Peyronies disease (PD) is a surprisingly common disorder that can cause significant sexual problems. The main clinical symptom of the disease is curvature of a penis during an erection.
PD is a condition in which inflammation or scarring of the tough covering of the erectile portion of the penis leads to symptoms. It usually starts with inflammation and, over time, becomes scar and stabilizes. During this first, or inflammatory phase, patients may have pain (either just in the flaccid state or with erection), tenderness, a mass from the scarring, curvature or other deformities. Often, men notice that the process changes during this period. Men usually notice that the penis gets shorter and narrower, sometimes just at one part of the penis. This period lasts for a variable amount of time, ranging from months to years. Eventually, the disorder goes into the second, or stable phase. Usually the pain is gone (except sometimes during intercourse) and the deformity is stable.
No one knows the exact cause of PD. In general, we believe that it is an abnormal healing response to an injury (sometimes very minor). After this injury the body acts abnormally and causes inflammation and scarring.
It occurs in 3.5% to 9% of men, depending on age. Some research suggests that the disorder is more common in men who have had their prostate removed for prostate cancer (up to 15% of prostatectomy patients).
Several items are crucial to making sure you get the right diagnosis and treatment.
Diagnosis first starts with taking a detail history from the patient. Many practitioners will often use questionnaires to get further details on the patient’s symptoms.
In addition to the history, a physical exam is done and the deformity is documented. The patient may take a photograph of the erection at home or we can give an injection in clinic to give an “artificial erection” that can be examined.
Additionally, an ultrasound (safe, quick, and painless) can be helpful to assess the penile tissue and direct treatment strategy.
ED is VERY common with Peyronie’s disease, at least 50% of men with PD have some ED also. Since the scarring affects the tissue surrounding the erection bodies (and often affects the erection bodies themselves), men often have arterial (“inflow”) and storage (“outflow”) problems.
In the early stages the best treatments are medical, not surgical. There are many reported treatments for PD, but most have no data to support them. However, men are often desperate and will try anything, even if it is unlikely to help. This is unfortunate because, while there is no perfect medical treatment for PD, there are certain strategies that are more likely to help than others.
The treatment strategy depends on many factors and needs to be individualized for each patient. They may include pills, injections (a medication that goes directly into the affected area), and traction devices.
In the later stages, once the deformity is stable, treatment options include injections with medications to “dissolve the scar” or surgery. A patient only needs treatment if the deformity is enough that they cannot have intercourse (for example, if they have pain or their partner has pain) or if there is associated ED. The name of the medication to “dissolve” the scar is called Xiaflex. A patient requires a series of 8 injections, each of which are followed by penile “stretching” exercises at home. The research shows that patients experience around 30-35% improvement of curvature over the course of treatment.
For patients who want immediate and reliable results, or patients who fail Xiaflex therapy, surgical options exist. The actual surgical treatment depends on both the situation as well as patient goals. We have developed a chart that summarizes the different general surgical approaches.
Generally, surgical approaches include reconstructive and/or prosthetic surgery. The most popular reconstructive approach is to place permanent sutures in the penis on the opposite side of the curvature to straighten it out (“plication”). This approach has few risks but is very reliable in making the penis straight. It does not correct the following: 1) notches, waists, or other non-curvature deformities 2) length/width loss that is often associated with PD.
Alternatively, the plaque/scar can be expanded and a patch can be placed (“grafting”). Although this can correct other deformities and may possibly reclaim some of the length/width loss, there are significant risks associated with this approach including worsening ED (up to 40%, depending on the patient) and further scarring. This should only be performed by a surgeon who has extensive experience in this type of reconstruction.
If the patient has ED associated with PD or if the patient develops ED (e.g. after a grafting procedure), usually the best approach is with a penile prosthesis. This often corrects both the ED and the deformity at that same time. For other patients, the prosthesis does not fully correct the deformity and additional procedures must be done, such as plication or grafting. For a comparison of the benefits for each surgery option, please review the following link: http://www.turnsresearch.org/library-article/3-operations-for-peyronies-disease