What is Peyronie’s Disease?
Peyronie’s disease is an acquired penile deformity (curvature) due to scar tissue in the penile shaft. This can cause penile pain and discomfort, can reduce or diminish the quality of erections, can complicate sexual intercourse, and can cause significant psychological burden for affected men and their sexual partners.
Peyronie’s disease is characterized by the development of fibrotic plaque in a man’s penis that leads to a constellation of potential symptoms including penile curvature, deformity, shortening, pain, and erectile dysfunction.
Peyronie’s disease can be found in up to 8.9% of men, most often occurring among men in their 50’s to 60’s but may occur in men of all ages. Peyronie’s is different than congenital penile curvature, as the latter is present since the time of birth, where Peyronie’s is acquired later in life. Some men will have penile pain associated with the onset of symptoms. Curvatures can range in severity from a slight bend to significant curves greater than 90 degrees.
Peyronie’s disease can be very distressing to both the man and their partner. In fact, among men completing depression questionnaires, nearly 50% meet the threshold for clinically meaningful depression, and just over 50% of men report relationship stress because of their Peyronie’s disease. Studies have also found that men with Peyronie’s often feel isolated and have difficulties communicating their symptoms to health care professionals. It is important to let the doctor know if you are feeling depressed so that a referral can be made to a mental health expert.
What Is the Natural History of Peyronie’s Disease?
Peyronie’s disease is variable among men. Based upon studies in the literature, we know that over the course of 1-year complete resolution of penile pain occurs in nearly 90% of men. With respect to penile curvature, only 12% of men will report improvement over 1 year if left untreated, while 21-40% will report no change in symptoms and 48-76% will report worsening curvature. Unfortunately, physicians’ abilities to predict those men who will improve or worsen is limited based upon available data.
What Causes Peyronie’s Disease?
The underlying cause for Peyronie’s is not known and is under investigation in doctor’s labs around the world. What is known, is that the cells present (i.e. fibroblasts) in the structural lining (i.e. tunica albuginea) of the erectile chambers (i.e. corpora cavernosa) function irregularly and produce abnormal amounts of collagen and fibrin leading to plaque formation. Normally, when the penis changes from a soft/ flaccid state, to an erect state, a series of neurochemical reactions occur that result in more blood entering the penis than leaves. For this to occur, the smooth muscle in the penis must relax and expand, as does the tunica albuginea (lining of these erectile chambers). However, the lining that has a Peyronie’s Plaque cannot stretch and expand like the remaining normal penis; thus, as the erection expands in length, the non-expanding plaque causes that section to be shorter than the opposite side resulting in a curve. Similarly, as the penis expands in girth with an erection, the plaque fails to expand and stretch and may result in an indentation, narrowing or tapering. Peyronie’s may also lead to erectile dysfunction by preventing normal relaxation and trapping of blood in the penile chambers (i.e. corpora cavernosa) at the site of Peyronie’s plaque.
Some conditions have an association with Peyronie’s, through either a personal history or family history. These include: Dupytren’s contractures, Ledderhose disease, and tympanic sclerosis.
Making the Diagnosis.
In most cases, based upon history and physical examination the doctor will be able to make the diagnosis. When the penis is flaccid, one may be able to palpate the ‘plaque’ or site of fibrosis on the penis; however, curvature to one’s penis and deformities can only accurately be assessed when the penis is erect. If one is interested in pursuing treatment (i.e. the curve is both bothersome to you and functionally impairing), then the doctor will perform a penile curvature assessment where he will induce an erection with medication and perform a very detailed assessment of the abnormalities as well as ultrasound assessment of the plaque.
What are Treatment Options?
Many agents have been tested in Peyronie’s disease. These include intralesional therapies (penile injections), oral therapies, topical therapies, penile traction devices, low-intensity acoustic shockwave, and surgical procedures.
Injection of medications to the Peyronie’s plaque in the penis is considered a 1st line approach for a large proportion of men with Peyronie’s. Verapamil and Interferon injections are some of the medications that are thought to disrupt collagen synthesis and scar formation. They are used in men with acute disease (within 6 months of the most recent change to curve or penile pain with erection).
The most recent addition to therapeutic options in Canada is a collagenase agent (i.e. Xiaflex) which selectively breaks down the collagen comprising the Peyronie’s plaque. In the original clinical trials, men treated with Xiaflex had on average a 17-degree reduction in curvature compared to 9 degrees among placebo with no active medication. This is often combined with penile modelling or traction devices that stretch the plaque. A study published in June 2019 combined Xiaflex injections with a Restorex Penile traction device and demonstrated a 33.8-degree improvement among men receiving injections and using the traction device for 1 hour per day.
Verapamil gel, a topical version of the drug, has also been effective in eliminating pain upon erection, decreasing the size of plaque, decreasing curvature, and improving erection quality in patients with Peyronie’s disease.
Penile vacuum therapy and penile traction techniques may provide some benefit to treatment in combination with above intralesional therapies. These techniques are thought to stretch and lengthen the shortened Peyronie’s plaques leading to re-organization of the scar fibers.
Low Intensity Shock Wave Therapy (LiSWT) which has also been shown to be an effective treatment modality for Peyronie’s disease as well as vasculogenic erectile dysfunction.
The actual mechanism of LiSWT for Peyronie’s disease is not fully understood. However, electron microscopy studies have demonstrated actual histological changes within the Peyronie’s plaque following LiSWT. Additional studies also reported an improvement in penile curvature by more than 15° in 33% of men who received LiSWT with a corresponding decrease in penile plaque hardness in 60%. LiSWT is believed to reduce the pain associated with Peyronie’s disease and to improve the quality of erection by promoting the generation of new and stronger blood vessels at the level of penile shaft.
The Canadian Urological Association 2018 guideline states that “contemporary guidelines have clearly demarcated ESWT’s role in Peyronie’s disease management and the Committee concurs with this approach, supporting ESWT for potential penile pain improvement” .
For men that are not candidates for other forms of therapy and are both psychologically and functionally bothered by their Peyronie’s Disease, surgery may be an option. This may include different techniques depending upon the nature of the curve, deformity, and baseline erectile function. The doctor will discuss these if they are appropriate but generally include:
- Penile plication – shortening the ‘long side of the penis’ opposite the curve
- Penile plaque excision and grafting – the scar tissue is cut and stretched, and a graft is sewn in place
- Penile implant device that replaces the erectile tissue and helps to straighten the penis (typically reserved for men with significant curvature and erectile dysfunction).