Is My Carrot…Crooked?

You’ve seen the commercials. And if you haven’t, you’re now going to YouTube to find them. A while ago I asked my local pharma rep what’s with the ‘crooked carrot’ marketing campaign? She laughed and said ‘We had to find something that wouldn’t get us censored and taken off the air! How else can we market to men with crooked erections?’ She has a point – a straight one if you will.

If you ‘break’ your penis, the fascia is what breaks

The medical term for a crooked carrot is Peyronie’s Disease. Peyronie’s Disease is a build-up of scar tissue along the fascia that surrounds your erectile chambers. You have two cylindrical chambers in your penis responsible for erections called the corpus cavernosum. They are surrounded by a strong protective tissue layer called fascia. This fascia layer in the penis is called the tunica albuginea, and this is where PD occurs. If you ‘break’ your penis, the fascia is what breaks.

With Peyronie’s disease, there is scarring of the fascia and you often feel a plaque. I describe it to my patients as a ‘fingernail-like structure’ under the skin. It’s usually a bit ‘crunchy’ and you can feel it. When you have an erection, this plaque doesn’t change its shape or size, so it causes a bend. And there you have it – a crooked carrot.

So, do you need to have your carrot straightened?

Yes and no.

Let’s get back to defining your crooked carrot.

Your Urologist should ask you how long the curvature has been there, and whether or not it is painful. There are two phases to Peyronie’s disease. The first is the ‘acute’ or ‘active’ phase, and the other is the ‘chronic’ or ‘stable’ phase.

Active vs Stable

The active phase is when the disease is just beginning. It is often painful. In fact, the American Urologic Association Guideline on Peyronie’s Disease defines this phase as ‘penile and/or glandular pain or discomfort with or without erection.’ This may last up to several months, until we graduate you to the ‘stable’ phase. During this phase, physical changes to the penis may or may not be visible. Erectile dysfunction may begin developing. The active phase is managed with over-the-counter pain medications including Advil or Motrin (ibuprofen).

About 1/3 of patients presenting with Peyronie’s have erectile dysfunction

Once the pain has resolved and the physical changes, if present, have been there for 3 months – you are now in the ‘stable’ phase. This is when you can seek treatment. About 1/3 of patients presenting with Peyronie’s Disease have erectile dysfunction.

Important note here: your Urologist will need to know where the plaque is, and how it affects your erections. Many providers will administer medication in clinic to induce an erection so they can see for themselves. If you are good at selfies, some will accept home photos of your crooked carrot as well.

Now let’s get back to treating your carrot

Whether or not your plaque should be treated depends on where it is, how long it has been there (see above – you can’t be treated during the ‘active’ phase), how much curvature it causes, and whether or not you have issues because of it. I have several patients who have plaques that don’t cause them any issues. They feel the plaque, but it doesn’t cause curvature or trouble with erections. I don’t recommend treatment for these folks.

If you have ED and any degree of curvature, you should get a penile implant. It fixes both

I have others with plaques that don’t qualify for treatment based on their location. If you have a plaque that is causing curvature greater than 30 degrees, you might be a candidate for injection treatment. If you have erectile dysfunction and a plaque causing any degree of curvature, you should get a penile implant. It fixes both in one procedure.

So, what exactly is injection therapy for PD?

The company responsible for the crooked carrot ad scheme makes an FDA approved medicine for Peyronie’s called Xiaflex^®. Xiaflex is injected directly into your plaque. The medicine helps weaken and break down the plaque causing your carrot to bend.

Know what to expect

Xiaflex is not an easy treatment and has potential side effects. I always have a long talk with my patients before starting this treatment. They have to be ready for the comprehensive plan and accept potential risks. Xiaflex injections can be painful and the treatment requires 4 series of 2 injections each over the course of 6 weeks. There can be significant bruising and swelling following the injections and there are other potential risks. The medicine that helps break down the plaque may also impact the penile skin and fascia layer causing necrosis (tissue death) or penile fracture. And, YOU CAN NOT HAVE SEX during treatment or you will fracture your penis! I have seen this happen…

The procedure goes something like this: you get a penile block – a numbing injection. Make sure your urologist does the numbing step – apparently, they don’t all do it – Ouch! After your carrot is numb, the urologist takes a very tiny needle and carefully isolates the plaque and injects the Xiaflex right into it. This is not a simple task, and not all Urologists offer this procedure. Make sure you call and confirm that they treat Peyronie’s before showing up.

Your homework is to model your penis. I don’t mean dress him up and take him to NY Fashion Week

After the injection, your homework is to ‘model’ your penis. I don’t mean dress him up and take him to NY Fashion Week – your Urologist and/or the pharmaceutical rep will talk you through the modeling process. Modeling is done with your hands at home. You are basically helping to straighten your penis with exercises your provider teaches you in the office. And most importantly – you have to avoid sex! If you have any sort of trauma while the Xiaflex is working, you can fracture your penis. You don’t want to end up in the operating room having a penile exploration performed – Double ouch! Save yourself the trouble and follow the instructions – please!

There are other injection materials on the market that work in a similar process including clostridium histolyticum (aka active ingredient in Xiaflex), intralesional collagenase, verapamil, or interferon alpha-2b. Your Urologist will counsel you regarding which injection type they perform in the office.

Straightening your carrot with injections requires special training

If you are a candidate for injection therapy and choose this treatment option, go to the Xiaflex website to find a Urologist in your area who is registered for administering the medication. Straightening your carrot with injections requires special training.

What if the injections don’t work, or I’m not a candidate?

There are surgical options for Peyronie’s disease in addition to injection treatments. These procedures include plaque excision/grafting, plication surgery, and/or an inflatable penile prosthesis. If you have erectile dysfunction and Peyronie’s disease – your answer is the IPP. It fixes both! Plaque excision/grafting and plication surgeries have a unique set of complications – make sure you see a urologist who is trained to do these procedures. Go to the good Dr. Wallen’s post to read about surgical treatments for Peyronie’s Disease.

What should I NOT do?

Don’t let anyone: radiate your penis, perform shockwave ultrasound therapy on your penis, or prescribe vitamin E, tamoxifen, omega-3 fatty acids, or procarbazine. Some patients may receive shockwave therapy for PAIN but that is the only indication.

The Bottom Line: If you have >30 degrees of curvature, a palpable plaque, and performance issues because of this, find a Urologist. Crooked carrots might be OK for dinner, but they aren’t always OK for dessert.

What’s Off The Record?