Peyronie Disease

Peyronie disease is a condition where the penis consists of three tubes of tissue, one containing the urethra and two long tubes filled with spongy tissue, called corpora, which swell when engorged with blood, producing an erection. The two tubes are contain a thick elastic membrane (tunica albuginea). In Peyronie’s Disease, a scar develops in the tunica and restricts elasticity of the penis, so that the erection deformity is seen with the penis curving towards the side of the plaque.

With an erection the penis can rotate in a twisting fashion (corkscrew penis). In some cases the rotation is so severe the patient looked down on his erect penis, he was actually viewing the underside.

Besides producing curvature, this scar tissue plaque can interfere with erections. Sometimes the patient’s erection will be firmer on the body side of the plaque and softer beyond the plaque. The plaque may not be felt when the penis is flaccid but is readily demonstrated with erection.

It is found frequently on the topside of the penis (dorsal); next, on one side (lateral); and least frequently on the bottom (ventral). It can be bilateral or nearly circumferential, then producing not curvature but shortening.

The plaque is most of the time hard, sometimes lumpy and about 25{b3b011aadac538a55a5f3a1f3843dacae511a7fa031f7693495761f9c3e0ebc4} will have calcium. I have biopsied one rock-hard plaque that showed actual bone formation (ossification).

The condition can occurs in men 30 to 50 years of age and has been reported in all races. It may present itself first with pain which seldom lasts longer than six months. The condition usually stabilizes by 12-18 months and occasionally will regress. Complete disappearance is rare.

When curvature is marked, the patient can find penetration awkward and difficult and thrusting can cause pain to his partner. When shortening is marked, he may have trouble remaining inside during copulation.

The combination of soft erections and penile distortion is often devastating, and patients can become seriously depressed.

Cause: The cause of Peyronie’s disease is unknown but is associated in some cases with a history of penile trauma, including rough sex. In around 10{b3b011aadac538a55a5f3a1f3843dacae511a7fa031f7693495761f9c3e0ebc4} of patients a concurrent deformity of the palm is seen, called Dupuytren’s contracture, where scar tissue forms beneath the skin and causes flexion contractures, where the finger is locked downward towards the palm. Rarely, the same deformity may occur in the sole. In some cases the disease appears to be familial, particularly in men of Scandinavian descent. I have seen a Peyronie’s patient from a Swedish family whose father, brothers, uncles and male cousins all had the condition in the penis, palms and soles.

Diagnosis: By examining the erect penis, the diagnosis can be made. The mature plaque(s) can usually be seen on plain X-ray even when not calcified or ossified. CT and MRI scans are seldom necessary.

Treatment:
I. a). Mild Curvature with good erections – no treatment is needed unless the patient insists on cosmetic improvement. This is handled by (1) making the long side shorter, with a series of plication sutures or, (2) making the short side longer by incising the plaque transversely. Usually nothing further is needed; a tissue graft is rarely necessary.

I. b). Mild curvature with poor erections – The erectile dysfunction is the chief problem here and can be treated by the intra-urethral pellet, Muse; Viagra; or a penile prosthesis. Intracavernosal self-injection theoretically could make the curvature worse, so I prefer to avoid it. Experience suggests that in these patients erectile dysfunction often worsens faster than might otherwise be expected. The penile prosthesis is an attractive option in these cases.

II. a). Moderate to severe curvature with good erections – here the curvature is the problem. This is treated by making the short side longer or the long side shorter. The latter tends to shorten the penis, and patients do not happily accept a shorter penis. Therefore, the short side is made longer by exposing the plaque and making a series of short elliptical transverse incisions through the plaque down to, but not into, the spongy tissue, making the plaque discontinuous – dividing it into disconnected segments – allows the penis to expand symmetrically on erection. To do this it may be necessary to elevate the neurovascular bundle. Temporary, patchy sensory loss may occur postoperatively but I have never seen it permanent, or even last longer than 3 months.

II. b). Moderate to severe curvature with poor erections – the penile prosthesis has been very successful with these patients. Just by inflating the prosthesis alone, adequate straightening may occur. Often inflating the prosthesis by manually “molding” the penis gently but firmly bending it opposite the curve – additional straightening can nearly always be obtained. If still more straightening is needed, an incision is made and the plaque exposed and incised or excised.

In those patients whose disease has left them with unacceptable shortening, we have obtained highly satisfactory results by combining the above procedures with a lengthening procedure. Significant length gain can be obtained in this manner.

Patients can go home the same day or the next day. Intercourse can take place in 6 weeks. Complications can include bleeding, infection, numbness, shortening, inadequate curvature correction, discomfort lasting more than a few days. We have never seen permanent sensory loss, worsening of erections, or ejaculatory problems.

It is important for patients to understand that while penile curvature can be markedly improved and erectile function restored, once the patient has Peyronie’s disease, his penis will never be the same as before the disease developed.