on the opposite side. This form of treatment is fairly simple and quick to perform but can result in shortening of the penis that may not be acceptable in some cases.
Grafts are appropriate in cases of more severe penile curvature where the penile shortening from a plications procedure would be unacceptable. The procedure involves cutting or removing the Peyronie’s plaque and placing a piece of artificial material to allow the penis to fill with blood. The purpose of a graft is to add tissue to the curved side of the penis. There are several different types of graft material available designed to provide strength and flexibility and induce little to no inflammation.
The procedure is performed by carefully exposing the scar tissue under the skin of the penis, identifying and isolating the nerves that provide sensation to the head of the penis and placing the graft after either removing or incising the plaque. After the graft is sewn in place, an artificial erection is created to check the straightness of the penis.
Graft surgery is not appropriate for men that are unable to achieve a firm erection either naturally or with oral medications. For those patients, an inflatable penile prosthesis may be more appropriate.
For surgeons, please see my tips for using SIS grafts for Peyronie’s correction.
A Penile Prosthesis is a silicone mechanical device that replaces the erectile mechanism of the penis. Two cylinders provide rigidity to the penis and is filled with fluid held in a reservoir by depressing a pump located in the scrotum. It is used for men with the most severe curvature and for men who cannot achieve a rigid erection. The prosthesis placement is a surgical procedure that can be performed on an outpatient basis.