Peyronie’s Disease: Causes, Diagnosis, and Treatments
What Is Peyronie’s Disease?
Peyronie’s Disease, or PD, is a common condition that affects about 1 in 20 men and typically happens to men in their 50’s and 60’s. Although everyone is different, it most often leads to penile curvature, shortening, and a palpable bump (or ‘plaque’). Some men also experience symptoms of penile pain, narrowing of the penis, or other deformities. Even though the condition has the biggest impact on sexual intimacy, it has psychological effects as well. Specifically, men with PD often experience a loss of confidence, masculinity, relationship satisfaction, and can even suffer from anxiety and depression.
What Causes Peyronie’s Disease?
The exact cause of Peyronie’s Disease is unknown. Some forms of PD are likely genetically linked, while other forms may be ‘spontaneous’ and due to repeated minor trauma to the penis. The condition is more common in men with diabetes mellitus, erectile dysfunction or following prostate surgery. Once an (minor) injury has occurred, men with PD experience abnormal scarring to the firm lining of the penis (‘tunica’), which then leads to an inflexible scar called ‘plaque.’ When these men get an erection, the rest of the penis is able to stretch, while the plaque remains rigid, leading to the characteristic penile curvature.
How Do I Know if I Have Peyronie’s Disease?
There are no lab or imaging tests that can confirm if you have Peyronie’s Disease. Men who experience a new penile curvature, penile pain with deformity, or a new bump that they can feel on the penis are more likely to have the condition. Other symptoms include a loss or gain in penile sensation, loss of penile length, tapering or narrowing of the penis, or an hourglass-like narrowing. Men who have lifelong curvature most likely do not have PD, but rather have something known as congenital penile curvature.
How Should I Treat Peyronie’s Disease?
There have been hundreds of different treatments described for Peyronie’s Disease that date back to as far as 3000 BC! Examples of historical treatments include bathing in the Holy Waters of Barege (France), use of mercury, and other similar ill-advised therapies – needless to say, these are no longer recommended. Several treatment options that are commonly used today are discussed in greater detail below.
Oral medications are commonly used for the treatment of PD. However, oral medications alone have not consistently been shown to be effective, and the American Urological Association has recommended against some oral therapies, including Vitamin E. Although there are a few studies which highlight improvements with some oral treatments, additional studies are required to determine if oral therapies are effective and in which settings they may be most useful, i.e. early phase, combined with other treatments, etc.
Traction therapy involves stretching the penis to increase the length or improve penile curvature. The majority of 1st generation devices use similar mechanics to stretch the penis and require treatment for 3-9 hours daily for 3-6 months to achieve benefits. Published studies on these devices have shown variable outcomes, with some studies showing no improvements with treatments.
More recently, a 2nd generation technology called RestoreX® has been developed by a team at the Mayo Clinic and licensed to PathRight Medical, Inc. In contrast to the earlier therapies, the RestoreX device permits counter traction, achieves greater forces, and only requires 30-60 minutes of daily use. Results from a randomized study at Mayo Clinic showed improvements in length (approximately 1 inch) and curve (30%) among the majority of men who used the treatment. There are no known permanent side effects with traction therapy.
Several different types of injection medicines have been used to treat PD over the years including Xiaflex®, verapamil, and interferon, however Xiaflex is the only FDA approved injection medicine for the treatment of PD. Although the way in which verapamil and interferon may work is not known, Xiaflex has been shown to dissolve PD plaques, allowing for a gradual reduction in penile curvature.
Injections typically require multiple treatments over a period of up to 6 months. Xiaflex is administered by giving two injections (separated by 1 – 3 days) every 6 weeks for up to four series. In contrast, verapamil or interferon is given with one injection administered weekly or every other week for up to 12 injections. Injection therapy for PD should only be administered by physicians with significant experience, as there is a learning curve to drug administration to achieve best outcomes.
Based on two recent studies, Xiaflex is likely best when combined with RestoreX and sildenafil, the active ingredient in Viagra®. In one of the combination studies of Xiaflex and RestoreX, 95% of men achieved some improvement in penile curvature and more than 50% of men achieve greater than 50% reduction in curvature. The most common side effect of injections is bruising, however there are few long-term risks with this therapy. Because of its low side-effect profile injection therapy is commonly used as a first-line therapy prior to surgery.
There are two main surgeries that are performed for PD: penile plication and incision/excision and grafting. These treatments are very effective at improving penile curvature and are normally only performed in men who have stable disease: greater than 6 months with no change in curvature and no penile pain. Penile plication is performed by stitching the opposite side of the curvature to “pull in” that part of the penis, while incision and grafting involves cutting the scar and placing a graft over the newly created ‘gap.’ Side effects of plication include palpable sutures, temporary pain / bruising, and reduced penile size, while incision/excision and grafting can also lead to worsened erectile function or changes in penile sensation.
Although the penile length usually does not change by much with surgery, the overall volume of the penis is reduced, which often gives patients the perception of length loss. There is limited long-term data available on surgery, with some showing that penile curvature returns in a percentage of men. Because of these findings, surgery is increasingly being considered as a second line treatment for PD.
Scams / Buyer Beware
There are several different treatments which are being increasingly offered / advertised to patients and which have either no evidence or evidence showing that they don’t work and are not cleared by the FDA to treat PD. These treatments include low energy shockwave, stem cells, and platelet rich plasma. Physician groups that specialize in PD and other men’s health conditions such as the Sexual Medicine Society of North America have released statements warning consumers against the claims of efficacy that these technologies make. The American Urological Association similarly has recommended against shockwave therapy to treat penile curvature.
Peyronie’s Disease is a common condition that results in a significant impact on quality of life, including psychological aspects. The cause for PD is not fully known, although it may relate to repeated minor trauma to the penis in men who are susceptible. Recent advances with treatment include a new injectable (Xiaflex) and traction (RestoreX), which are increasingly being considered as first line treatment. Men who fail or reject first line treatments may be successfully treated with surgery, or as recommended by their doctor. Patients should be aware of and avoid various scams that are common with PD, including shockwave, stem cells, and platelet rich plasma until greater evidence is available.
Dr. Landon Trost is the original inventor of the RestoreX traction device and may have financial incentives associated with the invention.
About the Author
Dr. Landon Trost, MD is the former head of Andrology at the Mayo Clinic in Rochester and the current President of the Male Fertility and Peyronie’s Clinic as well as Cure PD, a charity established to further research and education for Peyronie’s Disease. He also serves as a panel member for the American Urological Association’s Guideline on Peyronie’s Disease.