Peyronie’s Disease - What You Need To Know
NEARLY 80% OF MEN WITH PEYRONIE’S DISEASE ALSO REPORT SOME DEGREE OF ERECTILE DYSFUNCTION (ED).
Multiple causal factors may contribute to Erectile Dysfunction (ED). Peyronie’s disease, or Peyronie disease, is also a common affliction, affecting up to 23% of the worldwide male population between the ages of 40 and 70 years.* In many cases, Peyronie’s disease leads to ED.
* Because both patients and doctors underreport Peyronie’s disease, the actual numbers may be much higher. Regardless, it is clear that Peyronie's disease is correlated with age. Although rarely seen in young men, Peyronie’s disease has been reported by men in their 30s.
PEYRONIE'S DISEASE DEFINED
In men with Peyronie’s disease, fibrous scar tissue develops beneath the surface of the penis, leading to excessive curvature of the male organ. Initially, swelling and inflammation occur followed by the development of a hard scar on the penis, affecting a man’s ability to have a normal erection.
The scar tissue (aka plaque) develops inside the tunica albuginea tissue (a thick, elastic membrane primarily made of elastin and collagen). This membrane envelops the corpora cavernosa, the two cavernous bodies that fill with blood during an erection.
The plaque commonly resides on the top or bottom of the penis which results in the bending of the male organ. As scar tissue develops, sexual intercourse is difficult and erections become painful. In some cases, excessive curves in the penis can make sexual intercourse impossible.
The effects of PE can be devastating to a man’s confidence and sexual health - often causing pain for both the individual with the disease and their partner. Peyronie’s is often connected to ED which may result in relationship challenges with a significant other. While a curved erection by itself may not necessarily be an issue, the associated pain and discomfort of a significant bend that is characteristic of Peyronie's Disease can, in some patients, be mitigated with treatment.
PEYRONIE'S DISEASE - MAIN CAUSES
THE EXACT CAUSE OF PEYRONIE'S DISEASE REMAINS ELUSIVE. FOR MOST MEN WHO DEVELOP PD, IT IS SPONTANEOUS AND NOT PRECEDED BY AN INJURY. THAT SAID, PEYRONIE'S DISEASE CAN BE CAUSED BY:
Acute penile injury
Chronic penile injury
Autoimmune disease
Whether a singular event or occurring repeatedly over time, injury to the penis can lead to Peyronie’s Disease. These events may include vigorous sexual or physical activity that results in stress to or the bending of an erect penis or trauma to a flaccid penis. That said, Peyronie’s Disease can also occur spontaneously without a known trauma to the organ.
Bleeding and swelling within the tissue of the tunica albuginea can occur following an injury. The resulting immune response can form an inelastic and fibrous plaque (i.e. scar tissue) which affects the overall elasticity and flexibility of the penis and produces organ curvature - which can also compromise erectile function.
Men with autoimmune diseases (and particularly connective tissue disorders) may have a higher chance of developing Peyronie’s Disease. The patient’s immune system may attack cells in the penis, resulting in scarring and inflammation. For example, Dupuytren's disease (a cord-like thickening across the palm) is associated with 15% of men suffering from Peyronie's Disease.
ADDITIONAL AUTOIMMUNE CONDITIONS AND GENETIC DISPOSITIONS ASSOCIATED WITH PEYRONIE’S DISEASE:
Systemic lupus erythematosus
Behcet’s syndrome
Scleroderma
Sjögren’s syndrome
Plantar Fasciitis
Age and family history are other factors that may contribute to the prevalence of Peyronie’s disease. For men with shared genetics, the likelihood of having the condition may increase among families. As one ages, the elasticity of tissue diminishes — which may further contribute to Peyronie's disease.
THE APPEARANCE OF PEYRONIE'S DISEASE
Signs of Peyronie’s Disease vary from mild to severe. Symptoms may progress slowly or quickly.
Indicators of Peyronie’s Disease may include:
Painful erections and/or sexual intercourse
Plaque formation (felt through the skin as “hard lumps”) on the penis
Shrinkage or narrowing of the penis
Erectile dysfunction
Symptoms may dissipate without causing a permanent curvature of the penis. Often, however, the pain subsides even if the curve remains. Researchers believe painful erections result from active inflammation within the plaque, which abates over time.
Significant curvature may make sexual intercourse challenging. Additionally, the scar tissue associated with Peyronie’s Disease may diminish the girth or length of your penis.
TREATMENT OPTIONS FOR PEYRONIE’S DISEASE
Treatment for Peyronie's Disease is considered more effective in the early stages of the condition. Roughly 20% of active patients may improve spontaneously, while 40% stabilize and another 40% progress further with the disease.
MEDICATIONS FOR PEYRONIE’S DISEASE
Two concerns might need to be addressed with Peyronie’s Disease - the issue of mitigating curvature, indentations, or atrophy associated with Peyronie’s Disease as well as a possible secondary issue relating to a man’s challenge in maintaining a full erection.
1. TREATMENTS TO ADDRESS CURVATURE, INDENTATION OR PENILE ATROPHY
The following treatments can be employed to soften or minimize the fibrotic plaque that develops with Peyronie’s:
Oral Medications
Vitamin E plus Colchicine - Vitamin E is a strong antioxidant that is reported to reduce collagen deposits within the injured tunica albuginea. Colchicine is an anti-inflammatory. In a randomized trial, the combination of these two medications demonstrated a reduction in plaque size.
Pentoxifylline - Pentoxifylline is a nonspecific phosphodiesterase inhibitor which prevents deposition of collagen type I, decreases transforming growth factor (TGF) beta-1-mediated fibrosis, and reduces calcification. Studies have found that pentoxifylline improves or stabilizes calcifications with patients reporting decreased curvature.
Intralesional Injection Therapies
Verapamil - Intralesional verapamil is believed to influence fibroblast metabolism by decreasing the production of collagen and concurrently increasing collagenase activity. The majority of studies have shown mild improvement in penile pain, plaque size, and penile curvature. Verapamil injections may be taken alone or in combination with other therapies.
CCH (Collagenase Clostridium Histolyticum) (AKA Xiaflex) - Xiaflex is the only FDA-approved intralesional treatment for men with PD. It does not change the curvature, however, Xiaflex is effective in reducing plaque size. Therefore, it is recommended that this treatment be followed with “modeling,” which is forcible bending of the penis in the direction opposite to the curve (see below) or a traction device.
P-Shot / PRP (Platelet-Rich Plasma) - The P-Shot incorporates a concentrated cocktail of growth factors and platelets from the patient’s blood which is injected into the targeted plaque. PRP mobilizes local stem cells, accelerating tissue regeneration and the formation of new vascular networks. Please see this page for more information.
Topical Therapy
Verapamil - in addition to being an injectable treatment (as noted above), Verapamil may be used as a topical ointment. Better studies are needed to determine its efficacy.
Remodeling / Mechanical Treatments
Vacuum Erection Device (VED) - The negative pressure of a VED enlarges small blood vessels within the penis and increases blood flow. Studies indicate that when used regularly (two times a day for 10 minutes) over several months, men can achieve satisfactory results for stabilizing or improving the curvature of the penis. A study conducted at the University College London Hospital reported that most men who used VED twice a day experienced improvements in penile curvature, length, and pain after three months.
Penile Traction Therapy - In a study of ten men with PD, nine of whom had failed medical therapy, traction for two to eight hours a day for six months led to increased stretched flaccid penile length, reduced curvature, and increased erect girth. Further studies have shown that, in conjunction with oral agents and injection therapy, traction may modestly improve curvature and stretched penile length.
Modeling exercises - Modeling procedures are conceptually similar to traction but rather than using a device, a patient administers gentle straightening and stretching exercises in opposition to the curvature at home several times a day. These exercises are best used in conjunction with intralesional injections and/or oral therapies.
Regenerative Therapies
Low-Intensity Shockwave (i.e. GAINSWave) - In a randomized trial comparing shockwave versus placebo in 100 patients, men appreciated a statistically significant decrease in curvature and plaque size. In another study using shockwave plus high doses of Vitamin E, 72% of patients reported a decrease in curvature with an average reduction of 23 degrees after three months of therapy. It has been our clinical observation that Shockwave therapy is an effective clinical intervention for patients who struggle with symptoms of Peyronie’s disease and ED. Proposed mechanisms of action included a breakdown of fibrotic tissue by shockwaves and induction of inflammatory response for plaque lysis and removal. Shockwave therapy has been evidenced in over 40 published studies to improve ED.
P-Shot / PRP (Platelet Rich Plasma) - see above and this page for more information.
2. TREATMENTS TO ADDRESS ERECTILE DYSFUNCTION ASSOCIATED WITH PEYRONIE’S DISEASE
Oral PDE5 Inhibitors (Viagra, Cialis, Levitra) - All of these medications work via the same mechanism - delaying the breakdown of nitric oxide.
Regenerative Therapies - see above for information about these treatments.
SURGERY FOR PEYRONIE’S DISEASE
Early non-surgical medical intervention is the best first line of therapy and is likely to be more effective as the disease is evolving.
Surgery should be considered a last-resort treatment option for Peyronie's Disease with patients urged to wait at least a year after the onset of symptoms before considering this approach.
However, For long-term cases where curvature doesn’t allow for sexual intercourse and men’s symptoms have not improved, surgery may be recommended. There are several surgical procedures to treat Peyronie's disease including device implantation, grafting, and plication - all of which are completed in a hospital by a urologist.
Adverse side effects resulting from surgery may include numbness, atrophy, and ED. It should be noted that 20% of patients report new onset erectile dysfunction after surgery and for those patients who had preexisting ED, 45% reported worsening erectile dysfunction and problems with achieving orgasm.
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