Crooked Erections After Prostate Surgery

Peyronie's Disease (Penile Curvature) After Prostate Cancer Treatment

Doctor comforting patient who has crooked erections after prostate surgery

Jose Luis Pelaez Inc/Getty Images 

Crooked erections, also known as Peyronie's disease or penile curvature, may occur after surgery for prostate cancer, though this may be more common with some procedures than others. A build-up of scar tissue causes the penis to bend when erect, leading to painful erections and emotional distress for both a man and his partner. Injections into the penis, shockwave therapy, and other treatments may help. But fortunately, once diagnosed, the condition sometimes goes away on its own and doesn't often worsen.

It's important to note that Peyronie's disease is not a disease in the truest sense of the word. Some physicians have described this build-up of scar tissue as similar to a scar the develops following surgery, or scarring in the joints due to arthritis.

Incidence

Peyronie's disease or crooked erections is not a new condition and has been recorded all the way back to the thirteenth century. Once thought to be rare, it's now believed to affect 0.5 to 13 percent of men at some time in their lives.

Unlike crooked erections due to other causes, Peyronie's disease often develops quite rapidly after a prostatectomy. But relatively few studies have looked at the incidence of a crooked penis in association with prostate surgery.

A 2015 study found that 17.4 percent of men developed penile curvature following a radical prostatectomy, with the average time between surgery and the development of crooked erections being 12 months. In this study, the average degree of curvature was 27 degrees.

An earlier 2010 study revealed similar findings, with an incidence of 15.9 percent in men who underwent a radical prostatectomy. The average curvature in that study was 31 degrees.

A 2018 study set out to determine if the incidence might be lower with robotic-assisted prostatectomy and use of a suprapubic catheter (a catheter that is placed in the bladder through the skin at the front of the pelvis rather than through the urethra). In this study, only 1.84 percent of men developed penile curvature following surgery.

Since little research has been done, and the study design of these trials varied, it's too soon to say conclusively whether the incidence is lower with the robotic procedure. In addition, the study looking at robotic prostatectomy included men who did not have a Foley catheter after the procedure (catheters are considered a risk factor for the development of Peyronie's disease).

Signs and Symptoms

When the penis is flaccid (non-erect), men may not be aware of a crooked penis. With an erection, however, the curvature is noticeable, and this can make erections very painful. The most common site of curvature is dorsal (the top of the erect penis) and less often, ventral (the bottom side).

In addition to a bent penis, men may notice firm non-tender bumps or plaques in the penis and decreased length or girth of the penis. (Penis size may change after prostatectomy with or without Peyronie's disease).

Complications

A crooked penis with erections is often painful, and this certainly can interfere with a fulfilling sex life. In addition to physical discomfort, this can lead to anxiety and relationship concerns for both men and their partners.

Causes

A crooked penis or Peyronie's disease occurs when scar tissue builds up in the tunica albuginea, the fibrous lining of connective tissue that surrounds and helps trap blood in the corpora cavernosa—the two spongy chambers that hold blood and are responsible for making the penis rigid during an erection. This causes the penis to bend when it becomes erect. The precise mechanism that leads to scarring, however, is uncertain.

With prostate surgery, it's thought that it may begin with inflammation and swelling that heals with scarring (fibrosis). Dysfunctional wound healing can be seen in other areas of the body, such as the elevated, thick keloid scars that sometimes occur on the skin after an injury or surgery. The same mechanism may be at play in crooked erections.

In cases of Peyronie's disease unrelated to prostate surgery (trauma to the penis, autoimmune diseases/connective tissue disorders), repeated small injuries may be causative—similar to the chronic wear and tear that contributes to arthritis.

Penile curvature is also associated with conditions such as contractures of the palm of the hand or soles of the feet (Dupuytren's contracture).

It's important to note that crooked erections after prostate surgery may be related to the surgery or one of the other possible causes of Peyronie's disease.

Risk Factors

Since little research has been done on this connection, there is only a small amount of information available regarding potential risk factors.

With penile curvature after prostate surgery, risk factors may vary depending on the type of procedure performed. It appears that that the use of an indwelling catheter following prostatectomy is associated with a greater risk. In the studies reviewed above, it was also found that a crooked penis is more likely to occur after surgery in white and younger men.

Risk factors for non-prostate surgery related Peyronie's disease include age, diabetes, high blood pressure, smoking, and excess alcohol consumption. There also appears to be a genetic component, and Peyronie's disease may be more common in men who have a family history of the condition.

Diagnosis

The diagnosis of penile curvature can often be made by taking a careful history and performing a physical exam, with other tests often reserved for when the diagnosis is uncertain or surgery is being considered.

Physical Exam

Ideally, a physical exam will look at both the flaccid and erect penis. Doctors will evaluate the degree of curvature, the length, and girth of the penis, and its rigidity. Since Peyronie's disease may be associated with Dupuytren's contracture, and examination of the hands and feet is often done as well.

Imaging

In some cases, an ultrasound (penile duplex ultrasonography) may be done. In addition to confirming the diagnosis (plaques appear as thickening), an ultrasound can be helpful in determining the extent of the plaques, whether they involve the penile septum, and whether they are located near nerves or blood vessels.

If the plaques involve arteries, they may contribute to erectile dysfunction. Calcifications may also be seen. Rarely, magnetic resonance imaging (MRI) may be done. A computed tomography (CT) scan is generally unhelpful in evaluating penile curvature.

Procedures

An intracavernosal injection test (ICI is a definitive test that can be done in the doctor's office. It may be done alone or with an ultrasound, and it's most often done if invasive treatment is being considered.

In this test, a doctor injects a medication into the base of the penis that leads to an erection. If an erection does not occur, it raises concerns about blood flow to the penis.

Differential Diagnoses

The diagnosis of a crooked penis after prostate surgery may be fairly clear, although the period of time between surgery and penile curvature (on average, 12 months) can make men wonder if something else is going on.

Due to the symptoms, some men become concerned that they may have penile cancer. In addition to Peyronie's disease, other causes of a crooked penis after prostate surgery may include:

  • Trauma
  • Scleroderma
  • Alcohol abuse
  • Syphilis (tertiary syphilis gumma)
  • Gout (gouty tophi)
  • Diabetes
  • Metastases from cancer such as lung cancer (rare)
  • Sarcoma of penis (rare)
  • Sclerosing lymphangitis of the penis

Treatment

For men who are in a relationship, it's very helpful to address treatment options with both men and their partners. Approaching options as a team can help couples cope with some of the issues they are facing much better than if it is considered "his problem" alone.

With all potential treatments, men and their partners need to weigh the benefits and risks, as well as realize that people are different when it comes to preferences for treatment.

Of the treatment options available, intralesional and surgical therapies are backed by the most evidence.

Pain Control

For some men, the only concern is discomfort with intercourse. When penile curvature is mild, treatment with nonsteroidal anti-inflammatory drugs such as Advil (ibuprofen) for pain may be sufficient.

Intralesional Injections

There are three primary types of injections that may be used and have been found to be effective for at least some men. These medications are injected directly into the penis and are most effective when treatment is used early on. Methods include:

  • Intralesional collagenase (Clostridium histolytic): This treatment is used for men who have intact erectile function either with or without medications and when curvature is greater than 30 degrees, but less than 90 degrees. Side effects may include pain, bruising, swelling, and rarely, coronal rupture.
  • Intralesional interferon a-2b: Possible side effects may include swelling and flu-like symptoms.
  • Intralesional verapamil

Extracorporeal Shockwave Therapy (ESWT)

There has been controversy over the effectiveness of ESWT—the external delivery of shockwaves to break up scar tissue—for treating Peyronie's disease.

A 2016 study helped clarify this, and found that the procedure could relieve pain and significantly reduce penile plaques, but, statistically at least, had little effect on the penile curvature or sexual function.

Surgery

There are a few different surgical procedures that may be used to treat a crooked penis after prostate surgery. These include:

  • Surgical plication of the tunica albuginea: In this procedure, a piece of the penis is removed from the opposite side of the plaque to straighten the penis. Side effects include shortening of the penis (in many to most men) and decreased sensation.
  • Plaque incision/excision and/or grafting: This procedure can sometimes improve curvature and restore sexual function, but doesn't result in penile shortening.
  • Penile prosthesis surgery (implanting an inflatable penile prosthesis)

Management of Erectile Dysfunction

For men who experience erectile dysfunction along with a crooked penis, treatment may also include drug therapy or vacuum-assisted devices.

Complementary and Alternative Therapies

A number of alternative therapies have been tried for men with Peyronie's disease, but thus far, none of these appear to work any better than a placebo.

Therapies that have been examined include vitamin E, omega-3-fatty acids, and vitamin E with L-carnitine. Other oral therapies that have been tried without significant success include tamoxifen and procarbazine.

Psychosocial Support

While these treatment options can address the physical aspect of a crooked penis, the emotional ramifications should be addressed as well. If the condition is affecting their relationship, some couples find it helpful to talk about it with a therapist.

While some people may find it intimidating, or feel they can manage their feelings alone, it's actually a sign of courage to seek out help in this area if it is affecting your partnership. Even when physical concerns can be adequately treated, working to improve intimacy in non-sexual ways can be a plus.

Prognosis

For roughly 20 percent of men, penile curvature goes away on its own in time. Fortunately, the condition doesn't usually progress significantly once it is present. As far as prognosis with the treatment options discussed, there are many variables, and it's important to work with your doctor to learn what might be best for you based on your symptoms.

Prevention

It's not always possible to prevent a crooked penis, but it's a good idea to talk to your doctor if you will be having prostate surgery. With all of the controversies surrounding prostate cancer treatment, there are many other reasons to learn about the disease and get a second or third opinion as well.

It's also a good idea to minimize your risk factors for Peyronie's disease, such as making sure your blood pressure is well controlled if you have hypertension, managing your blood sugars if you have diabetes, quitting if you smoke, and limiting alcohol use.

A Word From Verywell

Penile curvature or a crooked penis after radical prostatectomy isn't uncommon based on recent studies and can cause significant pain and distress. Fortunately, there are several options for treatment if the condition is affecting your sex life and relationship. Your doctor won't know to offer these treatments, however, unless you are open about your symptoms and how they are affecting your life.

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