Peyronie's Disease

Both Peyronie’s Disease and congenital penile curvature can be found in adolescents and young adults and therefore the age of onset is not a good criterion to distinguish between the two conditions. However, in patients with congenital penile curvature there is no palpable lump, which is instead indicative of Peyronie’s Disease.  Also, while most congenital curvatures are ventral, in most patients with Peyronie’s Disease the penis bends upward. Waist deformities are also absent in patients with congenital curvature, which tend to be more gentle and harmonic than the one of patients with Peyronie’s Disease.

While erectile dysfunction is a common finding in patients with Peyronie’s Disease, most patients with congenital penile curvature have adequate erections, as there is no association between cardiovascular risk factors and congenital penile curvature. To render the situation more confusing, some of the patients with congenital penile curvature may eventually develop Peyronie’s Disease later in life and therefore both conditions may coexist.

Peyronie’s Disease is an acquired condition characterized by the formation of scars in the tunica albuginea of the penis. These scars can be easily palpated as a lump and tend to be tender for a few months during the initial phase of the disease.

Peyronie’s Disease plaques cause loss of elasticity of the tunica of the penis and this reduces the capacity of the penis to stretch during erections. Patients therefore frequently report penile shortening and deformity such as curvature and narrowing of the shaft penis, which become visible during erections. In flaccidity the lumps can still be palpated, but the deformity is not visible.

Peyronie’s disease is frequently associated with other known cardiovascular risk factors, such as diabetes, high blood pressure, high cholesterol levels, obesity and tobacco smoke. It is now established that more than 60% of patients have at least one known cardiovascular risk factor.

Worsening of the quality of the erections is quite common in patients with Peyronie’s Disease; although this can be potentially caused by the plaque itself, as it allows the blood to be rushed out of the tunica of the penis, certainly also the cardiovascular risk factors play a role by causing obstruction to the arteries feeding the penis, thus reducing the blood inflow into this organ.

Since Peyronie’s Disease can be associated with penile pain, shortening, deformity and worsening of the quality of the erection, it can be cause of severe distress in both the patient and the partner.

At present, the actual mechanism causing Peyronie’s disease is still unknown. It is suspected that Peyronie’s Disease occurs in the genetically predisposed patient following trauma to the erect penis during sexual activity. It is believed that patients with Peyronie’s Disease present an imbalance in the factors that regulate the healing process following tissue damage and this leads to excessive local tissue proliferation.

Typically Peyronie’s Disease presents an initial acute and a chronic phase. The acute phase is characterized by the formation of the plaque, which is tender at palpation as there is an active local inflammatory process. During this phase, stretching of the plaques, as physiologically occurs during erections, elicits vivid pain. Plaque size and type of deformity tend to change over time during this phase. The chronic phase starts when the inflammatory process eventually settles, usually within 9 months from the onset of the condition. At this stage the pain generally settles and the deformity does not change any more in time. 

Peyronie’s Disease is a quite common condition as it affects around 10% of men. Although it is typically a condition of the fifth and sixth decade of life, Peyronie’s Disease can occur at any age. Usually in the adolescent the condition tends to be more aggressive in terms of size of the plaque and degree of deformity produced.

Potentially any male can develop Peyronie’s Disease, although the condition is more likely to occur in the fifth and sixth decade of life and in patients with cardiovascular risk factors.

Due to the strong link between Peyronie’s Disease and disease, patients presenting with this condition should always be actively screened for the known cardiovascular risk factors such as high blood pressure, diabetes and high cholesterol levels.

The initial, acute phase of Peyronie’s Disease is usually characterized by the formation of a tender nodule on the tunica of the penis. Erections at this stage tend to be painful and patients usually notice a penile deformity, which, at this stage, still changes over time.

The inflammatory process progressively settles and this leaves a non-tender nodule on the tunica of the penis. At this stage erections are generally not painful and patients usually complain of penile shortening and deformity, which become apparent during erections. Many patients also report a progressive worsening of the quality of the erections.

Peyronie’s Disease diagnosis is based on history taking and on the examination of the patient. Frequently patients report that the disease has started following a trauma to the penis during sexual activity. Examination of the penis will demonstrate the presence of a lump, which can be elastic or indurated in texture.

Deformity can be assessed only during erections, when the tunica albuginea of the penis is stretched to its maximum capacity. Self-photography of the erect penis can be a useful tool to identify the nature of the deformity. However, this can underestimate the exact tridimensional extent of the curvature, as the picture is by definition bi-planar. Also, an incomplete erection will make the deformity appear less pronounced.

Alternatively, an artificial erection can be induced in the office with the administration of a vasoactive medication. This allows the surgeon to assess more precisely the tridimensional extent of the curvature and better plan the treatment options.

As patients with Peyronie’s Disease frequently have cardiovascular disease, which might have produced a degree of obstruction of the arteries feeding the penis, a thorough assessment of the penile blood supply should be carried out performing an Eco Colour Doppler Ultrasound Scan. This investigation will provide the surgeon with extremely precious information that will also help to better decide which is the most appropriate treatment option for each specific patient.

There are various treatment options for Peyronie’s disease depending on the progression of the disease:

a) There is very little evidence that medical treatment is effective during the beginning phase of the disease. Treatment options such as oral medication, topical treatments and supplements such as oral vitamin E, Tamoxifen, Pentoxyphilline, Potassium Paraaminobenzoate, Colchicine and Verapamil have been offered to patients with no proven success on reducing penile curvature or plaque size, however they may help with pain management and potentially slowing the progression of the disease. 

b) There may be rationale for penile stretching and straightening exercises during the acute phase of the disease. This can be achieved either by enhancing natural erections with the administration of  Phosphodiesterase Type 5 Inhibitors such as Sildenafil, Tadalafil and Vardenafil, or mechanically, with the use of a vacuum or stretching device. Either treatment on its own is unlikely to show an enormous benefit, and should be performed together to get any result. The evidence of the effectiveness of the use of the vacuum pump or penile stretching device in isolation to mechanically straighten the penis is minimal. In the best-case scenario, the regular use of these devices may just slightly reduce penile curvature, which would be beneficial only in very selected patients (under 10%).

c) Injections of the Collagenase of the Clostridium Histolyticum (Xiapex®) is one of the latest treatment options available for Peyronie’s and the first non-surgical therapy that has proved effective in treating Peyronie’s plaque. These injections treat the curvature by “chemically” softening the plaque and restoring some of the length lost due to the scarring process. Xiapex® injections provide better results if combined with the regular use of a vacuum pump or of the penile stretching device in order to provide extra stretch of the plaque softened by the Collagenase of the Clostridium Histolyticum. These should be performed at 4 weeks intervals and the residual curvature should be assessed after the third injection, once the healing process at the level of the plaque is likely to be complete. If significant deformity persists, the cycle injection/stretching can be repeated. In expert hands, Xiapex® injections are a simple and safe procedure and can be performed in the outpatients’ clinic and would typically be the first line of treatment (subject to Consultant doctors diagnosis).

d) Surgery represents the gold standard treatment for Peyronie’s Disease and its aim is to guarantee a penis straight and hard enough to allow the patient to engage in penetrative sexual intercourse without pain or discomfort. The choice of the best surgical approach, apart from patients’ preference, should take in consideration the quality of erection and the degree of deformity and shortening. In patients with preserved erections, the curvature can be corrected either by shortening the longer side of the penis, which has not been affected by Peyronie’s Disease, or lengthening the shorter side incising the plaque and interposing a graft. Both procedures can be performed as a day case. Before the introduction of Xiapex, surgery was the only effective treatment for penile curvature caused by Peyronie’s and still remains the most successful for most patients. Surgery should only be performed after the disease progress has stopped which usually occurs 12 months from onset (chronic phase).