Diseases & Conditions

Peyronie’s Disease

Authors: Hunter Wessells, MD
Last updated: November 21, 2005

• Overview |
• Symptoms |
• Causes |
• Risk Factors |
• Diagnosis |
• Complications
  
• Treatment |
• Self-care |
• Other Articles of Interest
  
• Providers |
• Request an Appointment

Overview

Peyronie’s Disease is a relatively uncommon condition affecting the male penis. Its exact causes are unknown, but probably the condition represents an abnormal response to injury in susceptible individuals. The structure injured is the tunica albuginea, the fibrous white coat that surrounds the erectile bodies of the penis. Most often, the precipitating trauma is a bending injury to the erect penis.; However, other causes such as urethral catheterization, blunt trauma to the flaccid penis, and medications have been reported. The inflammatory plaque of the tunica albuginea should not be confused with the plaque found in atherosclerotic vessels such as the heart or arteries. A Peyronie’s plaque is the thickened fibrous inflammatory nodule that is usually palpable along the shaft of the penis. Disordered collagen fibers and loss of elasticity prevent the expansion of the tunica albuginea under conditions of erection. This is directly responsible for the symptoms.

Symptoms

The three most common symptoms of Peyronie’s disease are a palpable penile plaque, painful erection, and penile curvature. The onset of these symptoms may be abrupt. The painful erection is not usually related to penetration, but to the pressure and turgidity of the penis, which is deformed by the presence of the non-expansile plaque. Thus, the plaque causes deviation of the penis. If the plaque is on the top of the penis, the curvature will usually point towards the ceiling. Conversely, if the plaque is on the under-surface of the penis, the erect penis will point towards the floor. Various combinations of curvature, as well as narrowing of the girth of the penis and penile shortening, all are possible. Erectile Dysfunction is another less common effect of Peyronie’s disease. The abnormality of the tunica albuginea can lead to failure of the normal mechanism for occluding the veins of the deep penis and pressurizing the penis. Thus, patients with Peyronie’s Disease may suffer from the inability to obtain an maintain an erection, specifically due to failure of the venous mechanism and a condition known as venous leak.

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Causes

The cause of Peyronie’s Disease remains obscure. Men with Peyronie’s Disease report a history penile trauma more commonly than men with other conditions such as prostate enlargement or erectile dysfunction. However, not all men with Peyronie’s Disease report a distinct history of trauma. Furthermore, not all men with trauma to the penis develop Peyronie’s Disease. Thus, some investigators have postulated a genetic or environmental set of predisposing factors. A most exaggerated form of penile bending injury, namely penile fracture, involves a distinct rupture of the tunica albuginea. In cases when this is recognized and treated immediately with surgical repair, Peyronie’s Disease is very uncommon. In contrast, less severe bending injuries may lead to microscopic tears within the tunica albuginea, setting up an inflammatory process within tunica albuginea which is difficult to clear. A number of growth regulating proteins, including transforming growth factor beta have been implicated in the pathogenesis of the Peyronie’s plaque.

Risk Factors

A number of variables have been associated with a higher likelihood of Peyronie’s Disease amongst population of men. These include a history of Dupuytren’s Contractions of the tendons of the palms of the hand, use of beta-blocker drug therapy, and hypertension. None of these associations have been clearly determined to have a causal relationship with Peyronie’s Disease however.

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Diagnosis

The diagnosis of Peyronie’s is based on history of a penile plaque or penile pain, and the physical examination finding of an induration or thickening of the tunica albuginea, namely the plaque. The penis is best examined with the shaft put on full-stretch so that the examiner can palpate the dorsum of the penis along the tunica albuginea for areas of hard thickened nodules. The use of self-photography to demonstrate the deformity of the penis during penile erection can be a useful adjunct and help the Urologist determine the severity of the curvature and other deformity.

A penile blood flow study using color duplex Doppler ultrasonography can serve several purposes. First of all, ultrasonography can image the plaques and determine their size, thickness, and degree of calcification. Heavily calcified plaques, that are like areas of bone formation, are very unlikely to respond to conservative therapy. The penile blood flow study can also, with a combination of a penile injection, determine the underlying integrity of the arteries and veins of the penis. This is important to diagnose potential venous leakage, as well as to plan surgical therapy for more severely affected individuals.

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Complications

The natural history of Peyronie’s Disease is variable. The presence of a Peyronie’s plaque should prompt medical attention, because only a third of patients overall are expected to have improvements in their condition. Some men will stabilize and be left with a moderate degree of penile curvature, which still allows them to function sexually. However, a significant minority of the patients will have progression of their plaque and develop severe curvature, narrowing, shortening of the penis, and possibly erectile dysfunction. The degree of penile shortening can be distressing to men, and the narrowing of the girth of the penis, which we term an hourglass deformity can lead to instability of the penis during erection and erectile dysfunction, despite normal underlying vascular function.

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Treatment

Treatment for Peyronie’s Disease can be divided into oral pharmacotherapy, intralesional therapy, and surgical reconstruction. We advocate treatment for all patients with Peyronie’s Disease, even with those with mild conditions.

Oral pharmacotherapy
For a man with mild curvature, moderate pain, less than 30-degree angulation with no hourglass narrowing or major shortening of the penis, we recommend oral therapy. Choices of agents include oral colchicine, an anti-inflammatory agent commonly used for the treatment of gout, as well as Potaba. Small uncontrolled trials support the use of these medications, although none of them have undergone rigorous testing in randomized controlled trials.

Intralesional therapy
For more significant curvature, when pain is a significant issue, or the rate of progression seems concerning, we use intralesional therapy. Intralesional verapamil, a calcium-channel blocker, has been shown to reduce pain, curvature, with limited side effects. After numbing the penis with local anesthesia, a very small needle is used to infiltrate the plaque with verapamil. Six treatments separated by two weeks each, comprise our usual protocol. Results in the literature are encouraging, suggesting a 60% response rate amongst patients.

Surgical reconstruction
Surgical therapy should be reserved for men with persistent severe symptoms that have not improved. The plaque and curvature should have stabilized for at least 6 months before surgery is recommended. For severe curvature of the penis, precluding sexual penetration and normal function, we recommend surgery. Click on Figure 1 to see our algorithm. For men with mild curvature, minimal shortening of the penis, and no hourglass narrowing of the shaft, we recommend penile plication. This involves taking a series of small tucks on the side of the penis opposite the plaque. The penis has already been foreshortened by the plaque, and this plication equalizes the length of the two sides of the penis and creates a straight penis. This is an outpatient procedure, which can be performed in less than an hour and has few side effects.

For patients with severe angulation, distinct narrowing of the girth of the penis, or profound shortening of penile length, we offer reconstructive surgery with grafting. This involves release of the scar either by incising or excising the plaque, and grafting in a substitute for the tunica albuginea to expand the length and girth of the penis. Our preferred substitution material is a graft made out of the patient’s own saphenous vein. This vein is harvested from the ankle, trimmed and reconfigured into a flat patch-graft, like a patchwork quilt. This can be then sewn into the defect of the tunica albuginea, correcting girth and length discrepancies and rendering the penis straight. While penile length is improved modestly with this approach, over 90% of men can report a straight or nearly straight penis after surgery, and most can regain sexual activity. However, risks are associated with this approach including penile numbness (less than 10%), persistent angulation (less than 5%), and severe erectile dysfunction (less than 20%).

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Self-care

Men with Peyronie’s Disease should be encouraged to remain sexually active. There is no evidence that ongoing sexual activity will lead to worsening of the condition. Vitamin E has been proposed as a safe treatment for Peyronie’s Disease, but only uncontrolled trials with poor study design exists to support this.

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