Peyronie's disease

The bending of the penis characteristic of Peyronie's disease was first recorded over 250 years ago. Not surprisingly, perhaps, because Peyronie's disease affects between 1 and 3% of the male population.

The classic symptoms are curvature of the erect penis, pain, perhaps erectile dysfunction (difficulty in gaining or keeping an erection) and the presence of a hard plaque in the body of the penis. Interestingly enough, in a fairly large number of men, the condition spontaneously resolves. But for a lot of men, Peyronie's may be serious enough to prevent intercourse. Peyronie's often occurs in men who have other conditions such as Dupuytren's contracture, a shortening of the connective tissue in the hand, which suggests that there may be a genetic disposition to Peyronie's.

What happens inside the penis in Peyronie's?

We've described the normal structure of the penis elsewhere. In the early stages of Peyronie's, cells from the immune defense system invade the layers of the Tunica albuginea, which seems to promote the conversion of the flexible tissues of the tunica into hard and inflexible plaques of fibrous tissue which lack the stretch needed to allow the penis to become fully erect. The limited erectile capacity of the damaged tissue causes the penis to develop a bend (or an hour-glass shape, if the damaged tissue extends all the way around the circumference of the penis).

In the worst cases, the plaques become hard and rigid as they become calcified. The damage may extend into the erectile tissue as well as transgressing the tunical layer. But why does this happen? It seems that the disease process is initiated by damage to the tunica during sex or masturbation - a small fracture or tear, perhaps, which somehow results in aberrant wound healing and leads to the formation of scar tissue, which can become calcified and is then felt as a hard plaque in the penis.

There are two phases to Peyronie's. The first is an inflammatory phase which lasts between 3 and 12 months, during which a man will notice his penis becomes gradually more curved and during which he experiences some penile pain; the second is a more stable phase where the plaque stops developing and the curve of the penis stabilizes.

Men with Peyronie's who see a doctor will do so because they have some penile pain and/or deformity, though the two do not always go together. Between 2 and 11 % of patients complain that sexual intercourse has become difficult or impossible because the bend in their penis is so bad. And rather more - up to 40% - of men say that intercourse is unsatisfactory because of the pain they experience. Sadly, penile shortening is often a side-effect of Peyronie's.

Erectile dysfunction in Peyronie's disease

Erectile dysfunction is often associated with Peyronie's, and it can result from either psychological factors or physical ones. A man may be very anxious about his bent penis, and this anxiety may prevent him becoming erect. In other cases, especially where the deformity in the penis shaft is of the hour-glass form, his penis may not become erect beyond the hard plaque, so that only part of his penis becomes fully erect.

What can be done about it?

Various medications have been developed which are, in theory, designed to inhibit the cells and inflammatory processes which stimulate the development of the fibrous tissues and cause the bend in the penis. These are most effective in the early stages of Peyronie's, so it's worth getting to your doctor promptly. There are several medications available, including Vitamin E, Potaba, Colchicine, Verapamil and Tamoxifen. Different studies have revealed varying effectiveness of these medications: it's a matter of finding the one which is most effective for you. In general, though there is a lack of controlled studies, Verapamil seems to bring about the highest reduction in pain and penile curvature: in studies, up to 97% of men said their pain was resolved, and penile curvature was reduced by 54%, with two-weekly injections.
 

There is also, as you may imagine, a whole range of more invasive or interventionist treatments available, ranging from "Extracorporeal shock wave therapy", where high frequency sound waves are used to disrupt the plaques (a treatment which has produced promising results) to radiotherapy (which has also shown some promising results), through to surgery.

Penile straightening operations are still required in patients with considerable deformity, men who cannot enjoy intercourse because of the extent of the bend in their penis. Obviously there is a correlation between the degree of bending and the likelihood of surgery; in particular, where the penis bends laterally (sideways) intercourse may be more difficult and surgery more likely.

The Nesbit procedure was first described in 1965 to correct congenital penile curvature. An overall success rate of 82% has been quoted when the procedure is used to correct penile bending due to Peyronie's disease. The surgery is effective, but it can result in penile shortening and erectile dysfunction, and it is only carried out once the plaque has stabilized. In essence, the procedure removes enough material from the erectile tissue on the side of the penis opposite to the plaque to produce a straight erection, which is obviously somewhat shorter post-operatively than pre-operatively. The satisfaction rate of the operation is much lower for men who have erectile problems before the surgery than for those who do not, and for this reason a thorough examination of all the pre-operative aspects of the condition is essential.

It's important to point out that modern surgical techniques involve grafting extra pieces of vein tissues into the erectile tissues of the penis so that the loss of length is minimized.

Such grafting is especially useful in men who have the hour-glass deformity of the penile shaft. Long term follow up of patients who have undergone plaque excision and grafting has shown that 17% of patients required further surgery for curvature and that 20% of patients had significant erectile dysfunction. However, more recent studies using different and  more modern surgical techniques have achieved higher success rates: the Lue procedure, for example, which involves excising the plaque followed by grafting of a piece of tissue from the saphenous vein, can produce an excellent or satisfactory outcome in up to 92% of patients.

Insertion of a penile prosthesis

When severe erectile dysfunction and penile deformity due to Peyronie's disease are combined, especially in elderly men with diabetes, a penile prosthesis may be used. If mild to moderate penile curvature is present, the insertion of a penile prosthesis can restore penile length as well as correct the penile deformity with a high rate of success.