Peyronie’s Disease

by Shahrokh Shariat | Last Updated: October 29, 2019

What is Peyronie’s disease?

This is something you may never have even heard of, and I can guarantee you that there are some physicians that also probably haven’t heard of this condition. So why would I be talking about something that even your doctor may have never heard of?

Well, it’s because it’s really not that uncommon. Peyronie’s disease is a condition that affects the penis of a man and causes him to have the curvature with an erect penis. Let’s get into this in a little bit more detail…

François Gigot de la Peyronie was the first one to describe Peyronie’s disease. However, it even predates him by a few years. Roughly about 15% of men actually suffer from this condition, and they suffer most often in silence.

This is not something that guys are going to sit around on a barstool or talk to their buddies about at a baseball game or a football match and say “hey, how’s your penis, is it bent also?”

It doesn’t work that way for men, Were Not typically that open about our health conditions. And certainly not as intimate as a condition involving our erections. This situation goes back, as I said at least 400 years and probably even previously to that. An Italian anatomist first described it in the 1500s, and again it took till about the 1700s before François Gigot de la Peyronie was the guy that actually put his name to it. He was a court physician for Louis XV in France.

I wish I were an anatomical artist back in the 1940s because it seemed like it would be an easy job because the image to the left looks more like the back of a napkin calculation or sketch drawing, but it’s actually not a bad rendition of what Peyronie’s disease looks like.

We are going to go through this in some detail about what this condition is and then we are going to get into the treatment options later. But let’s spend a couple of minutes on this image. This comes from a textbook way back in 1940 that talks about three stages of development of Peyronie’s disease.

Again, it’s not quite three steps, and we don’t look at it like that these days, but we’ll see what this is good for. This is actually not too far from the drawings that I draw for my patients when I look at them in the office. It starts off as a little bit of a scar tissue as you see in the initial picture. It’s not quite much of a bend, and then our accomplished artists were able to start to show a little gradual curve and then a significant curve as the scar tissue builds up.

The three circles underneath are cross-sectional anatomy pictures, so now we are looking at it straight on and also slice by slice. It seems a little bit like a CT scan if you’ve ever seen any of those in your own lives. So these other two erectile bodies at the top are called the Corpora Cavernosa. This is a condition that affects the penis and erections by causing them to be bent. The problem isn’t actually inside the erectile bodies; it’s actually in the thick outer membrane called the Tunica albuginea.

So, imagine every time that a man gets an erection he should have perfect blood flow that goes all the way from the base of the cylinders of those corpora cavernosa which starts deep in the pelvis and then go all the way out to the tip of the penis. That’s what was supposed to happen regularly. In Peyronie’s disease, because of the scar tissue that forms, the minute that blood flow hits that scar, there is a restriction, and that limitation causes the penis to deflect upwards or to the right or the left or even down.

The Peyronie’s can go in all directions of the compass, and it just depends on where that scar is along the Tunica membrane. If you happen to have a plaque at the top of the penis on the dorsal side (the side you can see when you look down at it) then most often your penis will curve upwards. You will get a deviation straight up pointing to the sky.

Or severely enough some people with Peyronie’s have a curvature that actually goes back onto the belly, so it looks almost like a hook. Now imagine that same guy trying to have intercourse with that penis, and you can see the severity of this condition immediately. Even if his erections are healthy from a blood flow standpoint, he still has severe impairment in sexual function because of this situation.

The History…

I would like to go on to a little bit of history as well because of the understanding of Peyronie’s disease, even though we’ve known about this for 500 years plus. We’ve actually just started to get to the end of the basics of what the disorder is, and it’s a disorder of wound healing and of a protein called collagen but here’s what some of our early anatomists and physicians said. This goes back to the beginning of the 1900s (1913) and pretty much if you can blame anything on the penis you will blame it on venereal disease. In fact, that’s what Peyronie’s was thought to be for the most part.

We just learned, and that in fact it isn’t the corpora cavernosa but the Tunica membrane of that lining outside of the corpora and it develops in middle-aged men from attacks of urethritis. Where did urethritis come from up until the late antibiotics? Predominantly from gonorrhea, so they’re blaming this on a venereal disease which we know for years is not the case.

I like that, in fact, I’ve seen much bigger plaques than lima beans and pain may exist. This is perfect because of Peyronie’s disease and what we now categorize Peyronie’s as, an acute and chronic phase. That acute phase is characterized by pain, not only pain with the erection being bent and pain with intercourse but just because of the inflammation that the scar tissue is causing a man in his penis.

How Did They Treat Peyronie’s In 1913?

They handled it the same way they had treated everything before antibiotics came into existence and that was with Mercury. They would treat these guys with ointments of mercury, which we now know is a terrible idea for just about any disease you can imagine.

As you know, if you have been to the doctor recently, there often testing for toxic levels of mercury which we see a lot of in people that consume fish and so now, we’re trying to get all the mercury out of the body. In the old days that was a treatment for just about anything from rheumatoid arthritis to Peyronie’s disease and anything in the middle. Mercury is definitely not a good idea and not FDA approved.

None of these patients care to take the chances of surgery. I must confess that I had not thought I could offer much hope. This is great because as a guy that specializes in penile surgery, if I can to figure out how NOT to operate on somebody with Peyronie’s, just because of the risks of the operation and outcomes are not as perfect as I’d like to see them even with the excellent surgical technique. I would love to figure out how to keep guys out of the operating room. Dr. Guiteras, back in 1913 was saying what I still say today, let’s look at all the noninvasive or minimally invasive options for treating Peyronie’s disease before we look at a surgical outcome.

How Does A Guy Get Peyronie’s?

Or more importantly, how does the guy not get Peyronie’s?

Sadly, on the more critical side, I don’t know… These are one of those conditions that I could wake up tomorrow and have Peyronie’s disease as a man. We really don’t know what the trigger that makes these things happen is. So I can’t give you precise instructions on how to prevent it.

What we do know is that it’s associated with a few things. Let’s take a look at a few of these things…

That Tunica membrane is very thick, and it has to be rooted because it has to keep those cylinders of blood intact during an erection. So, if there’s any disruption in that Tunica that can set off a lot of inflammation and swelling. Potentially even bleeding into the penis if it is severe enough that something we call a corporal rupture or a penile fracture takes place – that is a surgical emergency and something that you would have to demand the use of the operating room.

It usually happens in a man having intercourse and inadvertently striking the pubic bone of his partner during sex. That causes a tear in that Tunica membrane – a bunch of blood comes out, and the penis ends up looking deformed and looking like an eggplant until we’re able to fix it and evacuate out that blood.

That’s not what happens in Peyronie’s most of the time, it’s not that dramatic, but the thought was that maybe it’s a lot of little tears and just a little bit of chronic wear in that Tunica membrane, that causes inflammatory tissue to come in and lay down instead of a lot of blood out.

What I like to say is that because we know Peyronie’s is a disorder of collagen wound healing, I want to use the analogy of imagine getting a tiny hole in your wall. Suppose you have a beautiful piece of drywall, and you get a hole in it. So what do you do with the hole?

You put it in spackle… Spackle is not as good as drywall that you get from the hardware store in the first place to build your wall, but it does an okay job. I think that’s a little bit of an analogy of what happens with Peyronie’s. If there is that injury, your body puts down this collagen spackle, which is what we call type III collagen. By doing that, the body covers up whatever hole you think is going to happen there but it doesn’t ever work quite as well as that native tissue. That’s referred to as a microtrauma.

We know that Peyronie’s disease is associated with men after prolonged catheterization. So, if a man has anything from heart surgery to brain surgery and he’s unable to urinate ordinarily. He has to have a catheter in for a while; there’s something about the pressure with that catheter that it may set-off an inflammatory response that may lead to Peyronie’s.

It’s the same thing with anything that I do as a urologist, if I have to put a scope inside somebody, in his urethra to evaluate the bladder or operate on his prostate, that may also be a risk factor.

We know that men that undergo prostate cancer surgery (a radical prostatectomy) when we remove the prostate we have to cut a vein on the top of the penis to prevent bleeding during the operation. There’s a thought that that blood vessel will cause back pressure inflammation and scarring and it’s pretty reliable in men after prostate cancer surgery that they will have a scar where that vein was cut at the base of the pubic bone.

That happens in about 16% of men that undergo prostate cancer surgery. So it’s not an insignificant number, but not that much more than baseline either, as we talked about the overall incidence of Peyronie’s disease.

Lastly, there’s something that I come across, and I see a lot of patients for, and they say that they Peyronie’s developed after they started treating their erectile dysfunction with injectable medicine. One treatment for erectile dysfunction is to put medication directly in the penis to cause an erection via an injection. That drug goes into the corpora cavernosa, not into the Tunica.

When a man hasn’t had an erection for a long time, his Tunica may have some atrophy, and with that atrophy, he may not notice that he hasn’t had an erection for many years. He will give himself an injection and boom, there comes the Peyronie’s and there occurs the curvature but he may have already had that a long time ago but just didn’t realize it because he wasn’t getting normal erections.

Either way, it’s a listed risk factor, it’s one to consider.

Associated Conditions

What are the other things that we see in men with Peyronie’s disease?

HLA – DQ5 (61% Of Sufferers Have HLA – DQ5 Haplotype)

There is a genetic component, this is something that runs high in men of northern European, Scandinavian descent and therefore I do see a family predisposition for Peyronie’s, I see brothers, I see fathers and sons that have this condition and most of the time there is a genetic basis for that. So, no matter what they do they still have a real predisposition for it.

Hypogonadism (40% Of Sufferers Have Low Testosterone)

Men with low testosterone or hypogonadism also show potential that they will have a little bit of crossover between the Peyronie’s and the low testosterone.

Radical Prostatectomy

Patients who have had a radical prostatectomy show a 15.9% incidence risk.

Dupuytren’s Contracture And Ledderhose Scarring

Dupuytren’s contracture is a contracture of the pinky bit of what we called the flexor tendons of the hand; you can get scar tissue right in there as well that leads to the deformity. It’s the same scar whether it’s on the penis or the hand. The Ledderhose scarring happens on the bottom fasciitis of the foot, the plantar fasciitis can also be very painful and debilitating, so those are the things that we know are associated with Peyronie’s.

Connective Tissue Disorder

On a scientific level, it’s a collagen-based disease where you’re not putting down the right kind of collagen for wound healing, you’re putting down rapidly synthesized collagen to get out of a bind, and that’s what the scar in the plaque forms at that deposition of collagen.

Progression Of Peyronie’s Disease

We talked a little bit ago about the difference between how we categorize it these days, not the three phases we learned about from that early medical knowledge dating back to the 1900s but now we look at it as an acute and chronic phase.

The acute phase lasts anywhere from a few months to up to a year and is usually characterized by plaque evolution of curvature evolution, in other words, maybe a man starts off with a little scar and says a 10-degree curve and some pain. Then a month later it’s developing into a 20 or 25-degree curvature, and he still has pain, and eventually, that will all settle down, and that’s where the acute phase gets changed over to the chronic phase.

The chronic phase lasts from essentially whenever his plaque stops curving to the point where he goes on for the rest of his life with this if he doesn’t get treatment. Only about 13% of men that developed around disease will have this resolved on their own. This is something that either requires treatment or the person will have most often a permanent deformity.

 

So What Does It Look Like, In An Actual Patient?

In a plain film x-ray, similar to the ones that you will get from other body parts, an x-ray of the penis will show healthy soft tissue but at the point where the plaque has formed it will be super dense because Peyronie’s plaques can be as dense and thick as a bone.

In fact, in some men, they can get what we call heterotopic ossification where in other words, they will have that Peyronie’s plaque that has become so severe that it turned to bone.

On ultrasound, it will result in acoustic shadowing at the point where the plaque has formed because the sound waves will not be able to penetrate it.

Medical Therapies

How do we treat Peyronie’s condition? It’s been around for a long time; we have tried Mercury, we have sought Iodine, we have been attempting everything…

Believe it or not, we haven’t had an FDA approved therapy for Peyronie’s up until about three years ago and will get to that in a second.

So What Would We Have Done In The Past?

We gave them pills; we gave them things that we thought would decrease the scar tissue formation or reduce inflammation, so that’s what Potaba comes in. L-arginine is an amino acid that improves nitric oxide flow into an organ. I still use this as a minimally invasive conservative therapy until we figure out whether a man is transitioning between acute and active phases.

But as a first-line treatment, it’s not very effective.

It’s the same thing with medications like Viagra and Cialis; they also may have some mild anti-inflammatory properties in addition to what we know they’re good for, which is improving blood flow and sustaining erections.

Pentoxifylline is kind of an interesting compound; it’s probably been studied the most and even has some randomized placebo-controlled trials. What we know it does is, it basically inhibits the body from laying down new scar tissue. So the thought is, if you get this inflammatory process cascading, getting worse and worse and you get put on pentoxifylline, then the new inflammation stops or slows down.

Then maybe the body will stop putting down that spackle, that type III collagen and return to more normal protein synthesis and we do see some efficacy with pentoxifylline. So we think that’s the mechanism.

It’s the same thing with tamoxifen, were not actually using that very often anymore, it has some side effects. Most appropriately it has a slightly increased risk of deep venous thrombosis, so we tend not to use it and avoid it, and again, none of these are FDA approved.

Intralesional Therapy (Injecting A Medicine Directly Into The Plaque)

What about putting medication directly into the plaque? You take a pill, it goes all over the body, and you hope a little bit ends up in the plaque… Why not go directly to the source?

It’s an excellent idea, in fact, that’s what we do, and that’s what we’ve done. There are three agents that we’ve traditionally put into this.

Verapamil is a calcium channel blocker, some of you may be on it for blood pressure, it’s a popular drug, it has been around for decades. The thought is that maybe since there’s some calcium in these plaques that if we inject a bunch of calcium blockers in there perhaps, it’ll soften up. It hasn’t really been that efficient and again; it’s not FDA approved.

Similarly, there’s another agent that’s actually a viral agent that we think sets up an anti-inflammatory reaction if injected directly into the plaque. The literature is a little bit better on this, a little painful and guys can develop some flu-like symptoms and even more severe symptoms than that. Again, it’s not FDA approved and not that well researched recently.

So that leads us to something called collagenase which we will spend a little bit of time on. That’s an injection of a medication that’s derived from a bacteria that actually is targeting to dissolve that abnormal collagen. Anytime in medicine, you see something that ends in “ase” that signifies that it’s an enzyme that breaks down proteins. So since we know that Peyronie’s disease is a type III collagen defect, what we want to do is, we want to dissolve type III collagen, and that’s what collagenase does.

Surgical Therapy

What about surgery? I’m a surgeon so don’t you think I would want to be in the operating theatre more than in the office?

For many conditions that are entirely accurate and Peyronie’s is no exception. There are men that I have to operate on as we have discussed earlier and then I’m happy to do so.

There are three different ways to do surgeries for Peyronie’s disease. The first way is something that has been around for about 100 years, and it’s called a penile Plication.

Penile Plication

Nesbitt is a urologist from the early 20th century. He first described this in about 1919 and mostly if you can imagine a penis which is bent upwards pointing towards the sky, what Nesbitt came up with is to actually put in some sutures on the bottom of the penis and then tied them so that you re-scaffold the penis straight. It was a delicate procedure, it was elegant, it was simple, and it’s something we still use today.

There are various iterations of it and new techniques to limit side effects, and the most significant side effect of this procedure is that whatever degree your curved and whatever level you’re straightening. That is how much penile shortening you’re going to get after this process.

Most men would try to avoid that at all costs because every man wants a bigger penis, not a smaller one. So, it’s something you have to counsel your patients on; you have to make sure that they have an adequate penile length so that if we do that Plication and make their penis straighter, they won’t be disappointed that it’s dramatically shortened its length. So it is an outstanding and appropriate operation for the right candidate.

Penile Plaque Excision And Graft

There are various ways to do that. It’s a tricky process, very involved and takes at least 2 ½ to 3 hours. The first part of the operation that you have to do and do it well is that you have to sneak under the nerves and blood vessels to the penis. It’s in a structure called the neurovascular bundle. The plaque runs right underneath that neurovascular bundle. So in other words, it’s upon me to get that plaque out without injuring the blood supply and the nerve supply to the penis.

So, the man would end up having numbness and decreased blood flow; I have to elevate that out of the way without putting anything and sneak under it and remove the plaque, then put a patch in. As complex as it is, which that is, the second part of it is what makes the surgery not so lucky. There’s really no other membrane in the body or even that we can get off the shelf that stimulates a normal tunica tissue. It has to have that perfect amount of strength and elasticity so that the penis can expand and contract at will.

We don’t know what that is. Therefore, we’ve had many different materials, both what we call autologous (meaning we get it from the patient himself) we’ve used the fascia from the mandible, we’ve used abdominal fascia, we’ve even used the inner lining of the cheek. So that once we remove the plaque we laid that in there, put that nerve bundle down and closed the guy up.

But, nothing acts exactly like the native tunica. I also have seen, and I typically use something called Tutoplasm which is derived from the pericardium of a human cadaver, and it works well, it doesn’t have any comorbidities or any side effects of having the second incision. The procedure is a little bit shorter because I don’t have to harvest a graft. But again, it’s not perfect but there are some men where nothing else works, and to restore some kind of natural function, we have to use that graft.

Lastly, There Is Something Called A Penile Implant

This is really a combination of surgery. For men that have significant erectile dysfunction AND Peyronie’s disease, they would make a perfect candidate for a penile implant. What this is, is a mechanical device that’s placed in the patient’s normal erectile tissue using two cylinders which go right into the corpora and is hooked up to a fluid-filled reservoir that is implanted underneath the bladder.

So, it’s underneath the skin and a little bit to the side of the bladder, and then it’s hooked up to a pump in the scrotum. Anytime a man wants to have intercourse; he merely transfers the fluid from the reservoir in the abdomen into that scrotal pump which then will push it into the cylinders.

It’s a very elegant, very successful operation. But again, if a man has normal erectile function and Peyronie’s disease then in some ways it’s putting him backward by putting in the implant. Because I’m getting rid of, rather indeed destroying his native erectile function to use this as a scaffold to straighten out his penis which is curved from Peyronie’s.

So, my ideal candidate for this procedure is one that has significant erectile dysfunction, does not respond to oral medication and has substantial Peyronie’s; then it’s a much more satisfactory and satisfying operation to do.

When Did The Game Change?

In 2013, the material that we talked about earlier which is Clostridium, collagenase or Clostridium hystolyticum the FDA approved collagenase. So this is the first drug now in the hundreds and hundreds of years as Peyronie’s being described in the literature that we have the FDA’s approval for medication.

So this really is a game-changer in the fact that now I can see a patient and prescribe a drug that can potentially improve his Peyronie’s by significantly. It’s not a pill; it’s an injection so not only is this something I don’t prescribe (by the way), I sign a candidate up for this after doing a careful evaluation and seeing what the degree of curvature is.

The same goes for his erectile function, but then I ordered the medication because it’s something that I personally have to inject directly into the plaque. Its a targeted therapy that if I missed the mark, it’s not going to work, so I have to be able to feel that man’s plaque and appropriately inject it.

Essentially I have to find where the plaque is, once I have located it, I squeeze it and push his corporate tissue out of the way. I need to make sure that my injection goes directly into his plaque. That’s the first thing I need to do.

I always use a topical anesthetic; I spray on medication so that the injection itself is not quite so painful. It takes about seven minutes for it to start working and then I sterilize the area with alcohol and then get ready to do the injection.

What Happens The Next day After The Injection?

As you can imagine with any medication that was directly injected into the plaque that causes lysis or destruction of tissue, you may have some localized events, and in fact, you do, it’s expected!

You will notice a characteristic bruising, not a lot of swelling and this is a mild and typical reaction. It’s nothing out of the ordinary here because by putting in that medication and diffusing across that tissue this is the body’s response to me setting up this enzymatic reaction.

The drug stays very local, however sometimes; the bruising can begin to show under the pubis as well. These side effects are pervasive and shouldn’t be considered adverse events.

[How] Is This A Game Changer?

Where are we going with this? Are we making any progress or are we winning the war on Peyronie’s disease? The answer is we’re doing a pretty good job. So in the first four years now that this has been FDA approved, where more and more physicians are learning how to do this and how to do it well, so we are treating a lot more men.

If you look at the raw data from the initial trial, what we saw is about a 34% or 35% reduction in curvature.

Does that mean that the guy’s plaque goes entirely away? No

But, what we found is that the majority of men were quite satisfied that they went through this therapy because it’s the only thing that has helped them. So my thoughts are that what we are seeing is that you’re able to convert a man that was unable to have intercourse (because of the severity of his curvature) to be able to have sex again normally. That’s a win, it’s not perfect, but it’s certainly a step in the right direction.

As we evolve and our techniques involve, and our understanding of this medication evolves, I think those numbers are going to get even better.

Collagenase Data

What Were The Actual Improvements Versus A Placebo-Controlled Trial?

The majority of men were very pleased and significantly improved their outcomes in their satisfaction having gone through this therapy. Even if they didn’t get a perfect result or went from 90° to 20° curvature. So I have to manage expectations appropriately, that what we may see is a nice gradual improvement. But there may still be some residual scar, and we may even need to look at other treatments.

In fact, that’s what I’m going to talk about now, what if 34% isn’t good enough, what if Mike’s typical patient essays you brought me from 60° down to 40°, but I want to be 20 or I want to be 15.

So, there are some men that I’ve been able to go on with additional cycles as I’d like safely and efficiently and have done quite well. Some men choose not to go through that or have difficulty getting authorization from their insurance company for this condition, and there are guys that I take to the operating room as well.

I have found that many men post–Xiaflex that I operate on, I’m able to reduce the severity of the surgery, I’m able, or rather I should say I have to do because they did get an excellent response to Xiaflex. It just wasn’t satisfactory enough to them.

With that in mind, I think what we’re going to see over the next few years is that more physicians are comfortable performing this procedure, this is a procedure only a urologist can do. This is not something you go to your primary physician for. You will need that referral and the more urologists that adopt this and get good at this technique; you’re going to see a lot more men come out with Peyronie’s disease because as I said earlier, this is a condition that they suffer from in silence for the most part.

Now they know they have a treatment and they know they have something effective that they can come and get and that’s what we’re going to see – a real revolution in this condition.

Frequently Asked Questions…

1. Can A Peyronie’s Erectile Dysfunction Be Prevented?

So, the first part is, that erectile dysfunction can be avoided. Most of the time what we see with erectile dysfunction is a disorder in blood flow to the penis. If you look at the leading causes that can be prevented in this country, it’s cigarette smoking, high blood pressure, high cholesterol, diabetes, and obesity.

Those are the big ones. If you’re able to reverse that, working with the physician, then you have an excellent chance of improving erectile dysfunction. There are some kinds of erectile dysfunction that can be prevented and that you do need more advanced therapy. Usually, men with pelvic surgery, nerve injury and those kinds of things will require a little more attention.

Peyronie’s disease as I said, we are not 100% sure if it can be prevented, it’s something that we don’t know exactly the smoking gun, it’s hard to know what we can do to avoid it. Healthy living is essential, but I see triathletes with Peyronie’s, I look at all kinds of men that have this and so overall, how you’re going to respond is by having a proper healthy diet, making sure you’re exercising a lot, and this is good news for anybody.

2. When Is The Peyronie’s Disease Operation Absolutely Needed?

The answer to that is never. Nobody is ever going to die from Peyronie’s disease. The only time that we move to the operating room is when a man is completely unable to have penetrative intercourse in his current state. That’s the only man that a surgeon would like to operate on because of the risks of the operation. If the man is not quite satisfied with his ability to have intercourse but is still able to have sex, I would rather talk that man out of surgery because of the risks and complications we discussed earlier.

Having said that, if a man is totally unable to have penetrative intercourse and he’s very dissatisfied, and he doesn’t get better with minimally invasive options like oral medication or the intralesional therapies or using the Phallosan Forte or SizeGenetics extenders then he would make the perfect candidate for an operation.

3. How Does The Level Of Pain Or Degree Of Curvature Affect The Decision To Get Surgery?

I don’t like to operate on anybody that still has pain because pain is defined still within the acute phase of Peyronie’s disease. So, especially if I’m going to do something like any Plication surgery where I have to go in and re-scaffold that penis straight. If that plaque is still evolving, most likely is going to continue to curve even after I operate on him.

I want the pain to be done once the pain is gone then the degree of curvature is important because if a man has a curve greater than 90°, it’s going to be very difficult for him to get any kind of result probably even with Xiaflex.

A guy that has severe curvature and healthy erectile function, he’s a perfect candidate for surgery.

4. What Is The Usual Range Of Penis Curvature In The Medical Community?

If there’s no pain, in other words, is it natural to have some degree of bend? The answer is it depends. Some men have perfectly hard straight penises, and some men have curvature’s naturally even up to 20 to 25 degrees. As long as that man is comfortable and his partner is pleased with the bend he has, or he was born with it, that’s not somebody I would need to fix.

But, some men are born with a condition similar to the way it manifests as Peyronie’s where they get significant curvature even without a plaque. This prohibits them from having regular intercourse. Those are the guys I tend to operate on, for most of the time we identify them still when they’re infants or at least in their early childhood.

My pediatric urology colleagues can take care of those men.

5. I’m Afraid Of Further Physical Damage From Cuts In The Long Run, How Effective Is Oral Medication For Erectile Dysfunction?

This is a big issue, as a surgeon and as a guy who makes a living doing this I can tell you that the operative technique can be perfect. The patient outcome would be excellent, or it could be somewhere in between, and so surgery is an earnest consideration to take for anything, but especially when it’s elective surgery.

So, I agree with you entirely regarding asking how effective is oral medication; the answer is it’s either 100% effective for you or 0% effective. So in other words, individual results are going to depend on all kinds of risk factors for erectile dysfunction.

I treat this condition both Peyronie’s disease and erectile dysfunction as anything else in my practice, with an individualized, tailored and targeted approach. That means we’re going to look at all aspects of your health from your general cardiovascular health to your hormonal levels to the degree of impairment you have with your sexual dysfunction to come up with the definitive and right therapy for you.

With that being said there are various well-known, popular and extremely useful male enhancement supplements that you can start to take to treat erectile dysfunction. A few of the ones I recommend to patients are VigRX Plus, Male Extra, ExtenZe and ProSolution Plus Pills. These are completely natural, so therefore side effects will be minimal to non-existent. Mainly non-existent in the majority of men.

As for Peyronie’s disease, you can begin to treat it using penis extenders. The main one we recommend is the Phallosan Forte in the way that it allows the penis to be straightened by holding it in the opposite direction to the bend in the penis.