Penile Curvature | Peyronie's Disease

 

Background

 

Curvature of the penis is known as chordee. Some curvature of the penis is normal and many men are born with a slight curvature - usually the bend is downward. This is known as congenital chordee. By comparison, Peyronie's disease is an acquired disorder of the penis characterized by deformity of the erect penis, painful erection and a plaque (a firm disc of scar tissue). Patients do not need to have all of these features to have Peyronie's disease.

 

Peyronie's disease is much more common than has previously been appreciated. It occurs in between 1-in-10 to 1-in-20 men and can occur at any age. The severity of the condition can vary markedly with some men barely noticing the changes and some men profoundly affected by the complete loss of erections and severe curvature which can make intercourse difficult or impossible.

 

Scarring occurs within the tunica albuginea. This restricts expansion of the penis resulting in shortening of the penis and if the scarring is lopsided, the shaft will expand unequally and the penis will be bent when erect. Scarring in the tunica may also result in loss of the penis' ability to retain the blood necessary to obtain a firm erection. This is known as venous leak. Erectile dysfunction can result.

 

There are usually 2 phases for Peyronie's disease:

 

  1. Acute/Initial Phase
  2. Chronic Phase

 

During the acute/initial phase, plaque formation, erectile dysfunction and pain are common. This phase usually lasts for about 6-18 months. Changes can be ongoing, and for this reason surgery is not performed during the active phase. In a small number of men, there can be spontaneous improvement in some aspects of the condition including reduced curvature, size or hardness of the plaque and gaining back some lost length.

 

The chronic phase is entered once no further progression in the condition is noted and can be confirmed by the absence of change for about 6 months.

 

Peyronie's disease is named for the surgeon to Louis XV, Francois de la Peyronie. He first described the diesease in 1743. Prounounced 'pay-roh-neez di-zeez'.

 

Information on penile anatomy can be found here. In general, the average length of an erect penis is about 5.5 inches.

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Causes

 

The cause of Peyronie's disease is unknown. Many hypotheses have been put forward including wound healing disorders, genetic, altered scar tissue formation and traumatic injury. Micro-tears of the tunica albuginea with repeated usage or penile fracture have been proposed as leading causes. In reality, the true cause is unknown, or 'idiopathic'.

 

This condition has been associated with a number of different diseases, including diabetes and connective tissue diseases such as Dupeytren's contractures (affect hands), plantar fasciitis (affects the feets) and tympanic sclerosis (affects the ear drums). It is unclear if these diseases cause Peyronie's or, more likely, if there is a similar disease process which leads to both. It is unclear if radical prostatectomy for prostate cancer is a risk factor for the development of Peyronie's disease.

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Diagnosis & Evaulation

 

The diagnosis of Peyronie's disease is made by an interview and physicial exam. Critical to evaluation is a review of the erect penis. Pictures are very helpful in this respect and are a requirement before surgery will be entertained. The location, direction and degree of curvature are important. Plaque size and location are also important. Ideally, pictures of the erect penis taken from the (1) top down and (2) side will be helpful in assessment.

 

What we will want to know about your condition - think about these questions before coming in.

  1. When did your first notice symptoms?
  2. Was the onset of your condition related to penile bruising or pain following intercourse?
  3. Do you have a plaque (a firm area on the penis)?
  4. Which direction is your penis curved? How much of a curve is present (e.g. 45˚)?
  5. Have you noticed that your penis has become shorter or narrower than before?
  6. How are your erections?

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Treatment: Overview

 

The treatment options and goals of treatment will depend on the phase of the Peyronie's disease (active or chronic) and the degree of curvature. The most important consideration is always FUNCTION. That is, the ability to obtain an erection which is satisfactory for enjoyable intercourse for the patient and their partner. This does NOT mean that the penis need be straight, free of bends, free of plaques or the same length as it was earlier in life. Having realistic expectations is critical. There is no man whose penile function can be restored to the way it was when they were in their teens! Treatment options can be classified as:

 

Treat the Curvature and Plaque Treat the Erectile Dysfunction
  1. General measures
  2. Penile traction therapy
  3. Oral medication
  4. Injection therapy
  5. Penile straightening surgery
    1. Plication
    2. Incision and grafting
  1. Oral medications: Cialis, Viagra, Levitra
  2. Injection therapy
  3. Penile prosthesis

 

Treatment: The Acute Phase

 

As of 2011, there is no medication that can reliably cure Peyronie's disease.

 

Historically, there have been a large number of treatments applied to this frustrating condition during the active phase, resulting in a very long list of treatments. Much of the lack of effectiveness of medications stems from the fact that the exact cause of Peyronie's disease is unknown.

 

General Measures

 

General measures such as a multivitamin, avoidance of further penile injury and potentially a penile traction device may limit the severity of the disease. You can safely engage in intercourse as long as it is mechanically possible - that is, don't force things. Ask your doctor if you are having trouble achieving an erection - medication may help.

 

PENILE TRACTION DEVICES may be effective in limited the loss of penile length during the active phase and may be used prior to penile surgery, especially placement of penile prostheses. Just about every man with active Peyronie's disease should try one. One issue with these devices is the relatively long length of time they need to be left on in order to be effective.

 

Medications

 

The optimal use of medical therapy is used during the active phase is controversial. The quality of the investigations of the various treatments is fairly limited and it is impossible to state that one treatment is clearly superior to others. In general, the effectiveness of medications is limited and it is not unreasonable to simply wait for the active phase to pass without any medication. Some of the commonly used treatments during the active phase include:

 

Penile verapamil injections

Mechanism of action: this calcium channel blocker may reduce scar formation; mechanical breakdown of the scar may result from the needle used to inject the medication

Administration: dosage varies, but a penile anesthetic block is placed and usually 2 ml of verapamil is injected into the plaque with needle (verapamil comes in 5 mg/2 ml vials (2.5 mg per ml); packs of 10.

One manufacturer is Sandoz DIN 02166739 (Code 8960)

Potential side effects: generally restricted to penile bruising; potential side effects include penile numbness

Pentoxyfylline (Trental)

Mechanism of action: improves blood flow through an unknown mechanism; may have anti-oxidant effects and limit scar formation

Administration: the usual dosage is 400 mg 2-3 times per day; best taken with meals

Potential side effects

Common: stomach upset (including nausea and vomiting), dizziness, headache, blurred vision, insomnia

Uncommon: abnormal heart beats, elevation in liver function tests, drug-induced hepatitis

 Vitamin E
Mechanism of action: antioxidant effect has been used to help with scar healing

Administration: 400 IU daily

Potential side effects

Common: there are virtually no common side effects unless vitamin E is taken at megadoses

Uncommon: Large scale trials in older individuals have suggested a possible increase in mortality and heart failure iwth long-term use of doses 400 IU or more. Should be used with caution if taking coumadin (warfarin).

Comments: Vitamin E has limited data to support benefit in Peyronie's disease. Some early studies with serious methodological flaws suggested improvement in pain and or curvature. Better designed studies have not demonstrated a significant benefit vs. a placebo. Having said that, the potential adverse effects are probably minimal and it is inexpensive.

Collagenase

Mechanism of action: breakdown of plaque

Administration: Intralesional Collagenase injections (Xiaflex 0.58 mg reconstituted in about 0.39 cc NS) x 4 cycles; each cycle 2 injections separated by 2 days follwed by penile remodelling 2-3 days after last injection. 6 weeks between injections.

Potential side-effects: Minor bruising from the injection. Rare cases of rupture of the corporal bodies with 'modelling' have been reported.

Comments: not covered by Pharmacare; approved for use by the FDA in the US

 

Penile Straightening Surgery

 

Surgery is only considered once the acute phase has passed. This generally means that there should have been no change in the degree of curvature, penile pain, size of the plaque or deterioration in erectile dysfunction for at least 6 months.

 

The goals of surgery are:

 

  1. Straighten the penis
  2. Obtain a uniform calibre
  3. Enhance or preserve pre-operative erectile function
  4. Minimize loss of length

 

As with any surgery, there is always the potential for complications which may include:

 

  1. Penile shortening. Peyronies disease is frequently associated with some loss of length. Age can also result in penile shortening. These may not be reversible and in addition, most types of surgery are associated with a small measureable loss of length in the range of 1-2 cm.
  2. Erectile dysfunction. Worsening of erections can occur with any of the corrective surgeries, but are most common with the incision and grafting approaches. If a man has borderline erections to start with, then surgery may result in the loss of native erections. In these situations, the placement of a penile prosthesis should be considered
  3. Penile numbness. Numbness and decreased sensation, especially of the tip, can occur with any kind of penile surgery.

 

This is not meant to be an extensive list of complications and there are other sorts of problems that can arise following surgery. Fortunately, many of these complications are minor and things such as penile numbness tend to improve with time. Many studies have demonstrated that men's recollections of their erectile ability and penile length are different than what it actually was - usually the recollection is biased towards an over-inflated memory of length and performance than was actually present. For this reason, it is very important that patients understand the potential complications and most importantly HAVE REALISTIC EXPECTATIONS OF WHAT SURGERY CAN DO FOR THEM. As mentioned previously the primary goal of surgery is allow a man to engage in intercourse without discomfort to him or his partner.

 

There are 2 primary types of penile straightening surgery.

 

FOR THE VAST MAJORITY OF MEN, A PLICATION APPROACH IS THE BEST SURGICAL OPTION

 

The primary reason that plicationis usally preferred is that plication is fairly straightforward, reproducible and associated with a much, much lower risk of erectile dysfuction, pain or numbness. Many specialists in erectile dysfunction and Peyronie's disease have largely abandoned grafting. While we continue to use grafting, we do so sparingly.

 

Plication Procedures Incision and Grafting

 

The curvature of PD is usually secondary to a scar/plaque related restriction of penile lengthening. This is akin to placing a piece of tape on a sausage balloon - inflation of the balloon results in normal expansion of one side but decreased expansion on the other which results in a curve towards the taped side (see a picture here).

 

Tunica albuginea plication (TAP) procedures straighten the penis by shortening the normal side. The common variants may be described as the 'Nesbit' procedure or 'Lue 16-dot" procedure.

 

Advantages

  1. Quick and easy
  2. Minimal risk to erectile function
  3. Predictable and fairly reliable method of straightening.

Disadvantages

  1. Typically results in a 1-2 cm loss of length

 

Ideal candidate: relatively minor degress of curvature, minimal erectile dysfunction, smaller plaques

Poor candidates: severe hour glass deformity, large degress of curvature, severe erectile dysfunction, large plaques

 

Incision and grafting involves incision the scar tissue and placement of a graft material to allow for expansion of the contracted area. In general, no attempt is made to excise (cut out) the scar because doing so is associated with a much higher risk of erectile dysfunction. This is a more extensive surgery than plication because it includes exposure of the spongy tissue of the penis and extensive incision into the tunica.

 

Advantages

  1. Can correct extensive curvature, especially hour-glass deformity
  2. Less risk of loss of length

Disadvantages (compared to plication)

  1. Increased risk of erectile dysfunction
  2. Increased risk of penile numbness
  3. Increased risk of hematoma formation
  4. Contracture of the graft may result in recurrent curvature

 

Ideal candidate: just about anyone who is not a candidate for the TAP procedure.

 

Note: multiple different types of graft material have been used. There is no single ideal graft material. Dr. Poon typically uses SIS (small intestinal submucosa) because it does not require harvest of any tissue from the patient and has a comparatively low risk of complications compared to other graft material.

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Frequently Asked Questions

 

Q: Is Peyronie's disease associated with penile cancer?

A: Unequivocally NO.

 

Q: Is having intercourse while I have Peyronie's Disease harmful?

A: No. You can engage in intercourse without any concern of worsening your condition

 

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On the Web

Penile extenders and traction devices. There are several manufacturers of these devices. One of the original extender device, known as the FastSize, is no longer manufactured. This link is not meant as a medical endorsement of these companies.

x4labs Canadian company which has competitive prices and delivery.There is no need to purchase the 'Peyronie's Disease Package'.

Size Genetics is a US company which sells these devices.

CUA Brochure on Peyronie's Disease

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General Urology Websites

Canadian Urological Association  Extenstive library of downloadable pamphlets on a wide range of urological conditions

Cleveland Clinic

Mayo Clinic

Medline Plus Produced by the US National Institutes of Health with information on virtually every health topic and extensive list of links

UrologyHealth.org The patient information site of the American Urological Association.