Peyronie's Disease

Overview

Peyronie’s disease is the bending or curving of the penis during an erection. It is caused by scar tissue in the part of the penis that becomes firm during an erection and can cause significant pain.

Our team of urologists at City of Hope are experts who use leading-edge methods to diagnose and treat this condition.

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At City of Hope, the physicians in our Division of Urology and Urologic Oncology are leading experts in treating patients with all types of urologic disorders and urologic cancers. Just as no two patients are alike, Peyronie's disease requires a unique treatment plan tailored to each individual to attain the best possible outcomes.
 
As a founding member of the National Comprehensive Cancer Network, our doctors also help develop and improve evidence-based prostate cancer treatment guidelines for patients throughout the country.

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What is Peyronie's disease?

Peyronies disease (Courtesy: National Institute of Diabetes and Digestive and Kidney Diseases)

Peyronie’s disease is a disorder in which scar tissue, called a plaque, forms in the penis. The plaque builds up inside the tissues of a thick, elastic membrane called the tunica albuginea. The most common area for the plaque is on the top or bottom of the penis. As the plaque builds up, the penis will curve or bend, which can cause painful erections. Curves in the penis can make sexual intercourse painful, difficult, or impossible. Peyronie’s disease begins with inflammation, or swelling, which can become a hard scar.

The plaque that develops in Peyronie’s disease is not the same plaque that can develop in a person’s arteries. The plaque seen in Peyronie’s disease is benign, or noncancerous, and is not a tumor. Peyronie’s disease is not contagious or caused by any known transmittable disease. Usually men with Peyronie’s disease are referred to a urologist.


Anatomy

The visible part of the penis is composed of three primary chambers: the urethra and its surrounding supportive tissue and the two paired chambers that become firm during erections. These structures are comprised of a dense elastic covering called the tunica aluginea. The tunica forms a long, balloon-like structure that is filled with a highly vascular spongy tissue.

When an erection occurs, the spongy tissue fills with blood and the elastic tunica is stretched and becomes firm. As the corpora becomes hard, there are small veins that normally allow the blood to exit the spongy tissue that become plugged to trap blood in the penis during an erection.

In the case of Peyronie’s disease, there is scar tissue that develops within the tunica albuginea which may be painful at first. You may be able to feel the scar tissue in the non-erect penis, which feels like a firm lump in the shaft. Finally, the scar tissue will cause the penis to point toward the side of the scar.

In severe cases, it may be difficult for men to keep an erection due to scar tissue opening the tiny veins that are normally closed during an erection.

In extreme cases, the scar tissue will form on both sides of the corpora cavernosa, and the penis will form an indentation or hourglass deformity. When this happens, the penis may have a hinge-like effect during an erection.

What are the causes of Peyronie's disease?

Medical experts do not know the exact cause of Peyronie’s disease. Many believe that Peyronie’s disease may be the result of

  •     Acute injury to the penis
  •     Chronic, or repeated, injury to the penis
  •     Autoimmune disease—a disorder in which the body’s immune system attacks the body’s own cells and organs


Risk factors of Peyronie's disease

The following factors may increase a man’s chance of developing Peyronie’s disease:

  •     Vigorous sexual or nonsexual activities that cause microscopic injury to the penis
  •     Certain connective tissue and autoimmune disorders
  •     A family history of Peyronie’s disease
  •     Aging (between 40 and 70 years of age)     

Signs and symptoms of Peyronie's disease

  •     Hard lumps on one or more sides of the penis
  •     Pain during sexual intercourse or during an erection
  •     A curve in the penis either with or without an erection
  •     Narrowing or shortening of the penis
  •     ED - erectile dysfunction


Symptoms of Peyronie’s disease range from mild to severe. Symptoms may develop slowly or appear quickly. In many cases, the pain decreases over time, although the curve in the penis may remain. In milder cases, symptoms may go away without causing a permanent curve.

(Source: National Institute of Diabetes and Digestive and Kidney Diseases)
 

How we diagnose Peyronie’s disease

First, your doctor must assess the degree of curvature. This can be accomplished through photographs taken at home or an erection can be induced in the medical office. This is important step, as some surgical options are better when there is less curvature, while others are better when there is more curvature.

The strength of a patient’s erection must also be measured. Surgery for Peyronie’s can decrease the ability to get erections, therefore it is important to know how strong a patient’s erections were prior to pursuing surgical therapy. Did you need medications to achieve an erection? Did you require injections? Were you able to get erections at all? These questions will help determine the best course of action.

Treatment options for Peyronie’s disease

There are phases to this disease that must be taken into consideration when deciding on the best treatment option.

During the acute phase when the disease is first noticed, there may be excessive pain and the curving of the penis may worsen. The acute phase may last up to 12 months.

If there are no changes to the curve and it is no longer painful, this is the stable phase.  

The most important things to consider when treating Peyronie’s Disease are: how severe the curvature is, if the curvature is stable and if the patient is able to get strong erections despite the disease.

During the acute phase:

Medications and injections:  Experts disagree on the ideal treatment during the active phase of the disease. There are many oral, topical and injection therapies that have been tested; though none of these have been widely accepted. This indicates that there are probably no good options for treatment in the active phase, and many of the injections have not held up in sound clinical trials.

Vacuum erection device and traction therapy:  Patients are encouraged to consider these options, as both devices have been shown to have similar effectiveness in studies. There has also been data to suggest that if these devices are used postoperatively, there are improved outcomes.

During the stable phase:

Xiaflex:  Patients using Xiaflex can expect to see a 30 percent improvement in the degree of curvature. Xiaflex is an enzyme that targets a certain part of the scar tissue found in Peyronie’s disease and breaks it down The injection with Xiaflex is done over four cycles, each cycle involving an injection of Xiaflex into the plaque, another injection after one to three days, followed by in-office penile modeling one to three days after that. The patient is then asked to do this penile modeling at home for six weeks before returning to the office for the next treatment cycle.

For the most part, Xiaflex is a well-tolerated medication. Some pain and soreness is possible at the injection site and there can be some buildup of blood under the skin (hematoma). In rare cases, the erect penis can crack and cause significant bleeding (penile fracture). To avoid this, patients are instructed to refrain from intercourse for two weeks after the injection.

Plication:  The goal of a plication is to “pull” the penis into a straight line. If the scar is on the top of the penis, the plication is done at the bottom of the penis to pull it into a straight position while the scar itself is left in place. This is a good option when the curve is less than 60 degrees and there is no hourglass deformity or instability of the erection. Plication can result in loss of penile length. The scar has already caused the penis to lose length so when the penis is straightened, the length lost is more apparent. For each 30 degrees of curvature, you can anticipate one centimeter of length loss. Other side effects may include penile pain, edema and infections.

The advantage of this approach is that there is really no impact on erectile function. In addition, most cases of plication can be performed through small incisions.

Plaque incision/excision and grafting:  In this type of repair, the plaque is either cut into or removed entirely, then replaced with a patch. The patch can be composed of a vein graft or cadaveric pericardium (tutoplast).  

The graft technique is best for curves over 60 degrees, in those with an hourglass deformity or patients experiencing any degree of penile instability with erection.

In this approach, there is restoration of any penile length that was lost, but it is not a good option for men with erectile dysfunction (ED), as it can worsen their condition.

All penile surgeries run the risk of pain, bleeding, infection and hematoma. With plaque incision/excision and grafting, there is a 20 percent chance that erectile function will worsen after the operation. Therefore, it is important to know how strong the patient’s erections were before the operation. This type of treatment should be avoided if there are any issues achieving an erection.

If the plaque is on top of the penis and the curve is upward, then the nerves that control the sensation at the top of the penis have to be delicately peeled off the tunica to expose the plaque. When this is performed, there is a chance of injuring the nerves, causing numbness to the head of the penis. It is not uncommon for there to be numbness immediately after surgery, but this should improve in the first few months post-op. 

Penile Implant:  In cases of Peyronie’s disease and significant ED, the best treatment is a penile implant. During the operation, there are several techniques that may be used to straighten the penis. In addition, the penis will straighten itself over time with a penile implant in place.  

Side effects of penile implant include infection, device failure, device erosion, penile pain and bleeding.

City of Hope brings expert urologic care to treating any urologic condition.

Urologic Surgeons - Duarte

Clayton S. Lau, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Kevin G. Chan, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Laura Crocitto, M.D., M.H.A.

Clinical Specialties

  • Urologic Oncology
  • Urology
Jonathan Lim Yamzon, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Bertram Yuh, M.D., M.S.H.C.P.M., M.I.S.M.

Clinical Specialties

  • Urologic Oncology
  • Urology

Urologic Surgeons - Community

Clayton S. Lau, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Seth A. Cohen, M.D.

Clinical Specialties

  • Female Pelvic Medicine and Reconstructive Surgery
Donald Hannoun, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Roger W. Satterthwaite, M.D., M.P.H.

Clinical Specialties

  • Urologic Oncology
  • Urology
Jonathan N. Warner, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
  • Reconstructive Urology
Kristina Wittig, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Jonathan Lim Yamzon, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Benjamin J. Yuh, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology
Bertram Yuh, M.D., M.S.H.C.P.M., M.I.S.M.

Clinical Specialties

  • Urologic Oncology
  • Urology
Ali Zhumkhawala, M.D.

Clinical Specialties

  • Urologic Oncology
  • Urology

Urologists - Community

Edward L. Davis, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
Philip G. Pearson, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
David W. Rhodes, M.D.

Clinical Specialties

  • Urology and Urologic Oncology
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