How Peyronie's Disease Is Treated

Peyronie's disease is a condition where the penis becomes curved due to the buildup of fibrous scar tissue. Historically, surgery has been the most effective form of treatment for Peyronie's disease. Surgical options include everything from shortening the longer side of the penis (plication), to insertion of erectile prostheses (penile implants), to the removal of lesions (excision/incision and grafting).

However, early in 2010, the Food and Drug Administration (FDA) approved a new medication known as Xiaflex as a non-surgical option. Xiaflex injections are currently the only FDA-approved non-surgical option for treating Peyronie's disease, although several other medications have demonstrated moderate success in the literature.

Finding a urologist experienced with the various options for treating Peyronie's disease is the best way to learn about what treatments may make the most sense for you. It takes good information for you to be able to effectively weigh your choices and figure out what treatment best fits your life, your needs, and your goals.

Surgeries and Specialist-Driven Procedures

In general, Peyronie's disease isn't treated until symptoms have stabilized. That's because sometimes symptoms can improve on their own. However, the exception to that rule is when you are in pain.

If your Peyronie's disease has made sexual penetration difficult, painful, or impossible, treatment may be able to help. There are benefits, and disadvantages, to both surgical options and office-based penile injections.

Intralesional Injections

The only FDA-approved non-surgical therapy for Peyronie's disease is the Xiaflex injection. Xiaflex contains several enzymes derived from bacteria that have been shown to be able to break down one of the proteins in Peyronie's disease plaque.

In clinical trials, penile curvature was significantly more improved with Xiaflex injections when compared with placebo and men were significantly less bothered by the condition. Each treatment cycle consists of two injection procedures (a short in-office procedure) and penile modeling (stretching). Each cycle takes approximately six weeks to complete with at-home stretching activity between cycles. An entire treatment course of Xiaflex consists of up to four cycles and takes approximately 24 weeks to complete.

However, concerns about the risks of Xiaflex treatment mean that access is limited. Injections have been associated with a low, but notable risk of penile fracture and severe penile bruising. Therefore, the injection can only be performed by urologists who have been certified by a risk evaluation and management program to know how to do so safely.

Other injections that have been used, off-label, for Peyronie's disease include:

• Verapamil, which can cause penile bruising and injection site pain as well as dizziness and nausea.
• Interferon alpha 2b, which can cause penile swelling, sinusitis, and flu-like symptoms.

Neither of these options has more than limited evidence, however verapamil is well-tolerated in office and can result in improvement especially for men lacking insurance approval of Xiaflex.

The American Urological Association 2015 guidelines allow healthcare providers to administer injections of either interferon or verapamil into the lesions of people with Peyronie's disease despite this limited evidence. However, healthcare providers are encouraged to counsel patients that these injections may not be effective.

Other injections that the AUA considers to be unproven are:

• Nicardipine
• Parathyroid hormone
• Dexamethasone or Betamethasone
• Iloprost

It is important to note that the AUA does not recommend treatment of Peyronie's disease with radiotherapy. There is no strong evidence suggesting that radiotherapy is more effective than simply waiting. Therefore, given the risks of radiation, it should not be used.

Surgical Treatments

Surgical treatment for Peyronie's disease is only appropriate for individuals with stable disease. This means that, before surgery, people must have had symptoms for at least 12 months and stable penile curvature for at least three to six months.

Plication: Plication is the simplest surgery for Peyronie's disease. Its use is generally restricted to men who can still attain an erection rigid enough for penetration. (Whether or not they need medical or vacuum assistance to get an erection.) Plication involves suturing the penis on the opposite side of the curve in order to shorten the long side. This reduces the curvature and may make the penis straight enough for sexual penetration. However, it can also shorten the length of the penis.

Excision/incision: The next surgical option for men who still have erectile function is plaque excision/incision, with or without tissue grafting. This involves surgical removal or interruption of the plaque that is causing the penis to curve. It may also involve placing a tissue graft. Serious adverse events of plaque excision/incision are considered to be relatively rare, rare but carries a higher risk of erectile dysfunction and less risk of penile shortening when compared to plication.

Penile prosthesis: Men who are unable to attain an erection sufficiently rigid for penetration may be offered a penile prosthesis. The most common types of penile prostheses are inflatable balloons that can help men achieve an erection. Indeed, this is the only type of penile prosthesis recommended for Peyronie's treatment. Surgical placement of an inflatable prosthesis is often accompanied by other procedures to straighten the penis. These can include any of the other surgeries described above.

Extracorporeal shock wave therapy: Extracorporeal shock wave therapy (ESWT) has also been shown to be effective in reducing Peyronie's pain. ESWT has not been shown to improve curvature, plaque size, or other symptoms. Therefore ESWT is only recommended for dealing with the pain of Peyronie's, not as a treatment for the underlying condition.

Over-the-Counter (OTC) Therapies

The only over-the-counter remedy for Peyronie's disease is non-steroidal anti-inflammatory drugs (NSAIDs). Over-the-counter NSAIDS have been shown to be effective at reducing the pain associated with Peyronie's disease, but not the disease itself.

This category of drugs can be used for pain relief in people with active disease. Both ibuprofen and naproxen are types of NSAIDs.

Prescriptions

With the exception of the use of prescription NSAIDS for pain relief, there is very little evidence for oral treatment of Peyronie's disease. Most studied treatments have only limited, or conflicting, evidence that they can improve penis curvature, length, or other symptoms.

There are no FDA-approved oral remedies for Peyronie's disease. Some medications that are occasionally prescribed include:

• Potassium para-aminobenzoate, which has been shown to potentially improve plaque size but not clinical symptoms.
• Vitamin E, which is commonly used without any strong evidence of success.
• Tamoxifen, which early studies suggested could be helpful, but those studies were not confirmed.
• Colchicine, which earlier studies suggested could be effective in combination with vitamin E, but a more recent study found it did not provide pain relief or improvements in penile curvature or plaque size.

Home Remedies and Lifestyle

There is very limited evidence that any home remedies can have an effect on treating Peyronie's disease. One treatment for which there is mild evidence is penile traction devices. These devices are used to gently straighten the penis.

Several small studies have suggested penile traction may be able to increase length and reduce penile curvature, particularly for men with active phase disease. Additionally, penile traction therapy with Xiaflex injection of penile plaque may be effective. However, further studies are needed before traction is likely to be widely recommended.

It is worth noting that hand molding of the penis is a component of some injectable treatments for Peyronie's. Hand molding may be done at home. It involves gentle reshaping of the penis, as taught by a healthcare provider. It is not generally considered to be a home remedy, rather it is an adjunct to other treatment.

Sexual intimacy can be an important part of many people's lives. For many men, sexual penetration feels like a critical component of intimacy. However, many individuals have satisfying, fulfilling sex lives without engaging in penetrative sex. For some people, having a medical condition such as Peyronie's disease, that affects their ability to enjoy sexual penetration, can serve as motivation to explore other ways of being intimate and sharing pleasure.