Peyronie’s disease is a penile disorder, in which the penis becomes curved due to plaque (scar) formation in the penile tissue under the skin. These patients have a painful and abnormal erection, which interferes with doing sexual intercourse properly.
To understand Peyronie’s disease, we need to understand the structure of the penis and the physiology of erection under normal conditions.
Normal penis
The penis is a spongy tissue that consists of urethra, and two corpora cavernosa. The urethra is a hollow tube that carries urine outside the body during urination and the sperms to the vagina during the sexual intercourse. Above urethra, there are two corpora cavernosa. Corpora cavernosa are two spongy tubes that contain blood sinusoids. Outside these structures, Tunica albuginea, which is a white fibrous tissue sheath, surrounds the urethra and the two corpora cavernosa. Tunica albuginea consists of collagen and elastin, which gives it the rigidity and flexibility.
During the erection, blood flow to the penis increases and fill the blood sinusoids within the corpora cavernosa leading to its swelling and stiffness, which compress the veins and prevents blood outflow from the penis. This process increases the intracorporal pressure, and the erection occurs. The tunica albuginea gives the penis its straight shape during the erection.
In Peyronie’s disease, scar tissue replaces a part of the normal tunica albuginea. This scar tissue consists of collagen fibers without elastin as in the normal tunica albuginea, which makes this scarred part rigid and inflexible. During the erection, the penis can’t take its straight shape and curves around scarring. The severity of the condition and its symptoms depend on the degree of the curving.
The human penis varies in size and shape among men, from straight to slightly curved. But, if there is a noticeable curving during the erection, you should see your doctor.
Peyronie’s disease affects about 10% of men; its incidence increases with age, but you shouldn’t consider it a sign of aging and ignore it.
Peyronie’s disease doesn’t resolve spontaneously and requires treatment, and early treatment is better because it can control the symptoms and prevent disease progression.
Now, we will discuss the Peyronie’s disease to know more about it by answering the following questions:
- What are the causes and risk factors of Peyronie’s disease?
- What are its symptoms?
- How do doctors diagnose it?
- What are the available treatment options?
» Also, we will discuss Peyronie’s disease versus the normal penile curvature.
Causes and risk factors of Peyronie’s disease
The exact cause of Peyronie’s disease is unknown, but the most common cause is penis injuries. Penis injuries may occur during sex -especially violent sex-, sports, or accidents. Scarring of the tunica albuginea occurs during the healing process because the body can’t control how much fibrous tissue needs to heal the injury. Peyronie’s disease doesn’t affect all people who exposed to penile trauma; there are some risk factors predispose to the condition, such as:
- Positive family history of Peyronie’s disease: People with a family history of Peyronie’s disease may have previous problems in wound healing in other parts of the body rather than the penis.
- Age raises the risk of Peyronie’s disease; it is more common among those over 50 years old.
- Connective tissue diseases: The risk of Peyronie’s disease is higher in those with connective tissue diseases, such as Dupuytren’s contracture (scarring of the subcutaneous tissue of the palms, which restricts the movement of the palm, and extends to some fingers causing their flexion).
- Other factors, such as Diabetes Mellitus, smoking, alcohol abuse, pelvic trauma, and some prostatic surgeries, may cause abnormalities in wound healing.
» The clinical picture of Peyronie’s disease starts from the scar of the tunica albuginea and the loss of elasticity of this scarred part.
The clinical picture of Peyronie’s disease
The main symptom in Peyronie’s disease is the curved penis during the erection. The site of the scar tissue determines the direction of the curvature. If the scar is in the upper (dorsal) surface of the penis, the curve will be downwards. If it is in the lower (ventral) surface, the curve will be upwards. The patient can feel the scar tissue under the skin of the penis as a hard band.
Pain is also a common symptom in Peyronie’s disease. Pain may occur either with erection or in a relaxed state. The pain often resolves over time (usually one or two years).
Many patients with Peyronie’s disease reported erectile dysfunction, which means difficulty in initiating or maintaining the erection. Erectile dysfunction occurs because, in Peyronie’s disease, the penile veins can’t close normally, and this leads to some blood outflow during the erection.
Short penis: Some patients notice reduced penile length with Peyronie’s disease.
All the previous factors (curved penis, penile pain, erectile dysfunction, and short penis) affect the sexual life of the patient. It makes sexual intercourse difficult and sometimes painful. Problems in sexual life have psychological consequences, either for the patient or his sexual partner. These psychological consequences include anxiety and stress because he doubts his sexual abilities and due to the fear of not having a child.
The course of Peyronie’s disease consists of two phases, acute and chronic phases, as follow:
- Acute phase: It takes from 6 to 18 months. During this phase, the scar tissue grows, and the penis curve increases more and more. Also, the pain occurs during this phase due to the scar growth and the associated inflammation.
- Chronic phase: This phase is the stabilization phase. During this phase, the scar tissue growth stops, and the penis curve becomes stable. The pain disappears in this phase.
If you noticed these symptoms, don’t wait and see your doctor. Penile deformity doesn’t resolve spontaneously in most cases, but early diagnosis and treatment provide a better chance to improve the penile condition and prevent worsening.
Diagnosis of Peyronie’s disease
Diagnosis of Peyronie’s disease passes by three stages: history taking, physical examination, and investigations.
1) History taking: When you tell your doctor your complaint about the curved penis, penile pain, and any other symptoms, he will ask you about previous exposure to penile trauma.
Also, he will ask you about some risk factors, such as:
- Do you have other members in your family who suffer from a similar condition or problems in wound healing?
- Do you suffer from any connective tissue disease, such as Dupuytren’s contracture or tympanic sclerosis?
- Did you have any pelvic or prostatic surgery before?
- Your habits, such as smoking and alcohol intake
- Do you suffer from any chronic health problem, such as Diabetes Mellitus?
Then, your doctor will ask you to expose your penis to do the physical examination.
2) In the physical examination, the doctor will palpate your penis to feel the scar tissue and evaluate its site and size. He also will measure the length of your penis. Also, your doctor may need to see your erection, and, to do this, he will inject a drug into your penis. These initial measurements help your doctor in the follow-up, which enables him to see if your condition improves or worsens. Your doctor also may need you to take some pictures for your penis during the erection at home, which may help accurate evaluation of the condition.
Your doctor may depend on the medical history and physical examination to reach the diagnosis of Peyronie’s disease. But sometimes, he will need to rule out some condition that presents with similar symptoms, such as penile cancer or congenital curvature, to confirm his diagnosis. Thus, he may order an ultrasound imaging of the penis.
3) Ultrasound imaging: In penile abnormalities, ultrasound is the most useful imaging technique. It uses the ultrasound waves to take a picture of the soft tissues in the body. It enables the doctor to see the site of the scar tissue and evaluate the blood flow to the penis.
On rare occasions, your doctor may need to take a biopsy from the scar tissue and send it for laboratory examination by a pathologist. He may do that when he needs to confirm his diagnosis and to rule out cancer, or if the condition deteriorates rapidly.
» After the diagnosis, your doctor will discuss the available treatments for Peyronie’s disease with you.
Treatment of Peyronie’s disease
The choice of treatment depends on:
- the stage of your condition
- the severity of the condition
- the presence of erectile dysfunction
Some mild cases don’t need treatment if there no effect on sexual life, and the doctor will only wait and see if there is any progression.
The available treatments include physical therapy (penile traction therapy), medications, and surgical operation. Each of these treatments has its benefits, risks, and suitable time to apply it. Your doctor will discuss with you the best treatment for your case. Now, we will discuss each of them.
1) Penile traction therapy
The idea of traction therapy is: stretching the penis on a mechanical device for some time. Traction therapy improves penile deformity and avoids shortening of the penis.
The drawback of traction therapy is that it requires a commitment for a long time, ranges from 30 minutes to 8 hours per day to reach the desired benefits. Your doctor will prefer traction therapy in the early acute phase. Also, he may do it in the chronic phase with other treatments or after surgery.
2) Medical treatment
In Peyronie’s disease, oral drugs don’t have a significant role because they didn’t show significant results in clinical studies. Thus, your doctor may inject some medications in your penis to destroy the scar tissue. These injectable medications include:
- Collagenase clostridium histolyticum (Xiaflex®): Collagenase is an enzyme produced in the body and by other bacteria; this enzyme destroys the collagen protein, which is the main component of the scar tissue. Doctors use this medication in moderate and severe cases of penile curvature. It improves the curving of the penis. To get a better outcome, your doctor may do modeling with the collagenase injection. Modeling means stretching and straightening against the direction of the curve.
- Verapamil: It is an antihypertensive drug, but it is showing efficacy in Peyronie’s disease. It interferes with collagen synthesis, which disrupts the main component of the scar tissue; thus, it improves the penile curving. It also relieves the penile pain.
- Interferon: It is a protein that inhibits the scar tissue formation and may help in its destruction. It also relieves the penile pain.
From the previous medications, collagenase is the only one approved by food and drug administration (FDA), while others need more studies to confirm their efficacy.
The role of vitamins in Peyronie’s disease:
Vitamin E didn’t show significant benefits compared to placebo (An empty pill without drug inside it) in the recent reliable studies.
Potassium benzoate (vit. B complex) has shown benefits in the reduction of the plaque size but not the penile curve. But, it is an expensive medication and causes gastrointestinal irritability (such as nausea and vomiting); thus, many patients don’t prefer it.
3) Surgical treatment
Doctors delay the choice of surgery until the disease enters the chronic phase where the plaque stops growing, the penile curve becomes stable, and the pain disappears. Also, surgery is only for those who have a severe condition and can’t have sex.
Before surgery, the doctor may examine your penis by ultrasound during its erection to see the blood flow inside it and decide the best surgical procedure for your condition.
Surgical procedures for Peyronie’s disease include:
- Plication (suturing): In this procedure, the surgeon will induce an artificial erection then he will make an incision in the outer skin of the penis. Then, he will straighten the penis, pinch the scar tissue together, and suture it. The final length depends on the length of the scarred part. The shortening of the penis approximately equals 1 cm for each 15-degree correction of the curving. Thus, this procedure is more useful in less severe conditions.
- Grafting: In this procedure, the surgeon makes an incision in the skin of the penis to expose the tunica albuginea. Then, he will remove the scarred part of tunica albuginea and replace it with a graft. He may take the graft from another part of your body during the operation, such as the saphenous vein (a lower limb vein) or temporalis fascia (the skin behind the ear). Also, the graft may be a synthetic material made from human or animal sources. There is no penile shortening with this procedure, but it is harder to do and may worsen erectile dysfunction. Thus, this procedure is done only in severe cases.
- Penile implants: The surgeon inserts a bendable and inflatable cylindrical tube into the corpora cavernosa. This implant takes the direction of the curve in the relaxed state. During the erection, it swells, erects, and straightens the penis to become stiff enough for sexual intercourse. This choice is useful for patients with Peyronie’s disease and erectile dysfunction. If the implant doesn’t correct the erection enough, the surgeon may combine it with an additional surgical procedure to straighten the penis more.
Other treatments for Peyronie’s disease are still under clinical research, such as:
- Iontophoresis: A technique uses an electrical current to apply the verapamil and steroid to the scar tissue through the skin without an injection.
- Shock wave therapy: It is a technique that uses sound waves to destroy the scar tissue.
- Radiotherapy
Normal penile curvature versus Peyronie’s disease
The human penis varies from man to man in the size and shape. Peyronie’s disease means a curved penis, but not every curved penis means Peyronie’s disease. Thus, we should answer the following question:
⇒ When can we consider the curved penis normal, and don’t worry about it?
When the penile curvature is less than 30 degrees, no progressive curving, and no painful erection, it is a natural condition that doesn’t need medical intervention.
If the curve increases, there is a painful erection, or it is difficult to have sex, it may be Peyronie’s disease, and you should see a doctor.
In normal conditions, the curved penis may be useful for some sexual positions, and even some people prefer it. Some people say that it may stimulate G-spot better.