Peyronie's Disease is characterized by the development of a fibrotic plaque (scar tissue) or hard bump of the outer layer of the erection chambers in the penis. It is both a physically and psychologically devastating disorder that is associated with various penile deformities including curvature, shortening, narrowing, hinging, pain and erectile dysfunction. Peyronie's disease may affect up to 9% of men. The natural history of the disease is controversial but recent studies show only 13% of men with Peyronie's Disease will experience a full recovery.
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PEYRONIE'S DISEASE TREATMENT
The exact cause of Peyronie's Disease is unknown, however most experts believe that repetitive trauma to the erect penis during sexual activity causes inflammation within the penile tissue. This inflammation will develop into a fibrous plaque in some men. Pain is the most common symptom of the disease at the early stages. In the later stages, the pain will disappear but erectile dysfunction may occur. The most common long term problem is penile curvature. This may be modest or severe. The curvature may not interfere with intercourse at all, may limit positions where intercourse is comfortable (for both partners), or may make intercourse impossible. Many men will notice an indentation of their penis where the plaque is located. This may destabilize the penis, and make it bend during intercourse. The penis may not be as rigid past the indentation or curvature. In some men, the plaque goes all of the way around the penis, and they will notice an "hour glass" effect, where it looks like there is an indented ring around the whole penis.
The sexual problems that result can disrupt a couple's physical and emotional relationship and lead to lowered self-esteem in both partners.
There are a many of proposed treatment options for Peyronie's Disease. These include oral medications, topical and intralesional agents, external therapies, and surgery.
The most common suggested oral therapies are Vitamin E, Colchicine, Potassium Aminobenzoate (POTABA), Tamoxifen Citrate, Carnitine and Pentoxyfylline. Pentoxyfylline was shown to decrease curvature in a recent study with 228 patients. The other oral medications show no evidence of benefit in reducing penile deformity.
Intralesional therapies (injecting medications directly into the penile scar tissue) include collagenase, verapamil and interferon. Collagenase treatment has shown promise in clinical studies as the most effective treatment option for Peyronie's Disease. A collagenase agent recently completed a large scale randomized trial and is being submitted to the FDA for approval. If approved, this will be the first FDA approved product specifically for Peyronie's Disease. Verapamil injections have shown positive results in reducing curvature and improving symptoms. The largest study to date showed that 60% of the men improved, by an average of 30 degrees. Interferon treatment has not been shown to be of therapeutic benefit.
External therapies include penile electroshock wave therapy, penile traction devices, and vacuum erection devices. Penile electroshock wave therapy has not shown reliable benefit as treatment. Several small studies have shown improvement in curvature and penile length with penile traction therapies. A small trial showed improvement in curvature in patients using a vacuum erection device.
Surgical options can be considered as part of a treatment plan for patients where Peyronie's disease has persisted for more than twelve months and has been stabilized for a minimum of six months. Surgical intervention should not be performed during active disease progression. Surgery is not recommended in patient's whose curvature is minimal and not impacting intercourse.
There are two main types of surgeries. The first is to correct the curvature by shortening the side of the penis directly opposite the curvature. This "evens" out the penis, and straightens the curvature. The second type may be used if a man has significant curvature; the plaque can be removed and then replaced with a graft. If a man has significant difficulty getting and maintaining the erection, in addition to a significant penile curvature, it is often worthwhile to place a penile prosthesis and straighten the penis simultaneously.
PEYRONIE'S DISEASE DIAGNOSIS
Your first appointment will typically be between 45 and 60 minutes. Here's what to expect and what will happen:
Your physician will take a history. He'll focus on whether you have had any history of penile trauma. He will ask for any other medical conditions you may have that may make you more likely to have developed this problem. He will need to know when the curvature began to develop. He will also ask you to quantify the curvature in terms of how many degrees and in what direction. It may be useful to take a picture from the side and from the top of the penis while erect, to provide important visual information about the amount of curvature you have developed. You will need to explain how much, if any, the rigidity of your erections has been altered.
- Physical Examination
Next, your physician will do a focused physical examination of the penis and testes. He'll be looking for evidence of scar tissue within the penis. You may even be able to feel this yourself by squeezing your penis gently through your fingers along its length and seeing if there are any hard nodules. The physician will check the sensation of your penis with a biothesiometer (a painless test that measures how intense vibrations need to be for you to sense them).
- Laboratory Testing
Your physician will usually check your hormone levels by taking blood from your arm.
There are several treatment therapies available for Peyronie's disease. Your physician will provide treatment options based upon how long you have had Peyronie's disease and whether it has stabilized or is progressive. At this point, we suggest patients use several treatment options simultaneously. Patients will be offered several different treatment options including oral Pentoxyfylline, verapamil injections, vacuum erection therapy and penile modeling.
Pentoxyfylline is an oral medication which has combined anti-inflammatory and anti-fibrogenic properties. A recent study by Safarinejad, et al. showed 36.9% of patients reported a positive response to treatment vs only 4.5% who received placebo. Pentoxyfylline will be taken two to three times a day. Pentoxyfylline appears most beneficial during active disease. It your Peyronie's is deemed to be in the chronic stable stage, we may not recommend Pentoxyfylline.
Verapamil is given via injection into the Peyronie's' plaque. Verapamil has been shown to inhibit fibroblast activity. Verapamil is given every two weeks for at least 6 injections. If there is improvement, additional cycles of six injections may be performed. Of course, an local anesthetic is provided prior to the injections.
A vacuum erection device can be used twice daily for 10 minutes. In a small study of 31 patients, 21 showed a reduction in curvature between 5-25 degrees.
Penile modeling will be taught to patients as well. Patients will straighten their penis gently when they get spontaneous erections.
Men who have had Peyronie's disease for at least 12 months with stability in the curvature for at least 6 months may consider surgical intervention. Surgical techniques used in the management of Peyronie's disease include plication, grafting, or placement of a penile prosthesis. The technique used will depend on patient preference and disease progression. Surgery cannot completely restore the penis to its former length or condition. Certain procedures will cause a shortening to the penis. As with all surgeries, there is a risk for decreased sensation to the penis as well as damage to the blood and nerve supply leading to impotence.
After all this discussion you can understand that it takes a very sophisticated evaluation to treat Peyronie's Disease. You'll be making difficult decisions about what treatment you'll undergo. Once a plan of treatment is determined, there is a significant amount of expertise required to incorporate the different options as well as to perform the various procedures involved in correcting the curvature. It is truly advisable to see a specialist when facing these decisions.
Michael Werner, M.D. has been treating Peyronie's Disease for more than 25 years. He recently was an investigator in the Xiaflex trials. He prides himself on taking a team approach to evaluating and treating your Peyronie's Disease. We understand that there are many options and that of course every man and every couple experiences Peyronie's Disease differently. We will also work with you to help you maximize your sex life while treatment is ongoing.
For more information about Peyronie's Disease contact us.