Peyronie's Disease

Peyronie’s disease is characterized by a plaque, or hard lump, that forms within the penis. The plaque, a flat plate of scar tissue, develops on the top or bottom side of the penis inside a thick membrane called the tunica albuginea, which envelopes the erectile tissues. The plaque begins as a localized inflammation and develops into a hardened scar. This plaque has no relationship to the plaque that can develop in arteries.

Cases of Peyronie’s disease range from mild to severe. Symptoms may develop slowly or appear overnight. In severe cases, the hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection. In many cases, the pain decreases over time, but the bend in the penis may remain a problem, making sexual intercourse difficult. The sexual problems that result can disrupt a couple’s physical and emotional relationship and can lower a man’s self-esteem. In a small percentage of men with the milder form of the disease, inflammation may resolve without causing significant pain or permanent bending.

The plaque itself is benign, or noncancerous. It is not a tumor. Peyronie’s disease is not contagious and is not known to be caused by any transmittable disease.

A plaque on the topside of the shaft, which is most common, causes the penis to bend upward; a plaque on the underside causes it to bend downward. In some cases, the plaque develops on both top and bottom, leading to indentation and shortening of the penis. At times, pain, bending, and emotional distress prohibit sexual intercourse.

Estimates of the prevalence of Peyronie’s disease range from less than 1 percent to 23 percent.1 A recent study in Germany found Peyronie’s disease in 3.2 percent of men between 30 and 80 years of age.2 Although the disease occurs mostly in middle age, younger and older men can develop it. About 30 percent of men with Peyronie’s disease develop hardened tissue on other parts of the body, such as the hand or foot. A common example is a condition known as Dupuytren’s contracture of the hand. In some cases, Peyronie’s disease runs in families, which suggests that genetic factors might make a man vulnerable to the disease.

A French surgeon, François de la Peyronie, first described Peyronie’s disease in 1743. The problem was noted in print as early as 1687. Early writers classified it as a form of impotence, now called erectile dysfunction (ED). Peyronie’s disease can be associated with ED—the inability to achieve or sustain an erection firm enough for intercourse.


How does Peyronie’s disease develop?

Many researchers believe the plaque of Peyronie’s disease develops following trauma, such as hitting or bending, that causes localized bleeding inside the penis. Two chambers known as the corpora cavernosa run the length of the penis. A connecting tissue, called a septum, runs between the two chambers and attaches at the top and bottom of the tunica albuginea.

If the penis is bumped or bent, an area where the septum attaches to the tunica albuginea may stretch beyond a limit, injuring the tunica albuginea and rupturing small blood vessels. As a result of aging, diminished elasticity near the point of attachment of the septum might increase the chances of injury. In addition, the septum can also be damaged and form tough, fibrous tissue, called fibrosis.

The tunica albuginea has many layers, and little blood flows through those layers. Therefore, the inflammation can be trapped between the layers for many months. During that time, the inflammatory cells may release substances that cause excessive fibrosis and reduce elasticity. This chronic process eventually forms a plaque with excessive amounts of scar tissue and causes calcification, loss of elasticity in spots, and penile deformity.

While trauma might explain some cases of Peyronie’s disease, it does not explain why most cases develop slowly and with no apparent traumatic event. It also does not explain why some cases resolve or why similar conditions such as Dupuytren’s contracture do not seem to result from severe trauma.


How is Peyronie’s disease evaluated?

Doctors can usually diagnose Peyronie’s disease based on a physical examination. The plaque can be felt when the penis is limp. Full evaluation, however, may require examination during erection to determine the severity of the deformity. The erection may be induced by injecting medicine into the penis or through self-stimulation. Some patients may eliminate the need to induce an erection in the doctor’s office by taking a digital or Polaroid picture at home. The examination may include an ultrasound scan of the penis to pinpoint the location(s) and calcification of the plaque. The ultrasound can also be used to evaluate blood flow into and out of the penis if there is a concern about erectile dysfunction.


How is Peyronie’s disease treated?

Men with Peyronie’s disease usually seek medical attention because of painful erections, penile deformity, or difficulty with intercourse. Because the cause of Peyronie’s disease and its development are not well understood, doctors treat the disease empirically; that is, they prescribe and continue methods that seem to help. The goal of therapy is to restore and maintain the ability to have intercourse. Providing education about the disease and its course often is all that is required. No strong evidence shows that any treatment other than surgery is universally effective. Experts usually recommend surgery only in long-term cases in which the disease is stabilized and the deformity prevents intercourse.

Because the course of Peyronie’s disease is different in each patient and because some patients experience improvement without treatment, medical experts suggest waiting 1 year or longer before having surgery. During that wait, patients often are willing to undergo treatments whose effectiveness has not been proven.

Medical Treatments

Researchers conducted small-scale studies in which men with Peyronie’s disease who were given vitamin E orally reported improvements. Yet, no controlled studies have established the effectiveness of vitamin E therapy. Similar inconclusive success has been attributed to aminobenzoate potassium (Potaba). Other oral medications that have been used include colchicine, tamoxifen, and pentoxifylline. Again, no controlled studies have been conducted on these medications.

Researchers have also tried injecting chemical agents such as verapamil, collagenase, steroids, and interferon alpha-2b directly into the plaques. Verapamil and interferon alpha-2b seem to diminish curvature of the penis. The other injectable agent, collagenase, is undergoing clinical trial and results are not yet available. Steroids, such as cortisone, have produced unwanted side effects, such as the atrophy or death of healthy tissues. Another intervention involves iontophoresis, the use of a painless current of electricity to deliver verapamil or some other agent under the skin into the plaque.

Radiation therapy, in which high-energy rays are aimed at the plaque, has also been used. Like some of the chemical treatments, radiation appears to reduce pain, but it has no effect on the plaque itself and can cause unwelcome side effects such as erectile dysfunction. Although the variety of agents and methods used points to the lack of a proven treatment, new insights into the wound healing process may one day yield more effective therapies.

Xiaflex (collagenase clostridium)

Xiaflex (collagenase clostridium) has been approved in the past for the treatment of Dupuytren's contractions with significant success. The theory is that the collagenase breaks up the collagen fibers resulting in a relief and improvement in a deformity associated with this condition.

This has recently been approved for treatment of Peyronie’s disease. In two clinical trials, a 35% improvement was noted in men with a penile deformity of at least 30 degrees (placebo improvement approximately 20%). Additionally, there was an improvement in the Peyronie's bother domain compared to placebo.

Corpora rupture (penile fracture) was reported in 0.5% of men with Xiaflex. Additionally, greater than 25% of the men reported an incident greater than placebo of penile hematoma, penile swelling and penile pain.

In Xiaflex administration/home treatment, a solution of 0.25 cc of reconstituted collagenase is injected into the plaque at the point of maximum deformity (based on a pharmacological-induced erection). A second injection into the plaque is repeated 1-3 days later both in the office. The patient returns to the office 1-3 days later for penile modeling which involves stretching the penis in the flaccid state along with bending for approximately 30 seconds and then repeated twice with 30 second rest periods. The patient then proceeds for six weeks to perform penile modeling activities at home which include stretching the penis for 30 seconds, three times a day and penile straightening at least once a day for 30 seconds. The patient should abstain from sexual activity for at least two weeks. Up to four treatment cycles may be administered per plaque.

Surgery

Three surgical procedures for Peyronie’s disease have had some success. One procedure involves removing or cutting of the plaque and attaching a patch of skin, vein, or material made from animal organs. This method may straighten the penis and restore some lost length from Peyronie’s disease. However, some patients may experience numbness of the penis and loss of erectile function.

A second procedure, called plication, involves removing or pinching a piece of the tunica albuginea from the side of the penis opposite the plaque, which cancels out the bending effect. This method is less likely to cause numbness or erectile dysfunction, but it cannot restore length or girth of the penis.

A third surgical option is to implant a device that increases rigidity of the penis. In some cases, an implant alone will straighten the penis adequately. If the implant alone does not straighten the penis, implantation is combined with one of the other two surgical procedures.

Most types of surgery produce positive results. But because complications can occur, and because many of the effects of Peyronie’s disease—for example, shortening of the penis—are not usually corrected by surgery, most doctors prefer to perform surgery only on the small number of men with curvature severe enough to prevent sexual intercourse.

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