What is Peyronie’s disease?
Peyronie’s disease is a condition that affects the penis causing 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 Peyronies disease. However, it even predates him by a few years. Roughly about 15% of men suffer from this condition according to the American Urological Association; they suffer most often in silence without seeking medical advice from their healthcare provider.
Men are typically not that open about men’s 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 put his name to it. He was a court physician for Louis XV in France.
This image comes from a textbook way back in 1940 that talks about three stages of development of Peyronie’s disease.
It starts as a bit of scar tissue forms as you see in the initial picture. It’s not much of a bend, then you can see a gradual curve and then a significant curve as the fibrous scar tissue builds up.
The three circles underneath are cross-sectional penis anatomy pictures, so now we are looking at it straight on and also slice by slice. So these other two erectile bodies at the top are called the Corpora Cavernosa. This is a condition that causes painful erections and causing a bent penis. The problem is 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 disease, because of the fibrous 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 Peyronies can go in all directions, it just depends on where that scar is along the penile length of the Tunica membrane. If you happen to have a plaque at the top, your curved penis will curve upwards. You will get a deviation straight up pointing to the sky.
More severely some people with Peyronie’s have a congenital penile curvature deformity that goes back onto the belly, so it looks almost like a hook. Now imagine that same guy engaging in sexual activity 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.
Even though we’ve known about this for 500 years plus. We’ve 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. At the beginning of the 1900s (1913), Peyronie’s was thought to be a venereal disease.
- Chronic Inflammation Of The Corpora Cavernosa?
The Tunica membrane of that lining outside of the corpora develops in middle-aged men from attacks of urethritis which predominantly came from gonorrhea, so they’re blaming this on a venereal disease which we know for years is not the case.
- They Vary In Size From A Pumpkin Seed To A Lima Bean Size.
I’ve seen much bigger plaques than lima beans and pain may exist. Peyronie’s disease we now categorize as, an acute and chronic phase. The acute phase is characterized by pain with the erection being bent during intercourse but also inflammation of scar tissue.
- It’s Causing Curvature To The Affected Side
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 with ointments of mercury, which we now know is a terrible idea.
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 surgical treatment.
How Does A Guy Get Peyronie’s?
Or more importantly, how does the guy not get Peyronie’s?
We don’t know what trigger makes these things happen. 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 a severe case that something we call a corporal rupture or a penile fracture takes place – that is a surgical emergency.
It commonly occurs during intercourse and inadvertently striking the pubic bone of his partner. That causes a tear in that Tunica membrane – a bunch of blood comes out, resulting in a penile deformity until we’re able to fix it and evacuate out that blood.
We know Peyronie’s is a disorder of collagen wound healing, If there is that injury, your body puts down this collagen, which is what we call type III collagen. By doing so, 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 microtrauma.
- Catheterization/Urologic Procedures?
Peyronie’s disease is associated with men after prolonged catheterization. So, if a man has anything from heart surgery to brain surgery or urinary tract infection. He has to have a catheter in for a while; there’s something about the pressure with that catheter that may set off an inflammatory response that may lead to Peyronie’s.
- Prostate Cancer Surgery?
We know that men that undergo prostate cancer surgery (a radical prostatectomy) when we remove the enlarged 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 common 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 benign prostatic hyperplasia. So it’s not an insignificant number.
- Vasoactive Injections (I Don’t Believe This)?
Some say that Peyronie’s developed after they started treating their erectile dysfunction with injectable medicine. Treatment options for erectile dysfunction are 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 abnormal curvature but he may have already had that a long time ago.
Either way, it’s a listed risk factor, it’s one to consider.
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.
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.
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
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 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 penile 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 Peyronie’s 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 of the penis will show healthy soft tissue but at the point where the fibrous 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 whereas, 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.
How do we treat Peyronie’s condition?
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 reproductive medicine 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. It inhibits the body from laying down new scar tissue. So 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 that type III collagen and return to more normal protein synthesis and we do see some clinical efficacy with pentoxifylline.
It’s the same thing with tamoxifen, we’re not 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 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. 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 been that efficient and again; it’s not FDA approved.
Similarly, there’s another agent that’s a viral agent that we think sets up an anti-inflammatory reaction if injected directly into the plaque. The medication guide literature is a little bit better on this, a little painful, and guys can develop some flu-like symptoms and even more severe PD symptoms than that. Again, it’s not FDA approved and not that well researched recently.
So that leads us to collagenase. That’s an injection of a medication that’s derived from a bacteria that is targeting to dissolve that abnormal collagen. So since we know that Peyronie’s disease is a type III collagen defect, what we want to do is dissolve type III collagen, and that’s what collagenase does.
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.
Nesbitt is a urologist from the early 20th century. He first described this in about 1919 and mostly if you can imagine a penis that is bent upwards pointing towards the sky, what Nesbitt came up with is to actually put in some sutures on the bottom of the penile shaft 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 whatever degree your curved erection and whatever level you’re straightening. That is how much penile shortening you’re going to get after this process.
Penile Plaque Incision And Buccal Mucosa Graft
Grafting can with an autologous graft, allograft, xenograft, and venous grafting. There is a rising interest in the use of A collagen fleece (TachoSil) as a grafting material.
The first part of the operation you have to do is sneak under the nerves and blood vessels to a structure called the neurovascular bundle. The Peyronies plaque runs right underneath that neurovascular bundle which must be elevated to remove the plaque so the man would not end up having numbness and decreased blood flow, then put a patch in.
The second part of the surgery is more tricky. There’s 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, but that nerve bundle down and closed the guy up.
But, nothing acts exactly like the native Tunica Vaginalis. 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 comorbidity or any side effects of having the second partial plaque excision. 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 except with a grafting procedure, and to restore some kind of natural function, we have to use that graft.
Lastly, There Is Something Called A Penile Implant
For men that have significant erectile dysfunction AND Peyronie’s disease, they would make a perfect candidate for inflatable penile prosthesis implantation. This is a mechanical device that’s placed in the patient’s normal erectile tissue using two cylinders that go right into the corpora and are 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 has significant erectile dysfunction, does not respond to oral medication, and has substantial Peyronies; 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 a Collagenase Clostridium Histolyticum injection (CCH injection) the FDA approved collagenase CCH treatment. So this is the first drug now in the hundreds of years as Peyronie’s being described in the literature that we have the FDA’s approval for medication.
now I can see a patient and prescribe a drug that can potentially improve his Peyronie’s significantly. It’s not a pill; it’s an injection so not only is this something I don’t prescribe, I sign a candidate up for this after doing a careful evaluation and seeing how severe penile curvature is.
The same goes for his erectile function, but then I order the medication because it’s something that I have to inject directly into the plaque. It’s a targeted therapy.
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?
with any medication 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 this is a mild and typical reaction and 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 effects.
[How] Is CCH Therapy A Game Changer?
So in the first four years that this has been FDA approved, where more and more physicians are learning how to do this we are treating a lot more men.
If you look at the raw data from the initial clinical 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
The majority of men are satisfied that they went through this therapy because it’s the only thing that has helped them.
As we evolve and our techniques involve, and our understanding of this medication evolves, I think those numbers are going to get even better.
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.
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.
Some men may require an additional treatment cycle for a second injection. Some 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 treatment manufactured by Auxilium Pharmaceuticals Inc. It just wasn’t satisfactory enough to them.
This is a procedure only a urologist can do. You will need that referral and the more healthcare professionals 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 option 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 Peyronie’s Erectile Dysfunction Be Prevented?
It can be avoided. Most 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.
However, there are some kinds of erectile dysfunction 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 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 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. If the man is not quite satisfied with his ability to have intercourse but is still able to have sexual intercourse, I would rather talk that man out of surgery because of the risks and complications we discussed earlier.
If a man is 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 injection therapies or using penile traction with 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 a painful erection 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.
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 even with a Xiaflex injection.
A guy that has severe curvature and healthy erectile function, he’s a perfect candidate for surgery after a physical exam.
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 curvatures 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 with hypospadias 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.
Oral medication is either 100% effective for you or 0% effective. Individual results are going to depend on all kinds of risk factors for erectile dysfunction.
I treat this medical condition both Peyronie’s disease and erectile dysfunction as anything else in my practice, with an individualized, tailored, and targeted approach. Meaning we’re going to look at all aspects of your sexual 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 and premature ejaculation. 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.
- READ MORE: VigRx Plus Review
- READ MORE: Male Extra Review
- READ MORE: Extenze Review
- READ MORE: Prosolution Plus Review
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 slight bend in the penis.
Shahrokh Shariat, MDProf. Shariat has published over 1400 scientific papers in peer-reviewed journals. In 2014 he received the Matula Award from the European Society of Urology (EAU), in 2017 the Gold Cystoscope Award from the American Society of Urology, probably the most important urologist award worldwide.
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