Peyronie's Disease (Curvature of the Penis)

Peyronie's disease is a condition in which scar tissue develops inside the penis.

• Peyronie's disease is the development of scar tissue inside the penis that results in an abnormal curvature of the penis.
• The exact cause of Peyronie's disease is not known; however, research has suggested these agents as possible causes of plaque or scar formation in the penile shaft.
  • Vitamin E deficiency
  • Beta-blocking drugs
  • Elevation in serotonin levels
  • Genetic causes
  • Trauma to the penis
• Some of the symptoms of Peyronie's disease include:
  • Pain during erections and/or during sex
  • Erectile dysfunction
  • Anxiety or stress
  • The inability to have intercourse
• Peyronie's disease is diagnosed by physical examination of the penis that shows abnormal curvature and plaque/scar formation that may be palpated.
• There is no cure for Peyronie's disease; however, symptoms can be treated with vitamins, supplements, and other medications.
• Complications of the disease include pain with intercourse, inability to have intercourse, erectile dysfunction, depression, and permanent abnormal angulation of the penis.
• The prognosis of Peyronie's disease varies from good to poor, depending on the individual's response to treatments.

Peyronie's disease (also termed Peyronie disease) is the development of scar tissue inside the penis that causes the penis to develop abnormal curvature (contracture) in the scarred area. The disease may occur in about 1% to 8% of men, most frequently in men aged about 40 to 70 years old. The disease also may occur more frequently in men who develop:

• Prostate cancer
• High blood pressure (hypertension)
• Diabetes

Occasionally, the disease can occur in younger men.

The symptoms of Peyronie's disease usually are a combination of one or more symptoms as follows:

• Unusual angulation of the penile shaft (either when flaccid or erect or both)
• Pain during erections and/or during sex
• Scarring or plaque palpated at the abnormal bend or angle of the penis
• An indentation of the penis shaft at the site of the plaque or scarring
• Erectile dysfunction
• Anxiety/stress
• Inability to have intercourse

The exact cause of Peyronie's disease is not known. However, whatever can cause plaque or scar formation in the penile shaft is a likely causal candidate.

• Researchers have suggested several possible agents such as vitamin E deficiency, beta-blocking medications, elevations in serotonin, and genetic causes.
• Some researchers think that minor vascular traumas to the penis (during sex, athletic, or exercise endeavors) that occur repeatedly over time may lead to scar formation.
• None of these possible agents or processes is proven to be the cause to date.

There are, in general, two phases of Peyronie's disease.

1. The acute phase lasts about 18 to 24 months and usually has the highest pain component.
2. The chronic phase (which begins about 18 to 24 months after the first symptoms) usually has less pain but in this stage, the plaque or scarring is more refractory to treatment (see below) and may begin to develop large calcium deposits (calcified plaque or scarring).

The patient's history of pain with erections and/or sex and the physical examination of the penis that shows abnormal angulation of the penile shaft or the presence of plaque or scarring felt or palpated in the penis is usually the basis for diagnosis.

• Urologists are specialists who usually diagnose and treat this disease.
• There are no definitive blood tests for this disease, although a human cell antigen, HLA-B7 has been associated with the disease.
• In general, no additional tests are necessary, but ultrasound techniques, when accompanied by an injection of the drug into the penis (intercavernous injection) can help show the doctor where and how extensive is the scarring and aid the doctor in determining treatments.

Several types of treatments are designed to reduce the symptoms of Peyronie's disease.

In December, 2013, the FDA approved collagenase clostridium histolyticum (Xiaflex) to treat individuals with Peyronie's disease. Each treatment cycle consists of two Xiaflex injections into the plaque in the penis to break up the collagen that causes the curvature deformity. Treatments consist of a maximum four injections.

Oral therapy with vitamin E, colchicine, PABA, tamoxifen, and other medications have been tried with limited success in some patients. Usually those in the acute phase of the disease responded best.

In the early stages of the disease, erectile dysfunction (ED) may be treated with such drugs as sildenafil (Viagra), vardenafil (Levitra), and tadalafil (Cialis, Adcirca).

Injection therapy uses combinations of drugs mentioned above and adds prostaglandin E1 or other drugs such as betamethasone alone or with hyaluronidase; PABA has been reported to reduce the penile plaque size.

Other drugs have also been used with varying degree of success. Verapamil (Calan, Verelan, Verelan PM, Isoptin, Isoptin SR, Covera-HS [a medication usually used for high blood pressure treatment]) appears to disrupt the production of a protein involved in the formation of Peyronie's disease lesions.

Another method is iontophoresis (also termed electromotive administration or EMDA) where verapamil and other drugs are applied to the penile skin and pushed through the skin with a low electrical current.

Shockwave therapy (done with a lithotripter device like those used to break up kidney stones) has been used on plaque or scarring that is calcified. Other mechanical devices, including vacuum-based machines and low-dose radiotherapy, have been tried. Although some successes are seen with these methods, the best results are in acute phase patients.

There are ongoing studies with different drugs (for example, interferons, and collagenase) and surgical techniques.

Surgical therapy is done on some patients. These surgical patients usually have to meet criteria that may vary from surgeon to surgeon. In general, surgical therapy is done when other methods have failed or the patient is in the chronic stage of the disease and erectile dysfunction is part of the patient's symptoms.

Surgical therapy may involve

• incision or cutting the scarred tissue,
• scar tissue removal,
• scar tissue removal with auto-grafting, or
• artificial graft material.
• In addition, implanted devices (penile implants) that allow the patient to sustain an erection are also utilized in some individuals.

Some individuals suggest stretching and/or milking the penis are exercises that can help reduce the penile curvature that occurs in the disease. Patients should discuss these techniques with their doctor (urologist) before using these methods.

The complications of the disease are mainly the symptoms of:

• Pain
• Painful intercourse
• Inability to have intercourse due to pain or erectile dysfunction
• Permanent angulation of the penis

In addition, surgical complications may include:

• Reduction in penis length
• Infections
• Loss of any erectile functions

Depression and stress can become significant complications.

The prognosis (outcome) of this disease is variable, from good to poor, depending on the response to treatment and the patient's emotional response to the symptoms and treatments. There is no treatment that will cure Peyronie's disease, but symptoms can be reduced.