Overview: Peyronie's Disease

What is Peyronie's disease?

Peyronie's disease is a benign condition that causes significant curvature and shortening to 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 orplaque on the 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. Name for Fancois de la Peyronie of France in the mid-eighteenth century, the condition has occurred over the years with a probable increase in prevalence in the past decade. Studies in Olmstead County in Minnesota suggest that 3% of the adult male population over age 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.

What causes Peyronie's disease?

The cause of Peyronie's disease remains a mystery although many investigators suspect that repeated injuires to the penis in men who tend to produce increased amounts of scar tissue, many produce the changes assocaited with Peyronie's disease. 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 the top of the shaft of the penis. Some men also have similar changs 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 which may vary from minor to significant. 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 disease include Padget's disease of bone, rheumatoid arthritis, use of vacuum erection device, penile injection, urologic instrumentation or catheterization.

Peyronie's disease is often self-limiting, running its course over 12-18 months. During this time, pain usually resolves spontaneously in 4-6 months, curvature may be moderate and plaque size 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.

Types of Treatments

Oral

While therapeutic ultrasound was used empirically for this condition 25 years ago, this equipment used often by physical therapy has not demonstrated effectiveness in resolving plaque, curvature, pain, and penile narrowing. Treatment today begins with medications in an effort to improve wound 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.

Injection Therapy

Successful treatment of the plaque with softening, decreased curvature and pain have 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 modeate 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 12-week period. Injection therapy, while effective in moderate and mild curvature, is unlikely to be successful in treating severe curvature or 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 functional sexually with erectile function and coitus if comfortable. 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 patient to functional sexual capacity.

Surgical

If medical and expectant therapy fails 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 eighteen 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 cannot be treated by other, more conservative methods. Significant curvature producing coital discomfort for patient or partner, erectile dysfunction, severe persistent pain, and hourglass deformity are all indications for surgical intervention. Surgical procedures can be divided into three possible alternatives. The first, simplest procedure termed Nesbit procedure is performed by shortening the penis on the side opposite to the curvature to cancel out the amount of the curve. This procedure that has fewest side effects is not appropriate for patients with severe curvature or very short penis, as it produces some shortening of the penis. Patients continue, however, to have erections and sensation of the penis unaffected by the surgery. Ejaculatory ability is also preserved. A more direct method for penile straightening is removal or incision (cutting) of the plaque itself, straightening of 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, 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, 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, simple straightening of the penis would not restore the patient's sexual function. As a result, placement of an penile prosthesis can straighten the penis and provide adequate rigidity of the penis for erection. This device which is usually of the inflatable penile prothesis 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 reported at the American Urological Association Annual Meeting, patients with Peyronie's disease and penile prostheses had high overall satisfaction rates and more than 80% 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% patient satisfaction rate.

Summary

Peyronie's disease is an uncommon condition whose prevalence is rising. The symptoms of penile curvature, shortening, pain, and erectile dysfunction should be treated initially 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.