Peyronie’s Disease

Peyronie’s disease, also called Induratio Penis Plastica, is an acquired fibrotic disorder of the penis. The symptoms are penis pain when erect, penis deformity and mass, and in some men, erectile dysfunction. Its origin is unknown. It usually starts with pain at erection and then progresses leading to penis deformity like narrowing and curvature. The disease stops on its own after 12-18 months, leaving scars and a permanent abnormal shape of the penis. The treatment focuses on preventing penile deformity during the progressive stage. When the disease becomes inactive, the treatment focuses on curvature correction and it is usually surgery. However, Xiaflex is the only licensed medication to treat penile curvature in some countries.

Natural history

We distinguish three stages of the disease: Early active, late active, and inactive. The early (painful erection) and late active stages (onset and progression of penile curvature and plaque) usually last 12 to 18 months. After this period of time, the disease becomes usually inactive. In this stage, the penile curvature is stable and does not get worse (does not progress).

Sometimes the active Peyronie’s disease can resolve spontaneously without or with minimal curvature and without any impact on sexual life. Most cases will have stable penile curvature at the end of the active disease. 

Symptoms

We distinguish symptoms of the early active stage, active late-stage, and chronic stable-stage of the disease.

Symptoms of the early active stage

The first symptom is a painful erection. It can vary from minor and unremarkable to severe pain, impacting the ability to maintain an erection and the quality of the sexual life. Some patients avoid sexual intercourse because of pain. In this stage, the patient can feel a hard nodule commonly in the dorsal part of the penis. The penile curvature is minimal or absent.

Symptoms of the late active stage

The patient complains about nodules/plaque, indentation, curvature, deformity, shortening during erection, and sexual dysfunction. These symptoms are usually progressive during the remaining active stage.

Symptoms of the inactive stage

The penile curvature, deformity, or shortening becomes stable and will not progress anymore. The resulting stable penile curvature might have no or severe impact on the patient’s sexual life because of curvature (impossible penetration) or erectile dysfunction related to the damage to the erectile mechanism.

Treatment

No surgical treatments

We do conservative treatment for patients in the early stage of the disease. Several options have been studied, including oral pharmacotherapy, intralesional injection therapy, and other topical treatments. Physical treatment based on Shock waves or iontophoresis. are also possible. While clostridial collagenase is the only drug approved for Peyronie’s disease by the American FDA (Federal Drug Administration), the European Medicines Agency (EMA) still has not approved any treatment. The research results on conservative treatment for Peyronie’s disease are often contradictory, making it difficult to provide good recommendations. The low quality of the studies is related to uncontrolled studies, the limited number of patients treated, the short-term follow-up, and different outcome measures.

Oral treatments

Vitamin E and Colchicine

Vitamin E is commonly prescribed at once or twice daily doses of 400 IU because of its wide availability, low cost, and safety. However, the research evidence does not allow to make recommendations. The combination treatment with vitamin E and colchicine (600 mg/day and 1 mg every 12 hours, respectively) in the early stage of disease for six months in patients with early-stage Peyronie’s disease seems to improve the plaque size and curvature. However, pain relief is less evident.

Potassium Para-aminobenzoate (POTABA)

Potassium para-aminobenzoate is not superior to other oral medications in treating penile pain, plaque size, and curvature. It seems it can have a protective effect on the deterioration of penile curvature.

Tamoxifen

The results are very conflicting, and we cannot make any recommendations.

Acetyl esters of carnitine

The combination of propionyl-l-carnitine with intralesional verapamil might reduce penile curvature, plaque size, and disease progression.

Pentoxifylline

Pentoxifylline seems to stabilize or reduce calcium content in penile plaques.

Phosphodiesterase type 5 inhibitors (Cialis 2.5 mg)

We cannot give well-supported recommendations on the use of PDE5I in patients with Peyronie’s disease.

Intralesional treatment

Injection of active agents directly into penile plaque delivers higher local concentrations and possible better action against the progression of fibrous tissue. However, dense or calcified plaque might be hard to infiltrate.

Steroids

We think intralesional steroids can control the inflammation responsible for Peyronie’s plaque progression. However, adverse effects include tissue atrophy, thinning of the skin, and immunosuppression. We cannot conclude with a well-supported recommendation.

Verapamil

The intralesional (plaque) verapamil injections might benefit from treating non-calcified acute phase or chronic plaques and stabilize disease progression or possibly reduce the penile deformity. Side effects are not common (4%). Minor possible side effects include nausea, light-headedness, penile pain, and ecchymosis.

Clostridium Collagenase (Xiaflex)

The American Food and Drug Administration (FDA) now approved the use of Clostridium collagenase for cases with a palpable fibrous plaque and penile curvature of at least 30°. The most reported side effects are penile pain, penile swelling, and ecchymosis at the injection site. Because of the risks of severe general and penile adverse reactions, Xiaflex should be administered by a healthcare professional only in certified facilities.

Interferon

Intralesional Interferon injections of Interferon α 2b (two times per week for 12 weeks) seem to improve penile curvature, plaque size and density, and pain. Possible side effects are general symptoms like myalgias, arthralgia, fever, and flu-like symptoms.

Physical treatments

Topical Verapamil

There is no evidence that topical treatments on the penile shaft allow adequate levels of the active compound within the tunica albuginea. Iontophoresis, known as transdermal electromotive drug administration (EMDA), may overcome the limitations on the local uptake of the drugs. However, we cannot conclude with well-supported recommendations.

Extracorporeal Shock Wave Treatment (ESWT)

It is a treatment using focused shock waves in the plaque in more sessions. The few studies so far have only shown significant improvement only for penile pain. We do have no strong support for the effects on the plaque and the penile deformation.

Traction devices

The FastSize Penile Extender has been studied and applied as the only treatment for 2-8 hours/ day for six months. It seems effective in reducing penile curvature and allowing the patient to avoid surgery.

Vacuum Devices

The application of vacuum devices follows the same principles as traction devices, with the drawback of being non-continuous.

Surgical Treatments

We do surgery on those patients who have their sexual life affected because of difficult or impossible penetration related to penile curvature. The penile curvature results from the disease’s early acute stage, which usually lasts 12 to 18 months. We define the chronic, late stage of the illness when the curvature is stable. In fact, at this stage, we do not expect any further changes. Procedures range from the simple straightening penile plastic (Nesbit Procedure) to plaque excision and substitution procedures. Choosing the most appropriate surgical intervention is based on:

• penile length assessment
• curvature severity
• erectile function status
• patient expectations

According to the postoperative penile length, we distinguish shortening and lengthening procedures. A penile prosthesis is another surgical option.

Penile Shortening Procedures

Penile shortening procedures are the Nesbit wedge resection and the plication techniques performed on the convex side of the penis. The short and long-term results of the Nesbit procedure are excellent. We achieve complete penile straightening in more than 80% of patients.

Patient selection

A good candidate for this surgery:

• patient with significant curvature affecting the ability to penetrate
• curvature, not more than 30 degrees
• patients who accept 1-1.5 cm penile shortening

Complications

Complications are uncommon (about 10%):

• Recurrence of the curvature
• penile hypoesthesia
• the risk of postoperative ED is minimal

Penile Lengthening Procedures

With tunic lengthening procedures, we make an incision in the tunica’s short (concave) side to increase the length of this side, creating a tunic defect that we cover with a graft (derma, vein, and buccal mucosa graft).

Patient selection

• Curvature more than 30 degrees
• Patients not accepting excessive penile shortening
• Patient with normal erectile function

Complications

• Recurrence of the curvature
• Erectile dysfunction

Penile Prosthesis

A penile implant is a surgically intrapenile placed device to produce a natural-looking and natural-feeling erection. In cases of severe deformity, the surgeon can do intra-operative ‘modeling’ of the penis over the inflated cylinders.

Patient selection

• Severe penile curvature
• Other penile deformities related to the plaque
• Erectile dysfunction

Complications

• Infection
• Urethral perforation
• Prosthesis extrusion

External resources

American Urological Association guidelines