A Patient's Guide to Peyronie's Disease (PD)
Thomas J. Stormont, MD
What is PD?
PD is scarring of the penile tissues that can cause pain or bending of the erect penis, sometimes leading to sexual difficulties. PD is benign, and does not develop into cancer. Not everyone has the same onset or severity of symptoms. The typical symptoms are curvature and/or pain with an erection, or a hardened scar, also known as "plaque." Penile curvature, the most common problem, causes bending which is usually upwards. The reason for the bend is that the plaque causes tethering and curvature towards that side of the penis with an erection. Severe plaques can lead to buckling or "hinging" with an erection, or a narrowing (hourglass deformity), and even shortening and/or softening of an erection leading to erectile dysfunction (ED).
How common is PD?
Historic estimates are that 1% of men have PD, but current estimates of approximately 10% recognize that PD is more common than previously thought. Two-thirds of patients are between 40-60 years old, but it has been reported to occur rarely in men in their twenties.
What causes PD?
It is not certain what exactly causes PD. It does not appear to be due to diet, infection, stress or medication. There may be a genetic predisposition, since it can run in families. What is clear is that it usually follows an injury to the erect penis. Most men do not recall any specific event, while others recall an injury during sex where they may recall a "popping" sound associated with pain and some bruising.
How does PD develop?
PD typically develops in two stages. During the acute or deforming stage there is usually some mild aching in the penis, which worsens with attempted intercourse. Patients may notice a palpable lump or nodule, followed by erectile curvature or bending. The entire process usually is gradual and takes months, but occasionally it can happen within weeks. The first stage is followed three to twelve months later with the stable phase, where the deformity stops and may rarely resolve on its own. At this stage, in about 30% of cases, the plaque will calcify. As stated earlier, the exact timing and severity of PD is highly variable and affects each man differently.
Are medications helpful?
Oral therapy is usually the initial treatment and may provide some relief by diminishing or reversing scarring, although the exact dose, length of therapy and ultimate effectiveness is generally unknown. Best results with oral medications seem to occur early in the course of PD, and it is generally reasonable to try a three- to six-month course of one or a combination. Some over-the-counter medications that have been utilized include L-arginine, vitamin E and aspirin or ibuprofen - but be advised to notify a physician before use. Prescription medications that have variable success include Pentoxifylline, Potaba or colchicine. Phosphodiesterase type 5 inhibitors (Viagara-like medications) may be helpful to help improve blood flow if there is a rigidity problem.
What about injectables?
This involves injecting a local anesthetic followed by a medication directly into the plaque. Verapamil, a "calcium channel blocker," is the most popular, safe and proven of the injectables. An injection is typically done every two weeks for 6-12 weeks, with the main side effect mild, harmless bruising. In the majority of patients it appears there is stabilization of the deformity, and often subtle but progressive decrease in the plaque and/or bending over time. If there is no improvement within 3-6 injections, it is unlikely that this therapy will be successful. Other injections (interferon, collagenase and steroids) have been used but have more side effects and less documented improvement.
When is surgery necessary?
Surgery should only be performed when other methods have failed and when PD is stable (no change in the plaque or curvature for at least six months). Surgery should only be performed when there is greater than 30 degrees curvature or when there is impaired rigidity that interferes with intercourse.
How successful is surgery?
While no treatment can guarantee complete success for PD, surgery is considered the gold standard for PD with infrequently side effects and success rates of over 95%. While the majority of men with PD don't undergo surgery, of those that do most are very satisfied. Most insurances and Medicare do cover surgical correction of PD.
What is the most common surgery?
The easiest and safest form of surgery - "plication" - is used to correct milder forms of PD. It is the least invasive of all surgeries and is best done with less than 70 degrees curvature with no rigidity problem. It involves shortening the longer side of the penis by placing "tucking" sutures under the skin. Success approaches 99% and recovery is rapid. Side effects, while rare, include incomplete straightening, loss of sensation, shortening and ED.
What about a prosthesis?
If there is an insufficient erectile response - even when taking medications like Viagra - a prosthesis may be recommended. This involves implantation of cylinders and a pump (all internal) to allow straightening and the ability to have an 'on demand' erection, with a high rate of mechanical reliability and less than 2% rate of infection.
When is grafting recommended?
This is a complicated procedure, reserved for the most advanced curvature in men who still have good erections. The curvature is usually greater than 70 degrees and/or there is significant buckling or an "hourglass"deformity. In this procedure, small areas of plaque are removed and then covered with grafts. The usual graft material used is treated cadaver or animal tissue, although sometimes grafts can be taken from other areas of the body. Grafting is considered more invasive and riskier than a plication procedure, mainly because of a higher risk of loss of rigidity and/or sensation.
