What Is Peyronie's Disease?

Causes and Treatment of a Spontaneous Curved Erection

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Peyronie’s disease is a condition in which fibrous scar tissues, called plaques, form beneath the skin of the penis, causing curved and often painful erections. The cause of Peyronie's disease is not well understood, although it is believed to be caused by repeated injury to the penis, typically during sexual intercourse or physical activity.

Peyronie's disease is not simply a curved penis that occurs naturally in men. Rather, it is a bend that develops spontaneously, often interfering with sex by causing pain and/or erectile dysfunction.

Peyronie's disease should not be confused with a penile fracture, a traumatic injury caused by a sudden blunt force to the penis.

Symptoms

Penises can vary in size and shape, including the way in which they bend or curve. A certain degree of penis curvature—referred to as congenital curvature—is considered normal. However, with Peyronie's disease, the bend develops spontaneously due to the long-term buildup of scar tissue. Depending on the location of the scar, the penis may either bend upward, downward, or to the side.

The degree of change can vary from one man to the next. In some cases, Peyronie's disease may only cause a slight indentation beneath the skin. In others, it can cause the penis to bend at an obtuse angle and even "hinge" at the site of the scarring, making sexual penetration difficult.

Pain during an erection or sex is a common feature of Peyronie's disease. Some men may even experience painful erections several days or weeks before a visible bend develops.

As the fibrous plaques harden and form nodules, the contraction of surrounding tissues can cause the penis to shorten by as much 1 centimeter (0.4 inches). The lateral contraction of tissues may also cause an hourglass-like narrowing of the penis shaft. While the abnormalities tend only to be visible during an erection, they can sometimes be seen when the penis is flaccid.

If the scarring affects the blood vessels that supply the corpus cavernosum (the two spongy tubes in the penis that enable erections), erectile dysfunction may develop. This is caused by the narrowing of the penile arteries (arterial stricture) which diminish blood supply.

As distressing as the symptoms may be, they can sometimes improve on their own without treatment. Moreover, not all men with Peyronie's disease will develop pain or sexual dysfunction, even when the curvature of the penis is significantly altered.

Causes

The underlying cause of Peyronie's disease is poorly understood. What scientists do know is that around 10 percent of men will be affected by the disorder, most commonly when they are in their 50s.

This suggests that repeated trauma, often minor and unknown, will instigate the formation of fibrous scar tissues, known as fibrosis. Under normal circumstances, fibrosis will be accompanied by the remodeling of tissues as part of the normal healing process. However, as people age, tissue remodeling begins to slow. So, rather than resolving, the scarring persists and gradually undermines the structural integrity of the connective tissues.

With Peyronie's disease, this can cause the connective tissues to spontaneously collapse, resulting in the abnormal penile curve.

Genetics

Age alone cannot explain Peyronie's disease given that younger men can also be affected. According to a 2018 study in PLoS One, roughly one in 65 men between the ages of 30 and 39 will develop Peyronie's. Even men as young as 18 have been known to develop the disorder.

This has led some scientists to suggest that genetics play a role in a man's predisposition to the disease. This is evidenced in part by research from the Baylor College of Medicine which reported that up to 20 percent of men with Peyronie's will have another fibrotic condition, such as Dupuytren's disease affecting the hands or Lederhose disease affecting the feet.

Although a number of genetic mutations are believed to contribute to the risk of Peyronie's disease, it is difficult to say what role, if any, they actually play. To date, there has been little evidence of a familial link to the Peyronie's disease. Moreover, Peyronie's is known to affect men of all races equally.

Other Risk Factors

The only other condition that clearly predisposes a man to Peyronie's is diabetes. In addition to increasing the overall risk, having diabetes appears to intensify the severity of the disease.

According to research in the Journal of Sexual Medicine, when comparing men with Peyronie's disease and diabetes to men with Peyronie's disease only:

  • Men with Peyronie's and diabetes had a greater degree of penile deformity (45.2-degree curve versus 30.2-degree curve).
  • Men with Peyronie's and diabetes were more likely to have severe curvature, defined as over 60 degrees (27.1 percent versus 5.5 percent).
  • Men with Peyronie's and diabetes were more likely to have painful erections (39.7 percent versus 25.5 percent).
  • Men with Peyronie's and diabetes were more likely to experience erectile dysfunction (81 percent versus 47 percent)

Although it is been long been believed that penile fractures can lead to Peyronie's in later years, a 2011 study in the International Journal of Impotence Research found no such association.

Although a penile fracture can cause nodules, abnormal curvature, and painful erections, the researchers could find no evidence of plaque consistent with Peyronie's disease. As such, penile fracture and Peyronie's are each considered separate and distinct conditions.

Diagnosis

Peyronie's disease is typically diagnosed by a urologist with the combination of a physical exam and imaging studies to confirm the presence of plaques.

The physical examination would involve the palpation (evaluative touching) to identify areas of scarring. The urologist may also measure your penis and ask you to bring a photograph of your erect penis to establish the degree of curvature.

The imaging study most commonly used to evaluate Peyronie's is a Doppler ultrasound. It a portable, non-invasive device that utilizes high-frequency sound waves to generate still and real-time images of underlying tissues. Doppler ultrasounds can also detect abnormalities in the blood flow consistent with erectile dysfunction.

Comprehensive imaging studies would require an injection of a drug such as Caverject (alprostadil) or papaverine into the penis to induce an erection. In this way, the urologist can identify how the various plaques and strictures cause erectile pain or dysfunction during sex.

Treatment

The treatment of Peyronie's disease will depend largely on the duration and severity of your symptoms. Unless your condition is especially severe, a urologist will usually take a watch-and-wait approach and monitor your condition for several weeks or months. This is especially true if the change in curvature is minimal and you can maintain an erection without significant pain.

In most cases, the acute formation of plaque will ease over time without treatment. In some cases, the condition may fully reverse.

According to research in the Asian Journal of Urology, as many as 13 percent of men with Peyronie's will experience spontaneous improvement within six to 15 months.

Routine monitoring will help identify the 30 to 50 percent of men who will experience a worsening of symptoms. It is this population who will benefit most from treatment.

With that being said, none of the available treatments are consistent in their effects. Moreover, many of these have minimal evidence to support their use. Although there have been recent advances in reparative surgeries. they are really only considered a last resort.

Oral Medications

A number of oral drugs are used in the treatment of Peyronie's disease. While there is evidence of their benefits, most studies have shown mixed results. Among the drugs most commonly used to treat Peyronie's disease:

  • Colchicine is an anti-inflammatory drug used in gout that has proven slightly useful in treating Peyronie's.
  • L-carnitine is a naturally occurring amino acid that some believe can reduce scarring by tempering tissue inflammation.
  • Tamoxifen is an anti-estrogen drug used in breast cancer which may reduce plaque size.
  • Vitamin E has proven minimally effective in reducing plaque size.
  • Potassium amino-benzoate, a potassium salt, may reduce plaque size but generally does not improve penile curvature.

Injectable Drugs

There are three types of injectable drug used to treat Peyronie's disease. They are each delivered by local injection into the penis and tend to be more effective than oral medication.

Of these, the only drug approved by the U.S. Food and Drug Administration for the treatment of Peyronie's is Xiaflex (collagenase clostridium histolyticum). Used for moderate to severe Peyronie's disease, Xiaflex works by breaking down the build-up of collagen in fibrotic plaques.

Clinical research has shown that, after eight injections delivered over 24 weeks, Xiaflex was able to reduce the penile curvature by 34 percent compared to men given a placebo who had an 18.2 percent reduction.

Among some of the other injectable drugs used to treat Peyronie's disease:

  • Verapamil, a calcium channel blocker used to treat high blood pressure, may also help break down accumulated collagen.
  • Interferon, a signaling protein used to treat serious viral infections like hepatitis, appears to disrupt the production of fibrotic tissue.

Penile Traction Therapy

Penile traction therapy (PTT) is a non-invasive technique that aims to correct the penile curve by gradually expanding tissues with traction. The technique, referred to as mechanotransduction, has long been used to treat other muscle and bone malformations, such as Dupuytren's contracture (caused by the contraction of hand tendons). PTT is also commercially used as a penis enlargement technique.

With PTT, it is theorized that the prolonged stretching of the penis will lead to an increased production of collagenase, an enzyme that breaks down collagen. By doing so, the plaques may gradually soften and extend.

PTT involves the use of a penile extender that fits over the shaft of the penis. One end of the device is pressed again the pelvis, while the other end is fitted snugly behind the head of the penis (glans). Extension rods connecting the two can be gradually expanded to stretch the penis.

Evidence remains split as to whether PTT actually works. A 2016 review of studies concluded that while many of the studies investigating the use of PTT were poor, the results were greatest in men who used the devices consistently and for longer periods of time (generally three hours per day for a minimum of six months).

Surgery

Penile surgery is considered a last resort for Peyronie's disease given the potential risks and high variability of success. Generally speaking, surgery would not be considered until you have had Peyronie's for at least one year and the curvature of your penis stops increasing and stabilizes for at least six months.

Even so, surgery should only be considered if the deformity is severe and the condition interferes with your ability to have sex. Among some of the more common surgical approaches:

  • Nesbit plication involves the application of sutures along side of the penis that doesn't have scar tissue. The sutures would run from the glans to the base of the penis, pinching (plicating) the tissues so that the abnormal curve is reduced.
  • Excision and graft surgery is reserved for more serious malformations. It involves the cutting out (excising) of scar tissue to release the penis. This would be followed by tissue grafts to fill holes in the tunica albuginea (the fibrous tissue that supports the corpora cavernosa).
  • Penile implants are used in men with intractable erectile dysfunction. These include semi-malleable implants that are permanently inserted between the tubules of corpora cavernosa and can be molded into different positions. There are also fluid-filled implants that can be inflated with a pump bulb in the scrotum.

Both penile surgery and surgical implants carry a risk of infection and adhesions (the sticking together of tissues). Both can lead to unexpected deviations in the penis shape after healing.

Excision and graft surgery also poses a risk of erectile dysfunction depending on the location and amount of tissue removed (as well as the skill of the surgical urologist). Nesbit plication tends to pose a smaller risk, although erectile dysfunction may occur as a result of infection.

Depending on the type of surgery you have, you may be able to go home the same day or be monitored overnight in the hospital. You can usually return to work in a few days and have sex in four to eight weeks.

Coping

As much as Peyronie's disease can affect a man physically, it can also cause extreme emotional stress and anxiety. Even if a man's sexual function remains intact, the sudden change in the appearance of the penis can cause a man to withdraw out of embarrassment or fear of rejection. These feelings can be further amplified if pain or erectile dysfunction directly interferes with sex.

If you have Peyronie's disease, there are several things you can to do cope:

  • Educate yourself. Start by understanding the nature of the disease by speaking with your urologist and asking for reference materials. It is important to share this information with your partner so that you both understand that neither of you did anything to "cause" Peyronie's.
  • Explore erectile dysfunction treatment. If you have difficulty maintaining an erection, speaking with your doctor about erectile dysfunction medications like Viagra (sildenafil), Cialis (tadalafil), or Levitra (vardenafil). You may also be able to sustain an erection with an elastic penile ring (also known as a "cock ring") found easily online.
  • Communicate. Let your sexual partner about what you are feeling physically and emotionally. Putting on a brave face or saying nothing only adds to the stress and can directly impact your relationship and how you feel about yourself.
  • Explore sex in its different forms. Sex is ultimately about more than just intercourse. You may be able to derive just as much pleasure from oral sex, toys, and role-playing. If you find this difficult, make an appointment to meet with a sex therapist as a couple.
  • Learn patience. As profound as the physical changes may be, they are not always permanent. Speak with your doctor about the appropriate treatment options, taking things one step at a time. Given the high variability of success, rushing from one treatment to the next may only add to your stress.
  • Seek help. If you are unable to cope, ask your doctor for a referral to a therapist or psychiatrist who can help you sort through your emotions. It is not "silly" to feel depressed after experiencing a sudden, striking change in your life, particularly one associated with sex.
  • Find support. It may also help to communicate with others who have Peyronie's disease. One of the best ways to do do is by connecting with any number of Peyronie's disease support groups on Facebook.
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