Also known as induratio penis plastica, bent penis, etc, Peyronies disease (PD) is a surprisingly common disorder that can cause significant sexual problems. A more thorough discussion of this subject may be found in the following articles and book chapters. [link to pentoxy article, BJUi atlas, JSM surgical technique, penile fracture article, septal fibrosis article, SIS article, ultrasound article, PD CME article, US chapter, UTD chapters, Reconstructive urology chapter]
WHAT IS IT?
PD is a condition in which inflammation or scarring of the tough covering of the erectile portion of the penis leads to symptoms. [pic of cross section] It usually starts with inflammation and, over time, becomes scar and stabilizes. During this first, or inflammatory phase, patients may have pain (either just in the flaccid state or with erection), tenderness, a mass, curvature or other deformities. Often, men notice that the process evolves during this period. The deformity may get worse, for example. Men usually notice that the penis gets shorter and narrower, sometimes just at one part of the penis. This period lasts for a variable amount of time, ranging from months to years. Eventually, the disorder goes into the second, or stable phase. Usually the pain is gone (except sometimes during intercourse) and the deformity is stable.
WHAT CAUSES IT?
No one knows the exact cause of PD. In general, we believe that it is an abnormal healing response. That is, there is an injury (sometimes very very minor) but the body acts abnormally and causes inflammation and scarring.
HOW COMMON IS IT?
It occurs in 3.5% to 9% of men, depending on age.
HOW IS IT EVALUATED?
Several items are crucial to making sure you get the right diagnosis and treatment.
We start with a questionnaire. [link]
In addition to the physical exam, the deformity needs to be examined and documented. The patient may take a photograph of the erection at home or we can give an injection in clinic [link to injection therapy] to give an “artificial erection” that we can evaluate in clinic.
Additionally, an ultrasound (safe, quick, and painless) is very helpful to assess the penile tissue and direct treatment strategy.
IS IT ASSOCIATED WITH ED?
ED is VERY common with Peyronie’s disease, at least 50% of men with PD have some ED also. Since the scarring affects the tissue surrounding the erection bodies (and often affects the erection bodies themselves), men often have arterial (“inflow”) and storage (“outflow”) problems.
HOW IS IT TREATED?
In the early stages, the best treatments are medical, not surgical. There are many, many reported treatments for PD, most of which have no data whatsoever supporting them. However, men are often desperate and will try anything, even if it is unlikely to help. This is unfortunate because, while there is no perfect medical treatment for PD, there are certain strategies that are more likely to help than others.
The treatment strategy depends on many factors and needs to be individualized for each patient. They may include pills, injections (a medication that goes directly into the affected area), and traction devices.
In the later stages, once the deformity is stable, treatment is usually surgical. A patient only needs surgical treatment if the deformity is enough that they cannot have intercourse (for example, if they have pain or their partner has pain) or if there is associated ED.
The actual surgical treatment depends on both the situation as well as patient goals. We have developed a chart [link] that summarizes the different general surgical approaches.
Generally, surgical approaches include reconstructive and/or prosthetic surgery. The most popular reconstructive approach is to place permanent sutures in the penis on the opposite side of the curvature to straighten it out (“plication”). [link to JSM technique article] This approach has few risks but 1) this does not correct notches, waists, or other non-curvature deformities 2) this cannot correct any of the length/width loss that is often associated with PD.
Alternatively, the plaque/scar can be expanded and a patch can be placed (“grafting”). [link to BJUi techniques article] Although this can correct other deformities and may possibly reclaim some of the length/width loss, there are significant risks associated with this approach including worsening ED (up to 40%, depending on the patient) and further scarring. This should only be performed by a surgeon who has extensive experience in this type of reconstruction.
If the patient has ED associated with PD or if the patient develops ED (e.g. after a grafting procedure), usually the best approach is with a penile prosthesis. This usually corrects both the ED and the deformity at that same time. Occasionally, the prosthesis does not fully correct the deformity and additional procedures must be done, such as plication or grafting.