Peyronie's disease

Definition

Peyronie's (pa-ro-NEEZ) disease is the development of fibrous scar tissue inside the penis that causes curved, painful erections.

Men's penises vary in shape and size, and having a curved erection is common and isn't necessarily a cause for concern. However, in some men, Peyronie's disease causes a significant bend or pain. This can prevent a man from having sex or may make it difficult to get or maintain an erection (erectile dysfunction). For many men, Peyronie's disease also causes stress and anxiety.

In some cases, medications may help. Surgery to treat Peyronie's disease is generally only recommended if the curvature and pain are severe enough to prevent sexual intercourse.

Symptoms

Peyronie's disease symptoms may appear suddenly or may develop gradually. The most common signs and symptoms include:

• Scar tissue. The scar tissue (plaques) associated with Peyronie's disease can be felt under the skin of the penis as flat lumps or a band of hard tissue.
• A significant bend to the penis. Your penis may be curved upward, downward or bent to one side. In some cases, the erect penis has an "hourglass" appearance, with a tight, narrow band around the shaft.
• Erection problems. Peyronie's disease may cause problems getting or maintaining an erection (erectile dysfunction).
• Shortening of the penis. Your penis may become shorter as a result of Peyronie's disease.
• Pain. You may have pain during an erection, only during an orgasm or anytime your penis is touched.

The curvature associated with Peyronie's disease may gradually worsen. At some point, it generally stops getting worse. In most men, pain during erections improves within one to two years but the scar tissue and curvature remain. Rarely, both the curvature and pain associated with Peyronie's disease improve without treatment.

When to see a doctor
See your doctor if pain or curvature of your penis prevents you from having sex or causes you anxiety. An accurate diagnosis is needed to determine whether treatment may help and to rule out other causes of your symptoms.

Causes

The cause of Peyronie's disease isn't completely understood, but a number of factors appear to be involved. It's thought Peyronie's disease generally results from the rupturing of small blood vessels inside the penis. For example, the penis may be damaged during sex, athletic activity or as the result of an accident. During the healing process, blood cells and other cells are trapped at the site of injury, which leads to the buildup of scar tissue. However, not all men who have a penis injury develop Peyronie's disease. It's thought that inherited traits may play a role in who is susceptible to the disorder.

Each side of the penis contains a sponge-like tube (corpus cavernosum) that contains many tiny blood vessels. When you become sexually aroused, blood flow to these chambers increases. As chambers fill with blood, the penis expands, straightens and stiffens into an erection. Each of the corpus cavernosa are encased in a sheath of elastic tissue called the tunica albuginea (TOO-nih-kuh al-bu-JIN-e-uh), which stretches during an erection. Injury to the penis can damage this tissue. If an injury heals properly, there are generally no long-term problems. In Peyronie's disease, problems in the normal wound-healing process result in permanent scar tissue. The section of the sheath with scar tissue is no longer flexible. When the penis becomes erect, the region with the scar tissue doesn't stretch, and the penis bends or becomes disfigured and may be painful.

In some men, Peyronie's disease comes on gradually and doesn't seem to be related to an injury. Researchers are investigating whether Peyronie's disease might be linked to immune system disorders.

Erect penis

Erect penis

The penis contains two cylindrical, sponge-like structures (corpus cavernosum). When a male becomes sexually aroused, nerve impulses increase blood flow to both cylinders. This sudden influx of blood ...

Risk factors

Minor injury to the penis doesn't always lead to Peyronie's disease. There are a number of factors that can contribute to poor wound healing and scar tissue buildup that may play a role in Peyronie's disease. These include:

• Heredity. If your father or brother has Peyronie's disease, you have an increased risk of getting the disorder.
• Connective tissue disorders. Men who have a connective tissue disorder appear to have an increased risk of developing Peyronie's disease. For example, a number of men who have Peyronie's disease also have a condition known as Dupuytren's contracture — a cord-like thickening across the palm that causes the fingers to pull inward.
• Getting older. The prevalence of Peyronie's disease increases with age. Age-related changes in tissues may cause them to be more easily injured and less likely to heal well.

Other factors, including other certain health conditions, smoking and some types of prostate surgery may be linked to Peyronie's disease.

Complications

Complications of Peyronie's disease may include:

• Inability to have sexual intercourse
• Difficulty achieving or maintaining an erection (erectile dysfunction)
• Anxiety or stress about sexual abilities or the appearance of your penis
• Stresses on the relationship with your sexual partner
• Difficulty fathering a child, because intercourse is difficult or impossible

Preparing for your appointment

If you have Peyronie's disease symptoms, you're likely to begin by seeing your family doctor or general practitioner. You may be referred to a specialist in male sexual disorders (urologist). Preparing for your appointment will help you make the best use of your time.

What you can do
Make a list ahead of time that you can share with your doctor. Your list should include:

• Symptoms you're experiencing, including any that may seem unrelated to Peyronie's disease
• Key personal information, including any major stresses or recent life changes
• Medications that you're taking, including any vitamins or supplements
• Family history of Peyronie's disease, if any
• Questions to ask your doctor

List questions for your doctor from most important to least important in case time runs out. You may want to ask some of the following questions:

• What tests will I need to have?
• What treatment do you recommend?
• Can you tell if symptoms are likely to worsen or improve?
• Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions you've prepared to ask your doctor, don't hesitate to ask questions during your appointment if you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to discuss further. Your doctor may ask:

• When did you first notice a curve in your penis, or scar tissue under the skin of your penis?
• Has the curvature of your penis worsened over time?
• Do you have pain during an erection, and if so, has it gotten worse or improved over time?
• Do you recall having an injury to your penis?
• Do your symptoms limit your ability to have sex?

Your doctor may also ask you to complete a survey, such as the International Index of Erectile Function, that may identify how the disorder affects your ability to have sex.

Tests and diagnosis

For most men, Peyronie's disease can be diagnosed with a physical exam and by answering questions about symptoms. Rarely, other conditions cause similar symptoms and need to be ruled out.

Tests to diagnose Peyronie's disease and understand exactly what's causing your symptoms may include the following:

• Physical exam. Your doctor will feel (palpate) your penis when it's not erect, to identify the location and amount of scar tissue you have. He or she may also measure the length of your penis. If the condition continues to worsen, this initial measurement helps determine whether the penis has shortened. Your doctor may also ask you to bring in photos of your erect penis you take at home. This can determine the degree of curvature, location of scar tissue or other details that might help identify the best treatment approach.
• Other tests. Your doctor may order ultrasound, X-rays or other tests to examine the penis when it's erect. Before taking images of your penis, you will likely receive an injection directly into the penis that causes it to become erect. You'll be given local anesthesia to lessen pain before the injection. Ultrasound is the most commonly used test for penis abnormalities. Ultrasound tests use sound waves to produce images of soft tissues. It can show the presence of scar tissue, blood flow to the penis and any abnormalities.

Treatments and drugs

Your doctor may recommend a wait-and-see (watchful waiting) approach if:

• The curvature of your penis isn't severe and is no longer worsening
• You can still have sex without pain
• Pain during erections is mild

If your symptoms are severe or are worsening over time, your doctor may recommend medications or surgery.

Medications
A number of oral medications have been tried to treat Peyronie's disease, but they don't appear to be as effective as surgery.

In some cases, drugs injected directly into the penis may reduce curvature and pain associated with Peyronie's disease. If you have one of these treatments, you'll likely receive multiple injections over several months. You'll be given a local anesthetic to prevent pain during the injections.

Evidence on the effectiveness of penile injections is limited. Medications that are used include:

• Verapamil. This is a drug normally used to treat high blood pressure. It appears to disrupt the production of collagen, a protein that appears to be a key factor in the formation of Peyronie's disease scar tissue.
• Interferon. This is a type of protein that appears to disrupt the production of fibrous tissue and help break it down.

Collagenase, an enzyme that breaks down fibrous tissue scar, is currently being studied for treatment of Peyronie's disease.

Surgery
Your doctor may suggest surgery if the deformity of your penis is severe or prevents you from having sex. Surgery usually isn't recommended until the curvature of your penis stops increasing, and your erections have been pain-free for at least six months.

Common surgical methods include:

• Shortening the unaffected side. A variety of procedures can be used to shorten the longer side of the penis (the side without scar tissue). The shortened side of the sheath and the less elastic, scarred side of the sheath end up being about the same length when the penis is erect. This results in a relatively straight erection. However, this procedure usually shortens the overall length of the penis. It's generally used in men who have adequate penis length and a less severe curvature of the penis. Nesbit plication is an example of this type of procedure. In some cases, this type of surgery causes erectile dysfunction.
• Lengthening the affected side. With this type of surgery, the surgeon makes several cuts in the scar tissue, allowing the sheath to stretch out and the penis to straighten. The surgeon may have to remove some of the scar tissue. A piece of tissue (graft) is sewn into place to cover the holes in the tunica albuginea. A graft may be tissue from your own body, human or animal tissue, or a synthetic material. This procedure is generally used if a man has a shorter penis, severe curvature or a complicated deformity. This procedure runs a greater risk of erectile dysfunction than does the shortening procedure.
• Penile implants. Surgically inserted penile implants replace the spongy tissue that fills with blood during an erection. The implants may be semirigid — manually bent down most of the time, and bent upwards for sexual intercourse. Another type of implant is inflated with a pump implanted in the groin or scrotum. Penile implants may be considered if a man has both Peyronie's disease and erectile dysfunction. When the implants are put in place, the surgeon will likely make some cuts (incisions) in the scar tissue to relieve tension on the tunica albuginea.

The type of surgery used will depend on your condition. Your doctor will consider the location of scar tissue, the severity of your symptoms and other factors. If you are uncircumcised, your doctor may perform a circumcision during surgery.

Depending on the type of surgery you have, you may be able to go home from the hospital the same day or you may need to stay overnight. Your surgeon will advise you on how long you should wait before going back to work — in most cases, a few days. After surgery for Peyronie's disease, you'll need to wait four to eight weeks before you masturbate or have sex.

Other treatments
Several other nondrug treatments for Peyronie's are being investigated, but evidence is limited on how well they work and possible side effects. These include radiation therapy, using intense sound waves to break up scar tissue (shock wave therapy) and devices to stretch the penis (penile traction therapy).

Nesbit plication

Nesbit plication

Nesbit plication is one type of procedure to shorten the side of the penis that doesn't have scar tissue. An injection of a saltwater solution delivers a drug to create an erection. (1) The outer ...

Coping and support

Peyronie's disease can be a source of significant anxiety and create stress between you and your sexual partner. The following suggestions may help you cope with Peyronie's disease:

• Explain to your partner what Peyronie's disease is and how it affects your ability to have sex.
• Let your partner know how you feel about the appearance of your penis and your ability to have sexual relations.
• Talk to your partner about how the two of you can maintain sexual and physical intimacy.
• Talk to a psychological counselor (psychotherapist) who specializes in family relations and sexual matters.