As the channel for semen and urine, the penis serves two important functions in men. But a disease described as early as the mid-18th century by a French physician, Francois Gigot de la Peyronie, which causes hardened patches on the penile shaft, can severely impact a man's sexual performance. If you have pain and penile curvature characteristic of Peyronie's disease, the following information should help you understand your condition.
What happens under normal conditions?
The penis is a cylindrical organ consisting of three chambers: paired corpora cavernosa that are surrounded by a protective tunica albuginea; a dense, elastic membrane or sheath under the skin; and the corpus spongiosum, a singular channel, located centrally beneath and surrounded by a thinner connective tissue sheath. It contains the urethra, the narrow tube that carries urine and semen out of the body.
These three chambers are made up of highly specialized, sponge-like erectile tissue filled with thousands of venous cavities, spaces that remain relatively empty of blood when the penis is soft. But during erection, blood fills the cavities, causing the corpora cavernosa to balloon and push against the tunica albuginea. While the penis hardens and stretches, the skin remains loose and elastic to accommodate the changes.
What is Peyronie's disease?
Peyronie's disease (also known as fibrous cavernositis) is an acquired inflammatory condition of the penis. It is the formation of a plaque or hardened scar tissue beneath the skin of the penis. This scarring is non-cancerous, but often leads to painful erection and curvature of the erect penis (a "crooked penis").
What are the symptoms of Peyronie's disease?
This scarring, or plaque, typically develops on the upper side of the penis (dorsum). It reduces the elasticity of the tunica albuginea in that area and, as a result, causes the penis to bend upward during an erection. Although Peyronie's plaque is most commonly located on the top of the penis, it may occur on the underside or on the lateral side of the penis, causing a downward or lateral bend. Some patients may even develop a plaque that goes all the way around the penis, causing a "waisting" or "bottleneck" deformity of the penile shaft. The majority of patients complain of generalized shrinkage or shortening of their penis.
Painful erections and difficulty with intercourse usually lead men with Peyronie's disease to seek medical help. Since there is great variability in this condition, sufferers may complain of any combination of symptoms: Penile curvature, obvious penile plaques, painful erection and diminished ability to achieve an erection.
Any of those physical deformities make Peyronie's disease a quality-of-life issue. Not surprising, it is linked to erectile dysfunction in 20 to 40 percent of sufferers. While studies have shown that 77 percent of men demonstrate significant psychological effects, the numbers, medical researchers believe, are under reported. Instead, many men affected with this truly devastating condition suffer in silence.
How frequently does Peyronie's disease occur?
Peyronie's disease affects a reported one to 3.7 percent (about one to four in 100) of males between ages 40 and 70, even though severe cases have been reported in younger men. Medical researchers believe the actual prevalence may be higher due to patient embarrassment and limited reporting by physicians. Since the introduction of sildenafil citrate, an oral therapy for impotence, doctors have reported increased incidence of Peyronie's cases. With more men being treated successfully for erectile dysfunction in the future, an increasing number of cases presenting to urologists are anticipated.
What causes Peyronie's disease?
Ever since Francois Gigot de la Peyronie, personal physician to King Louis XV, first reported penile curvature in 1743, scientists have been mystified by the causes of this well-recognized disorder. Yet medical researchers have speculated on a variety of factors that might be at work.
Most experts believe that acute or short-term cases of Peyronie's disease are likely the consequence of a minor penile trauma, sometimes caused by sports injuries, but more often by vigorous sexual activity (e.g., the penis accidentally being jammed into a mattress). In injuring the tunica albuginea, that trauma triggers a cascade of inflammatory and cellular events resulting in the abnormal fibrosis (excess fibrous tissue), plaque and calcifications characteristic of this disease.
Such trauma, however, may not account for those Peyronie's cases that begin slowly and become so severe that they require surgery. Researchers believe genetics or relationship with other connective tissue disorders may play a role. Studies already suggest that if you have a relative with Peyronie's disease you have a greater risk of developing it yourself.
How is Peyronie's disease diagnosed?
A physical examination is sufficient to diagnose curvature of the penis. The hard plaques can be felt with or without erection. It may be necessary to use injectable medications to induce an erection for proper evaluation of the penile curvature. The patient may also provide pictures of the erect penis for evaluation by the physician. Ultrasound of the penis may demonstrate the lesions in the penis but is not always necessary.
How is Peyronie's disease treated?
Because Peyronie's disease is a wound-healing disorder, changes are constantly occurring in the early stages. In fact, this disease can be classified into two stages: 1) an acute inflammatory phase persisting for six to 18 months during which men experience pain, slight penile curvature and nodule formations and 2) a chronic phase during which men develop a stable plaque, significant penile curvature and erectile dysfunction.
Occasionally the condition regresses spontaneously with symptoms resolving themselves. In fact, some studies show that approximately 13 percent of patients have complete resolution of their plaques within a year. There is no change in 40 percent of cases, with progression or worsening of symptoms in 40 to 45 percent. For these reasons, most physicians recommend a non-surgical approach for the first 12 months.
Conservative approaches: Instead of requiring invasive diagnostic procedures or treatments, men who experience only small plaques, minimal penile curvature and no pain or sexual limitations, need only be reassured that the condition will not lead to malignancy or another chronic disease. Pharmaceutical agents have shown promise for early-stage disease but there are drawbacks. Because of a lack of controlled studies, scientists have yet to establish their true effectiveness. For instance:
Injections: Injecting a drug directly into the penile plaque is an attractive alternative to oral medications, which do not specifically target the lesion, or invasive surgical procedures, which carry the inherent risks of general anesthesia, bleeding and infection. Intralesional injection therapies introduce drugs directly into the plaque with a small needle after appropriate anesthesia. Because they offer a minimally invasive approach, these options are popular among men with either early phase disease or who are reluctant to have surgery. Yet their effectiveness is also under investigation. For instance:
Other investigative therapies: The medical literature is replete with reports on less invasive methods for treating Peyronie's disease. But the effectiveness of treatments such as high-intensity focused ultrasound and radiation therapy, topical verapamil and iontophoresis, introducing soluble salt ions into the tissue via electric current, must still be investigated before these alternative therapies are considered clinically useful. Likewise, controlled studies using larger patient groups with longer follow ups are necessary to prove that the same high-energy shock waves used to break up kidney stones will have positive effects on Peyronie's disease.
Surgery: Surgery is reserved for men with severe disabling penile deformities that prevent satisfactory sexual intercourse. But, in most cases, it is not recommended for the first six to 12 months, until the plaque has stabilized. Since a spin-off of this disease is an abnormal blood supply to the penis, a vascular evaluation using vasoactive agents (drugs that cause erections by opening the vessels) is done prior to any surgery. A penile ultrasound if performed can also illustrate the anatomy of the deformity. The images allow the urologist to determine which patients are most likely to benefit from reconstructive procedures versus a penile prosthesis. The three surgical approaches include:
Penile prostheses: A penile prosthesis may be the only good option for Peyronie's disease patients with significant erectile dysfunction and insufficient blood vessels verified by ultrasound. In most cases, implanting such a device alone will straighten the penis, correcting its rigidity. But when that does not work, the surgeon may manually "model" the organ, bending it against the plaque to break the deformity, or the surgeon may need to remove the plaque over the prosthesis and apply a graft to completely straighten the penis.
What can be expected after treatment for Peyronie's disease?
Routinely, a light pressure dressing is applied for 24 to 48 hours after the surgery to prevent any accumulation of blood. The Foley catheter is removed after the patient recovers from anesthesia and most patients are discharged later the same day or the following morning. During the healing process, medications to counteract erections are usually prescribed. The patient is also asked to take antibiotics for seven to 10 days postoperatively to ward off infection, and analgesics for any discomfort. If patients have no penile pain or other complications, they can resume sexual intercourse in six to eight weeks.
Frequently asked questions:
What happens to the cells following penile trauma?
In theory, following any penile trauma, there is a release of growth factors and cytokines or daughter cells that activate fibroblasts, cells that produce connective tissue. They, in turn, cause abnormal collagen deposition or scarring, which damages the internal elastic framework of the penis. Similar wound-healing disorders are commonly seen in the practice of dermatology, with conditions such as keloids and hypertrophic scarring, both involving tissue overgrowth in wound healing.
Are Peyronie's disease sufferers prone to other related conditions?
About 30 percent of Peyronie's disease sufferers also develop other systemic fibrosis in other connective tissue in the body. Common sites are the hands and feet. In Dupuytren's contracture, scarring or thickening of the fibrosis tissue in the palm leads progressively to a permanent bending of the pinkie and ring fingers into the hand. While the fibrosis occurring in both diseases is similar, it is not clear yet what causes either plaque type or why men with Peyronie's disease are more likely to develop Dupuytren's contracture.
Will Peyronie's disease evolve into cancer?
No. There are no documented cases of progression of Peyronie's disease to malignancy. However, if your doctor observes other findings that are not typical with this disease—such as external bleeding, obstructed urination, prolonged severe penile pain—he or she may elect to perform a biopsy on the tissue for pathological examination.
What should men remember about Peyronie's disease?
Peyronie's disease is a well-recognized but poorly understood urological condition. Interventions need to be individualized to each patient, based on the timing and severity of the disease. The objective of any treatment should be on reducing pain, normalizing penile anatomy so that intercourse is comfortable and restoring erectile function in patients who suffer erectile dysfunction. Although surgical correction is ultimately successful in the majority of cases, the early acute phase of this disease is customarily treated by either oral and/or intralesional approaches. As medical researchers continue to develop basic and clinical research for a better understanding of this disease, more therapies and targets for intervention will become available.