It’s essential to shed light on a condition that affects about 5% of men both psychologically and physically, known as Peyronie’s Disease or PD – a condition that involves the abnormal presentation, often curvature, of the penis. Peyronie’s can manifest in several ways, and while the most common curvature is upward, the penis can also curve to the side or downward. How the penis curves and the degree of curvature is related to plaque accumulation. This plaque pulls on the penile structures, causing the penis to curve during erection. The most common cause of Peyronie’s Disease involves micro tears in the penis that, over time, create an exaggerated inflammatory reaction with resultant penile plaque accumulation.
What exactly constitutes abnormal? Typically, when the penis is severely misshapen or curved by more than 15 degrees, we consider a diagnosis of Peyronie’s.
While this may not seem like a lot, even mild curvature can be concerning to a patient and impede their desire to have sexual relations. However, when the penis reaches 35-45 degrees or more, patients are often referred for treatment as erections, and sex can be quite painful.
The Psychological Component of Peyronie’s
One of the reasons we are seeing more Peyronie’s Disease cases now than ever is that men are finally talking about it. What was once a source of embarrassment is now a topic that many men feel comfortable discussing with their urologist. Doing so allows for appropriate treatment of PD – options are discussed in this article.
The psychological component of Peyronie’s is important to consider because many men are concerned about what their sexual partner will think about the curvature, or they believe that they are somehow broken. This leads to a reduction in sexual activities that often causes even more significant psychological issues. While Peyronie’s itself does not cause erectile dysfunction, many men are concerned enough about it that they avoid sexual activity or find themselves unable to achieve an erection.
Treatment During the Active Phase
A recent study has shown the potential viability of Cialis or Tadalafil in arresting the worsening of Peyronie’s disease during its active phase (first 3-12 months). This is the only oral drug thus far that has shown any appreciable benefit in treating Peyronie’s Disease.
<30 degree curvature
For patients with curvature of less than 30 degrees and no significant pain during erection or intercourse because of their Peyronie’s, we typically take a wait-and-see approach, as about 15% of cases will remodel and improve, while 60% of cases will stay the same. Only about 25% of cases will worsen. We try to reassure them that sex is still possible and enjoyable for both partners with their degree of curvature.
>30 degree curvature
If the curvature is not less than 30 degrees, there is a palpable penile plaque, and patients are experiencing discomfort, we often counsel these patients toward the least invasive treatment option… Xiaflex (Collagenase Clostridium Hystoliticum) – a series of eight penile injections over four cycles. These cycles of two injections are administered over 2-3, and the medication injected into the penis is very effective in softening the plaque. With traction exercise and remodeling therapy, the curvature is reduced up to 30 degrees in some patients. It is effective in 45 to 60% of patients and represents an excellent first-line option.
We can reasonably determine the success of Xiaflex after the first two injections. If the patient shows some improvement at this point, we usually continue. That said, Xiaflex is not a curative option, and patients may occasionally return to baseline curvature. If they do see improvement, it will often be significant enough to enjoy sexual activity.
If Xiaflex therapy fails to improve curvature, we move on…
More Significant Curvature
When penile curvature exceeds 45° (and it can get up to 90°), most patients begin to experience significant discomfort with an erection and sexual intercourse. This discomfort often precludes sex and almost certainly makes the act far less enjoyable. For these patients, more aggressive treatment will likely be pursued.
- Plication is an elegant solution using sutures to pull the opposite end of the penis, eliminating some of the curvature. A plication is performed as an outpatient procedure, and patients return to regular sexual activity quickly with the benefits of significantly reduced curvature.
- Penile grafting is a reconstructive procedure that mechanically removes the penile plaque, and it is truly the only curative procedure available to most men. While it is very effective, it’s also the most invasive option, requiring a more significant recovery and the risks and considerations of a more invasive surgical procedure.
- For Peyronie’s patients who have co-occurring severe erectile dysfunction, a penile implant to address both issues in one surgery may be considered.
Can PD Be Prevented?
As much as we know about the male genito-urinary system, we still do not fully understand the causes of Peyronie’s. For some, there is a specific event, usually a trauma to the penis during intercourse, that they can recall as the catalyst for their problem. For most, however, no cause can be pointed to. Because of the increased likelihood of developing Peyronie’s, if a close family member had it, we also know that there is some genetic component to this condition.
Ultimately, however, the most crucial consideration is that patients understand that PD is nothing to be ashamed of. They should visit their men’s health neurologic specialist at the first signs of penile curvature. Doing so offers the best chance of treating PD and having the most significant number of treatment options available. Contact Dr. Kapadia for a consultation and to learn more.