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A man’s penis is an important part of his identity as a man. It serves a critical role in urinary function. Its function as a sexual organ is also important; sexuality is a source of physical pleasure, emotional bonding, and procreation.
Unfortunately, the penis is prone to injuries and problems just like any other part of the human body and some of these injuries may have an impact on a man’s enjoyment of sex. One particular problem that has received increasing attention in recent years is Peyronie’s disease, a condition in which painful, hard plaques form underneath the skin of the penis leading to penile curvature. If you have pain and penile curvature characteristic of Peyronie’s disease, the following information may help you understand your condition.
The penis is a cylindrical organ consisting of three separate chambers. On the upper (dorsal) portion of the penis there are two corpora cavernosa (penile tissue) that are surrounded by a tough but elastic layer of connective tissue called the tunica albuginea. The third chamber is called the corpus spongiosum; it is located below the corpora cavernosa and is surrounded by a thin connective tissue sheath. It contains the urethra, the narrow tube that carries urine and semen out of the body.
These three chambers are made up of highly specialized, sponge-like erectile tissue filled with thousands of venous cavities, spaces that contain very little blood when the penis is soft. During erection, blood fills these cavities, causing the corpora cavernosa to balloon and push against the tunica albuginea. While the penis hardens and stretches, the skin and connective tissue of the penis remain loose and elastic to accommodate the changes.
Peyronie’s disease (also known as induratio plastica penis) is a connective tissue disorder that causes the penis to curve. Men may also notice discomfort with erections and/or difficulty with intercourse. The principle manifestation of Peyronie’s disease is the formation of a plaque (a segment of flat scar tissue) within the tunica albuginea of the penis. This plaque can usually be felt through the penile skin. This plaque is not a tumor but it may lead to serious problems such as curved and/or painful erections.
The name “Peyronie’s Disease” is derived from the physician Francois Gigot de la Peyronie, personal physician to King Louis XV of France. De la Peyronie wrote an authoritative description of the disorder in 1743 and his name has been associated with the condition since that time.
The plaques of Peyronie’s disease most commonly develop on the upper (dorsal) side of the penis. Plaques reduce the elasticity of the tunica albuginea and may cause the penis to bend upwards during the process of erection. Although Peyronie’s plaques are most commonly located on the top of the penis, they may also occur on the bottom (ventral) or side (lateral) of the penis, causing a downward or sideways bend, respectively. Some men have more than one plaque, which may cause complex curvatures.
In some men an extensive plaque that goes all the way around the penis may develop. These plaques typically do not cause curvature but may cause a “waisting” or “bottleneck” deformity of the penile shaft. In other severe cases, the plaque may accumulate calcium and become very hard, almost like a bone. In addition to penile curvature, many patients also report shrinkage or shortening of their penis.
Since there is great variability in this condition, men with Peyronie’s disease may complain of a variety of symptoms:
Peyronie’s disease can be a serious quality-of-life issue. Studies have shown that over 75% of men with Peyronie’s disease have stress related to the condition. Unfortunately, many men with Peyronie’s disease are embarrassed about the condition and choose to suffer in silence rather than speaking with their health care provider about it. Please contact us if you think you may have this condition.
Recent demographic surveys have reported that Peyronie’s disease can be found in up to 9% of men between the ages of 40 and 70. The condition is rare in young men but has been reported in men in their 30s. The actual prevalence of Peyronie’s disease may be much higher than 9% due to patient embarrassment and limited reporting by physicians.
Interestingly, more Peyronie’s disease cases have been reported in recent years. This is likely due to the availability within the last decade of highly effective oral medications for the treatment of erectile dysfunction (ED). With more men seeking treatment for erectile problems, many cases of Peyronie’s disease that would have gone undiagnosed in the past have come to the attention of the medical establishment.
Scientists have been mystified by the cause of Peyronie’s disease since before it was characterized by Francois Gigot de la Peyronie. Although the process by which Peyronie’s disease occurs is still not entirely understood, much progress in our understanding of the disorder has been made in recent years.
Most experts believe that Peyronie’s disease is likely the consequence of a minor penile trauma. The most common source of this type of penile trauma is thought to be vigorous sexual activity (e.g., bending of the penis during penetration, pressure from a partner’s pubic bone, etc.) although injuries from sports or accidents may also play a role. Injury to the tunica albuginea may trigger a cascade of inflammatory and cellular events resulting in a process called fibrosis, a medical term for formation of excessive scar tissue. This abnormal scar tissue in turn forms the plaque of Peyronie’s disease.
Men with certain connective tissue disorders (such as Dupuytren’s contractures or tympanosclerosis) and men who have a close relative with Peyronie’s disease have a greater risk of developing the condition. Certain health conditions such as diabetes, tobacco use, or a history of pelvic trauma may also lead to abnormal wound healing and may contribute to the development of Peyronie’s disease.
Peyronie’s disease is in essence a derangement of normal wound healing. Because it is related to normal wound healing, Peyronie’s disease is a very dynamic process early on but over time, the inflammatory changes may decrease. In fact, this disease is usually divided into two distinct stages. The first phase is the acute phase; this portion of the disease persists for six to 18 months and is usually characterized by pain, worsening penile curvature and formation of penile plaques. The second phase is the chronic phase where the deformity remains in a stable state, and pain is no longer an issue.
A physical examination by an experienced physician is usually sufficient to diagnose Peyronie’s disease. The hard plaques can usually be felt with or without erection. It may be necessary to induce an erection in the clinic for proper evaluation of the penile curvature; this is usually done by direct injection of a medication that causes penile erection. Pictures of the erect penis may also be useful in the evaluation of penile curvature. In some cases an ultrasound or x-ray examination of the penis is used to characterize the plaque and check for the presence of calcification.
In about 13% of cases, Peyronie’s disease goes away without treatment. Many physicians recommend conservative (non-surgical) treatment for at least the first 12 months after symptoms present.
There are different options for treatment depending on the severity of your disease. Men who have a minimal curvature ( 30 degrees) or those who are unable to have intercourse due to the condition would benefit from either injectable treatment or surgery.
Conservative treatment options:
Injecting a drug directly into the plaque of Peyronie’s disease is an attractive alternative to oral medications. Injection permits direct introduction of drugs into the plaque, permitting higher doses and more local effects.
Xiaflex® – Xiaflex is an effective, new option that has recently been FDA approved for men with a penile curvature of about 30 degrees or more with a fibrous, palpable lesion. This is an injectable treatment that is administered in the clinic, and requires close follow-up. Xiaflex contains collagenase, which is an enzyme that degrades collagen, the fibrous material that Peyronie’s plaques are made of. It is administered as a series of two injections, for up to four cycles. After artificially inducing an erection in our clinic, the medication is injected directly into the penile plaque. After administration, we will instruct you on at home stretching and straightening of the penis that is required after you receive the injections. Side effects may include penile bruising, pain, and fracture.
Patients who may be eligible for Xiaflex exhibit the following symptoms:
Other penile injections such as verapamil and interferon have also used in the treatment of Peyronie’s Disease.
Other investigative therapies
Many alternative methods for treating Peyronie’s disease have been reported. Examples include high-intensity focused ultrasound, radiation therapy, shock-wave treatment, topical verapamil, hyperthermia, and many others. While the scientific rationale for these other approaches is sound, at this time there is not enough data to support their use outside of a research setting at this time.
Surgical Treatment of Peyronie’s Disease
Surgery is reserved for men with severe, disabling penile deformities that prevent satisfactory sexual intercourse. Most physicians recommend avoiding surgery until the plaque and deformity have been stable and the patient pain-free for at least six months. An evaluation of the penile blood supply using injection of erection producing medications is often done prior to any surgery. A penile ultrasound may be performed at the same time. These two tests permit assessment of whether or not the man has significant ED and may also provide important anatomical information that will help guide the choice of surgical procedure.
There are three general approaches to surgical correction of Peyronie’s disease:
A light pressure dressing is typically left on the penis for 24 to 72 hours after the surgery to prevent bleeding and hold the repair in place. In some cases, patients will wake up with a catheter in the bladder but this is usually removed in the recovery room. Most patients are discharged later the same day or the following morning. The patient is also often given several days of antibiotics to reduce the risk of infection and inflammation and a pain medication for discomfort. In most cases surgeons recommend not engaging in sexual activity for at least 4-6 weeks after surgery, longer in some cases of complex repairs. At your visit, we will discuss detailed post-operative instructions and expectations based on the type of surgery you had.
About 30 percent of men with Peyronie’s disease develop fibrosis in other areas of the body. The most common sites are the hands and feet. Dupuytren’s contracture is a condition classically associated with Peyronie’s disease in which fibrosis occurs in the tissue of the palm. Dupuytren’s contracture may lead to progressive permanent bending of the fingers. While the fibrotic process in Peyronie’s disease and Dupuytren’s contracture is similar, it is not clear at this time what causes either plaque to develop and why men with Peyronie’s disease are more likely to develop Dupuytren’s contracture.
Cells obtained from Peyronie’s plaques have shown a number of characteristics similar to cancer cells, such as the ability to resist a process of programmed cell death called apoptosis, and to form tumors when transplanted into mice with no immune systems. However, there has never been a case of Peyronie’s disease that has turned into a cancer in a human. However, if your doctor observes other findings that are not typical with this disease—such as external bleeding, obstructed urination, or prolonged severe penile pain—he or she may elect to perform a biopsy on the tissue for pathological examination.
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