understanding and treating Peyronie's Disease
Erectile dysfunction (ED) can stem from multiple causal factors. Peyronie’s disease is also a common affliction, affecting up to 23% of the worldwide male population between the ages of 40 and 70 years.
In many cases, Peyronie’s disease leads to ED.
NEARLY 80% OF MEN WITH PEYRONIE’S DISEASE REPORT SOME DEGREE OF ERECTILE DYSFUNCTION (ED).
While the actual numbers may be much higher (due to underreporting by patients and physicians), it is clear that Peyronie's disease is correlated with age. Although rarely seen in young men, Peyronie’s disease has been reported by men in their 30s.
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WHAT IS PEYRONIE'S DISEASE?
Peyronie’s disease affects a man’s ability to have a normal erection. Fibrous scar tissue develops beneath the surface of the penis, leading to excessive curvature of the male organ. Initially, inflammation and swelling occur. Thereafter, a hard scar develops on the penis.
The scar tissue — also called a plaque — forms inside the tunica albuginea tissue (a thick, elastic membrane primarily made of collagen and elastin). This membrane envelops the corpora cavernosa: two cavernous bodies that house blood during an erection.
Commonly, the plaque resides on the top or bottom of the penis, causing the male organ to bend. As scar tissue builds, erections become painful and sexual intercourse difficult. Excessive curves in the penis may make sexual intercourse impossible.
The effects of Peyronie's Disease are devastating to a man’s sexual health and confidence - often causing pain for the individual with the disease and their partner. It is often connected to erectile dysfunction and may result in relationship tension with a significant other. While a curved erection alone isn’t necessarily an issue, the associated pain and discomfort of a significant bend is characteristic of Peyronie's Disease and can, in some patients, be mitigated with treatment.
WHAT CAUSES PEYRONIE'S DISEASE?
The exact cause of Peyronie’s Disease remains elusive. For most men who develop PD, it is spontaneous and not preceded by an injury.
That said, Peyronie’s Disease can be caused by:
Acute penile injury
Chronic penile injury
Autoimmune disease
Injury to the penis — whether a singular event or occurring repeatedly over time — can lead to Peyronie’s disease. This might include vigorous sexual or physical activity that results in the bending or stress to an erect penis or trauma to a flacid penis. However, Peyronie’s Disease often occurs spontaneously, without a known trauma to the organ.
Following an injury, subsequent bleeding and swelling within the tissue of the tunica albuginea can occur. The immune response following an injury can form a fibrous and inelastic plaque (i.e. scar tissue). The formed plaque affects the overall elasticity and flexibility of the penis, producing organ curvature - which can also compromise erectile function.
Men with autoimmune disease (and particularly connective tissue disorders) may have a higher chance of developing Peyronie’s disease. The patient’s own immune system may attack cells in the penis, resulting in inflammation and scarring. Dupuytren's disease, for example, (a cord-like thickening across the palm) is associated with 15% of men suffering from Peyronie's disease.
OTHER GENETIC DISPOSITIONS AND AUTOIMMUNE CONDITIONS
ASSOCIATED WITH PEYRONIE’S DISEASE INCLUDE:
Behcet’s syndrome
Systemic lupus erythematosus
Sjögren’s syndrome
Scleroderma
Plantar Fasciitis
Family history and age also factor into the prevalence of Peyronie’s disease. For men with shared genetics, the likelihood of having the condition may increase among families. As one ages, the elasticity of tissue diminishes — which may further contribute to Peyronie's disease.
WHAT DOES PEYRONIE'S DISEASE LOOK LIKE?
Signs of Peyronie’s disease vary from mild to severe. Symptoms may progress slowly or quickly.
SOME INDICATORS OF PEYRONIE'S DISEASE INCLUDE:
Plaque formation (felt through the skin as “hard lumps”) on the penis
Painful erections and/or sexual intercourse
Erectile dysfunction
Shrinkage or narrowing of the penis
Symptoms may dissipate without leaving permanent curvature of the penis. Often, however, the pain subsides while the curve remains. Researchers believe painful erections are due to active inflammation within the plaque, which abates over time.
Significant curvature may make sexual intercourse challenging. Additionally, the scar tissue associated with Peyronie’s disease can diminish the length and girth of your penis.
Treatment for Peyronie's Disease IN Seattle, WA
Treatment for Peyronie's disease is considered more effective in the early stages of the condition. Roughly 20% of active patients may improve spontaneously, while 40% stabilize and another 40% progress further with the disease.
There are two concerns that might need to be addressed with Peyronie’s disease - (1) the issue of mitigating curvature, indentations or atrophy associated with Peyronie’s disease and a possible secondary issue (2) concerning difficulty maintaining a full erection that is often associated with or exacerbated by Peyronie’s disease.
1 - Treatments to Address Curvature, Indentation or Penile Atrophy
The following treatments can be employed to soften or minimize the fibrotic plaque that develops with Peyronie’s:
Oral Medications
Pentoxifylline - Pentoxifylline is a nonspecific phosphodiesterase inhibitor which decreases transforming growth factor (TGF) beta-1-mediated fibrosis, prevents deposition of collagen type I, and reduces calcification. Studies have found that pentoxifylline improves or stabilizes calcifications and patients reported decreased curvature.
Vitamin E plus Colchicine - Vitamin E is a strong antioxidant that is believed to reduce collagen deposition within the injured tunica albuginea. Colchicine is an anti-inflammatory. The combination of these two medications demonstrated a reduction of plaque size in a randomized trial.
Intralesional Injection Therapies
CCH (Collagenase Clostridium Histolyticum) (AKA Xiaflex) - Xiaflex is the only intralesional treatment for men with PD approved by the FDA. Though it does not change the curvature, Xiaflex is effective in reducing plaque size. Therefore, it is recommended that this treatment be followed with “modeling,” which is forcible bending of the penis in the direction opposite to the curve (see below) or a tractio device.
Verapamil - Intralesional verapamil is believed to influence fibroblast metabolism by increasing collagenase activity and concurrently decreasing the production of collagen. Most but not all studies have shown mild improvement in penile curvature, plaque size, and penile pain. Verapamil injections may be considered alone or in combination with other therapies.
P-Shot / PRP (Platelet Rich Plasma) - The P-Shot incorporates a concentrated cocktail of platelets and growth factors from the patient’s own blood which is injected into the targeted plaque. PRP is known to mobilize local stem cells, which accelerates tissue regeneration and the formation of new vascular networks. Please see this page for more information.
Topical Therapy
Verapamil - in addition to being an injectable treatment (as noted above), Verapamil can be used as a topical ointment. Better studies are needed to determine efficacy.
Remodeling / Mechanical Treatments
Penile Traction Therapy - In a study of ten men with PD, nine of whom had failed medical therapy, traction for two to eight hours a day for six months led to reduced curvature, increased stretched flaccid penile length, and increased erect girth. Further studies have shown that traction in conjunction with oral agents and injection therapy may modestly improve curvature and stretched penile length.
Modeling exercises - Modeling procedures are similar to traction in concept but rather than using a device, it involves a patient administering gentle straightening and stretching exercises in opposition to the curvature at home several times a day. These exercises are best used with intralesional injections and/or oral therapies.
Vacuum Erection Device (VED) - The negative pressure of a VED enlarges small blood vessels within the penis and increases blood flow. When used regularly (twice a day for 10 minutes) over the course of several months, studies indicate satisfactory results for stabilizing or improving curvature of the penis. A study conducted at the University College London Hospital found that most men who used VED twice a day experienced improvements in penile length, curvature, and pain after 12 weeks.
Regenerative Therapies
Low-Intensity Shockwave (i.e., GAINSWave) - In a randomized trial comparing shockwave versus placebo in 100 patients, there was a statistically significant decrease in plaque size and curvature. Another study using shockwave plus high doses of Vitamin E - 72% of patients reported a decrease in curvature with an average reduction of 23 degrees after three months of therapy. It has been our clinical observation that Shockwave is an effective clinical intervention for patients who struggle with symptoms of Peyronie’s disease and ED. Proposed mechanisms of action included a breakdown of fibrotic tissue by shockwaves and induction of inflammatory response for plaque lysis and removal. Shockwave therapy has been evidenced in over 40 published studies to improve erectile dysfunction. See this page for more information.
P-Shot / PRP (Platelet Rich Plasma) - see above and this page for more information.
2 - Treatments to Address Erectile Dysfunction Associated With Peyronie’s Disease
Oral PDE5 Inhibitors (Viagra, Cialis, Levitra)
All of these medications work via the same mechanism - delaying the breakdown of nitric oxide. You can read more about PDE5 Inhibitors on this blog post.
Regenerative Therapies
See above for information about these treatments:
SURGERY FOR PEYRONIE'S DISEASE
Early non-surgical medical intervention is the best first line of therapy and is likely to be more effective when the disease is evolving.
By and large, surgery is considered a last-resort treatment option for Peyronie's disease. It is recommended that patients wait at least a year after the onset of symptoms before considering surgical methods.
For long-term cases, however, when symptoms have not improved and curvature doesn’t allow for sexual intercourse, surgery may be recommended. There are several surgical operations to treat Peyronie's disease, including grafting, device implantation, and plication. These procedures are completed in a hospital by a urologist.
Adverse side effects may include atrophy, numbness, and erectile dysfunction. One serious concern is that 20% of patients report new onset ED following surgery, and for those patients who had preexisting erectile dysfunction, 45% reported worsening ED and problems with achieving orgasm.
