Peyronie's Disease
What Is It and How Is It Treated?
by Culley C Carson, M.D.
Culley C. Carson, III, M.D. is Professor and Chief, Division of Urology, Department of Surgery at the University of North Carolina Medical Center, and is a member of the A.F U.D.'s Sexual Function Health Council.
Peyronie's disease is a benign condition that causes significant curvature and shortening of the erect penis. This process, produced by scar formation in the fibrous covering of the erectile bodies of the penis, occurs most often in men in their late forties and early fifties. Men can frequently feel a lump or area of scarring, or plaque, on top of the shaft of their penis. Symptoms may begin after an injury to the penis during sexual intercourse or from other trauma. Many men notice a period of tenderness in the top portion of the shaft of the penis, most often during erection and worsened by sexual intercourse.
Named for Francois de la Peyronie of France in the mid-eighteenth century, Peyronie's disease has occurred over the years with a probable increase in prevalence in the past decade. Studies in Olmstead County in Minnesota suggest that three percent of the male population over the age of 40 have scar tissue in their penis from Peyronie's disease. Only about half of these men, however, have significant enough scarring, curvature, erectile dysfunction, or penile shortening to require surgical reconstruction. The cause of Peyronie's disease remains a mystery although many investigators suspect that repeated injuries to the penis in men who tend to produce increased amounts of scar tissue may produce the changes associated with the condition.
In young men and in men with normal healing properties, when the erect penis is bent, the elastic, fibrous covering of the erectile bodies stretches, recoils, and injuries heal without scar tissue. In susceptible men, however, these repeated small traumatic events result in injuries or tears, which heal with the formation of scar tissue, felt as a lump or plaque on top of the shaft of the penis. Some men also have similar changes in the palms of their hands from repeat small trauma; a condition referred to as Dupuytren's contracture. The results of these traumatic events and this scar tissue is a tethering of the penis at the level of the scar, resulting in curvature that may vary from minor to significant. Some patients may also have indentations in the erect penis called "hourglass" deformity. They may suffer from decreased penile length and erectile difficulties with complete erectile dysfunction or decreased duration of erection. Peyronie's disease, while troublesome, is in no way related to sexually transmitted diseases, sexual practices, or cancer of the penis or other organs. Risk factors that may increase the possibility of Peyronie's diseases include Paget's disease of the bone, rheumatoid arthritis, use of vacuum erection devices, penile injection, urologic instrumentation, or catheterization.
Peyronie's disease is often self-limiting, running its course over 12-18 months. During this time, pain resolves spontaneously in four to six months, curvature may be moderate, and plaque may diminish or soften. This natural history of Peyronie's disease usually culminates in a stable, nonprogressive curvature, which may or may not need further treatment.
While therapeutic ultrasound was used empirically for this condition 25 years ago, this equipment, used often for physical therapy, has not demonstrated effectiveness in resolving plaque, curvature, pain, or penile narrowing. Treatment today begins with medications in an effort to improve would healing and soften the scar tissue associated with the plaque. These medications include vitamin E and Potaba (potassium para aminobenzoate). Vitamin E in combination with colchicine, a medication for gout, has also demonstrated effectiveness in some clinical studies. While medication such as tamoxafen and steroids have been used, clear clinical benefit has not been demonstrated. Successful treatment of the plaque with softening, decreased curvature, and decreased pain has been demonstrated with direct injection of medications into the Peyronie's plaque. While trials of collagenase have not been successful, verapamil has been widely used with moderate success. The use of alpha- interferon has also been tried with some success. These injection procedures require six injections directly into the Peyronie's plaque over a twelve-week period. Injection therapy, while effective in moderate and mild curvature, is unlikely to be successful in treating severe curvature or those patients with erectile dysfunction.
During the healing period and the period of evolution of the plaque, it is important for patients to continue to be sexually functional with erectile function and coitus, if possible. Many patients can remain sexually active as curvature may be mild to moderate and pain in the penis may resolve quickly. In those patients with continued pain and severe curvature or partner discomfort, surgery may be required to return the patient to functional sexual capacity.
If medical and expectant therapy fail to resolve the Peyronie's disease and the results of the Peyronie's plaque have produced significant decreased sexual function, surgery may be an alternative for restoring coital ability. Surgery should be delayed, however, until the disease has stabilized and curvature has not progressed for six months or longer. Usually, surgical intervention prior to 18 months after disease onset is not recommended as progression or resolution may subsequently alter the results of surgical prevention. Surgery is most often used in patients with severe Peyronie's disease that can not be treated by other, more conservative methods. Significant curvature producing coital discomfort for the patient or his partner, erectile dysfunction, severe, persistent pain, and hourglass deformity are all indications for surgical intervention.
The first, simplest procedure, termed "Nesbit" procedure, is performed by shortening the penis on the side opposite the curvature to cancel out the amount of the curve. This procedure, which has the fewest side effects, is not appropriate for patients with severe curvature or a very short penis, as it produces some shortening of the penis. Patients do, however, continue to have erections and sensation of the penis after the surgery. Ejaculatory ability is also preserved.
A more direct method for penile straightening is removing or cutting the plaque itself, straightening the penis, and replacing the tissue of the curved portion of the penis with a graft. This procedure, often termed the "Horton-Devine" procedure, requires more special surgical ability and experience, and is a longer, more complex surgical procedure.
In both of these procedures, an incision similar to a circumcision is usually used with retraction of the skin of the penis to the area of curvature. An erection is created in the operating room to allow the surgeon to identify the severity of curvature. In the Horton-Devine procedure, the nerves of the top of the penis are dissected away from the curvature and an incision is made in the curvature, or the plaque itself is removed. The graft inserted may be a vein, undersurface of skin (dermis), tissue from the lining of the testicle (tunica vaginalis), or a packaged material such as cadaveric pericardium. All of these graft alternatives provide a flexible expansile tissue to replace the rigid, scarred Peyronie's plaque. While both of these procedures are generally successful at straightening the penis and maintaining erectile function, a few patients will notice decreased sensitivity at the tip of their penis, recurrent curvature, continued penile shortening, or difficulty with erection.
The third procedure is performed only in those patients with significant erectile dysfunction and deformity caused by Peyronie's disease. In patients with inadequate erection, a simple straightening of the penis will not restore the patient's sexual function. As a result, placement of a penile prosthesis can straighten the penis and provide adequate rigidity of the penis for erection. This device, which is usually of the inflatable penile prosthesis variety, allows the patient's penis to be straight and rigid enough for intercourse. The urologist implanting this prosthesis may perform a penile modeling procedure, once the prosthesis is placed, to complete the penile straightening. This procedure, which breaks up the scar tissue fibers of the Peyronie's plaque during surgery, will enhance the straightening of the penis and improve ultimate postoperative results. Risks of this procedure, in addition to those mentioned previously, include infection of the prosthesis, mechanical malfunction or prosthesis leak, and repeat curvature. In a recent study presented at the American Urological Association Annual Meeting in Atlanta, Georgia, patients with Peyronie's disease and penile prostheses had high overall satisfaction rates and more than 80 percent of patients stated that they would undergo penile prosthesis again for treatment of their Peyronie's disease. A similar study investigating patients undergoing plaque incision and grafting demonstrated a more than 90 percent patient satisfaction rate.
Peyronie's disease is an uncommon condition whose prevalence is rising. Its symptoms, including penile curvature, shortening, pain, and erectile dysfunction, should initially be treated conservatively with a high expectation for improvement or resolution. In those patients with continued erectile difficulties from curvature or inadequate erections, surgical procedures designed to care for Peyronie's disease have been refined and are usually successful with high patient satisfaction outcomes.
