Figure 1 Peyronie’s disease is an abnormal thickening of the shaft of the penis.
“How’s it hangin’? A little to the left? Or perhaps a little to the right?” A little is okay, but a lot…not so much. Peyronie’s disease, a poorly understood condition of the penis, causes up to 10 percent of men to literally get “bent out of shape.”1 Although this “disease” is not life threatening nor does it lead to any other ailments, it can be devastating to the man and his partner as it can render the penis so angled, twisted, or indented that sexual relations become impossible. Sometimes the condition is genetic, sometimes it’s related to an injury, but in most cases it seems to just be bad luck. The older you get, the more likely you are to develop it, but it can affect both younger and older men. This disease is rumored to have been the hallmark of a certain leader of the Free World, according to a certain intern who wore a certain blue dress.
Peyronie’s disease is actually named after a French 18th-century physician named Francois Gigot de la Peyronie, who himself had the condition. As a young student, he would sneak into the dorm rooms of his classmates with a protractor and measure the angles of their morning wood before they awoke.2 We still use protractors to measure the penis to this day, but usually with the patient awake and in the doctor’s office. This chapter explores what is known about Peyronie’s, as well as what can be done. Pills and supplements usually don’t help, but a variety of injections have been tried. Mechanical traction devices can help, but surgery has been the most reliable treatment for this strange syndrome until the very recent introduction of an FDA-approved injection called Xiaflex. Less commonly available treatments run the technological gamut, from the administration of acoustic shock waves or electrical current to the penis to the injection of stem cells.
Peyronie’s disease is not really a disease in the sense of a malady that holds you in its grip, draining your life force, unless you are a penis—then yes, by all means, it’s a bad deal. Peyronie’s disease is not an infection and it’s not a cancer. It’s actually an imbalance. The linings of the chambers of the penis that fill with blood are made of tissue that is both strong and flexible, consisting of molecules that stretch like elastic (called elastin) intermixed with molecules that are tough, called collagen. There is a delicate balance in the organization of these two molecules, but Peyronie’s disease causes them to become disorganized into a nodular mishmash.3 As a result, the affected part of the penis chambers cannot stretch like the rest of the chambers and so the penis kinks at that point, making the erection bent, twisted, or indented—sometimes all three. This nodule is called a plaque. It has nothing to do with dirty teeth or your coronary arteries; it’s a different kind of plaque. It is simply a buildup of disorganized tissue. The plaque may create a very obvious lump in the shaft or be hard to feel but still cause a bend in the erection. Sometimes calcium deposits will build up on the plaque, making it even harder and more irregular. The plaque most often arises along the top of the shaft, and less commonly, near the urethra. The bend will be on the side where the plaque is building up, and sometimes the location of the plaque will cause a complex bend in more than one direction. The plaque can also cause a narrowing like that in an hourglass, or an indentation on one side or another of the penis.
Peyronie’s disease strikes men of all ages, but it’s most common in men in their forties and fifties. It’s also more common after prostate cancer surgery. Peyronie’s comes on very rapidly in some cases and more gradually in others. There is usually pain in the erection for the first several months that gradually goes away. In a small percentage of guys, the whole thing goes away, as if it were just a bad dream. For others, it gets worse, and for most, it stays about the same. The condition may even change for up to 2 years, but more commonly it stabilizes in the first year.
Figure 1 Peyronie’s disease is an abnormal thickening of the shaft of the penis.
One known but uncommon cause of Peyronie’s is a syndrome in which other tissues in the body made of a mix of collagen and other molecules go haywire and too much collagen builds up. This is a hereditary condition, and it shows up as nodules and shortening of the tendons in the hands and feet, which are called Dupuytren’s contractures. The palm and fingers—usually the third or fourth fingers—won’t open all the way. An injection used to treat Peyronie’s is also used to treat the tendons in these people.
Another known cause for Peyronie’s is an injury. If the penis’s blood-filled cylinder is injured, the tissue will attempt to repair itself using collagen as a scaffolding until all the other molecules and cells have grown in, but in the case of Peyronie’s disease, the tissue makes too much scaffolding and becomes too stiff to stretch properly. It’s similar to when a person forms a keloid scar, which is a much larger scar than a skin injury usually forms because the scaffolding of collagen in the skin keeps forming long past what is needed. The penis is hard to injure when it’s soft because it usually yields to whatever is bluntly hitting it, so most of the injuries occur during sex, when the chambers that fill with blood are tense and cannot yield. Usually it’s a matter of a misplaced thrust or a sudden shift in position with the guy not completely in control. In other instances, if the penis is not fully erect but tough enough to stuff, it may allow more bending that then leads to an injury. Sometimes it’s a matter of “too much teeth” during oral sex. It’s possible that a minor injury can occur without much discomfort and so it may go unnoticed, but the tissues are still triggered to make too much collagen. A severe injury would be a penis rupture, which is unmistakable, as the internal bleeding suddenly swells the penis to the size and color of an eggplant. This is an emergency that needs to be surgically repaired. If it’s not repaired, there is a significant risk of its healing incorrectly, with excess collagen and curvature and possibly poor erections.
A commonly used remedy for impotence is self-injection of a prescription medication directly into the penis. The most common medication is called prostaglandin. Other common medications are trimix or quad-mix, mixtures of prostaglandin, phentolamine, papaverine, and atropine. They are injected with a tiny needle, but even so sometimes the needle injury sets off the collagen repair and Peyronie’s sets in. This risk is lowered by moving the injection site around so there is less trauma to any one part of the penis chamber. Still, the drugs themselves can cause a chemical reaction in the tissue that triggers Peyronie’s. Papaverine causes the most fibrosis, but this effect is lessened when it is diluted with the other ingredients.
Many men are cured of prostate cancer by surgical removal of the prostate; however, these men have a greater chance—about 16 percent greater—of developing Peyronie’s disease.4 It’s not due to an actual trauma to the penis during surgery but instead may be due to some decreased bloodflow to the penis as a result of nerve injury during surgery. The decreased oxygen levels may lead to more collagen formation in the penis.
The vast majority of cases seem spontaneous, without any obvious cause. The leading theory is that low-grade damage occurs during sex, like wear and tear on a shock absorber. More men with erectile dysfunction tend to get Peyronie’s and it may be that the penis is buckling a little too much during sex, causing increased strain on the tissue because it is not completely rigid. The tissues of the penis mount a low-grade inflammatory reaction to the tissue strain that normally would enable healing, but the chemicals released by the inflammation, also known as free radicals, damage the tissue further and throw the healing response out of balance. This results in the formation of the abnormal plaque tissue. It can come on surprisingly fast or evolve over a few weeks to months. The chances are higher for men over age 40 and worse if they have erectile dysfunction, diabetes, high blood pressure, cardiovascular disease, or are on dialysis.5
It’s hard to hit a moving target, so while Peyronie’s is still changing, treatment options are limited. Surgery is definitely off the table. It’s not a good idea to operate on an area that might change after you’ve already cut and sewn. One legitimate option in the first few months is to do nothing at all, in case this disease goes away on its own. Since in the majority of cases it does not, it’s reasonable to take a preemptive strike at it as a means of improving it or at least preventing it from getting worse. The key is to pick a treatment that can be effective without over-treating the tissues that may not need treatment after all.
The least invasive approach is taking supplements. Unfortunately, supplements rarely do much good as a stand-alone treatment. Vitamin E is commonly recommended, but there is little evidence it actually helps. L-carnitine is an amino acid that lowers the production of free radicals, the toxic chemicals released during inflammation. It doesn’t seem effective on its own, but one study showed that it improved the results of injection therapy (described later in this chapter).6, 7 Another commonly prescribed supplement is Potaba (potassium para-aminobenzoate). It’s an anti-inflammatory and antifibrotic agent. A few studies indicate it helps, but it’s hard to stick with it since you have to take six pills, four times a day, and it often causes stomach upset.8 Another antifibrotic medication, pentoxifylline, may reduce the calcification of newly forming plaques or even prevent plaques if taken right after a penis injury, but evidence that it really works is sparse. Colchicine is a medicine with anti-inflammatory activity that is used to treat gout. It may or may not be effective in treating Peyronie’s but often causes stomach upset. There is evidence that nitric oxide (NO) probably plays a role in reducing Peyronie’s plaque. Cialis and the other erection pills work by boosting NO in the penis. One study showed that daily low-dose Cialis reduced fibrosis in men with Peyronie’s.9 These medications also help counteract the weakening of the erection that the plaque often causes. Along these same lines, perhaps nutritional supplements that boost NO production may help, even if just a little.
A good option for early treatment is penile traction. Although it sounds medieval, it is rather effective. The penis is stretched when it is flaccid. This pulls apart the matrix of the plaque slowly and steadily. New, healthy cells grow into the tiny breaks that are created, and the penis gradually straightens. Indentations and narrowings can improve as well. Penile traction devices can be purchased without a prescription and are easily found online. They are often advertised as a way to make your dick bigger, but they don’t really, unless by that we mean regaining length that you lost from the Peyronie’s disease. You put your penis in the “rack” for 2 hours at a time, with a 20- minute break in between stretches. It’s necessary to use the device at least 4 hours a day, and up to 8 hours, in order for it to be effective. Collagen is very tough tissue and must be remodeled slowly but steadily. As time goes on, you gradually lengthen the traction device as your penis lengthens. The gains are usually accomplished over a 6-month period of daily use.10, 11
Figure 2 Using traction to treat Peyronie’s disease
A few different injections may break down the Peyronie’s plaque even if they do not completely dissolve it. Xiaflex is the only FDA-approved injection for Peyronie’s, but a couple of other agents were routinely used “off label” before Xiaflex became available. They include verapamil and interferon alphas. Creams containing these ingredients have also been tried, but the results are poor overall because of lack of penetration through the skin or into the tough plaque.
Xiaflex is a derivative of chemicals that the clostridium bacteria produce to invade the tissues they infect. The chemical, known as collagenase, breaks down the collagen in cell walls that puts up a defense against the bacteria. Xiaflex is a shot of that collagenase, repurposed to break down the unwanted collagen in the penis. It is very potent and very expensive. Each injection is only one-quarter of 1 cubic centimeter of fluid, and it costs a few thousand dollars to make a small batch. It’s the equivalent of injecting liquid diamonds. But hey, who says you can’t put a price on love? It has to be injected directly into the plaque and, although it may not completely dissolve the plaque, it will break it up so that it can expand and healthier soft tissue cells will grow into the gaps that form. Xiaflex must be given gradually because it also breaks down the walls of the blood vessels it may come in contact with. Furthermore, too much breakdown and the penis can rupture, which can be a surgical emergency.
The treatment is conducted in four cycles, with two injections per cycle, separated by 6-week intervals. Even then, there is about a 5 percent risk of the penis rupturing during sex or even just during an erection, so it’s important to avoid sex for 2 weeks after treatment. Also after the treatment, the guy performs some simple stretching maneuvers on his penis daily to provide a mini traction effect. Xiaflex injection is effective in at least 60 percent of men, with an average decrease in curvature of about 35 percent. This is an average, which means not much improvement for some but complete straightening for others. This injection cannot be used if the plaque and curvature are still changing. It is also not recommended if the plaque is too close to the urethra because of possible injury. Sometimes a plaque can become very calcified, which makes the tissue so rock hard that the medication cannot be injected into it.
Before there was Xiaflex, there was verapamil. Verapamil was developed as a medication for high blood pressure and heart irregularities, and that is normally how it is used, in pill form or as an injection into the veins. However, it also has the ability to break down collagen, but not as powerfully as Xiaflex. Nonetheless, more than 50 percent of patients using verapamil experience improvement.12 Verapamil injections are given about every couple of weeks, directly into the plaque, and they seem to work better when combined with home traction therapy.13
With verapamil, a larger volume of fluid is injected at much lower cost than with Xiaflex. The injections work gradually and are typically continued for a 6-month period, or about 12 injections total. Because the verapamil is injected into the plaque and not into the bloodstream, there is no effect on the blood pressure and no risk of an interaction with other medications. It can be used at any time after the onset of Peyronie’s disease, so a man does not have to wait until the disease stops changing, as with Xiaflex.
Interferon alpha-2b is another medication that has anti-collagen properties. Interferon stimulates the immune system and is typically used as an anticancer or an antivirus therapy. It breaks down collagen and it also stimulates some of the immune cells in the penis tissues to release their own collagenase (the chemical that makes Xiaflex work). Like verapamil, interferon alpha-2b is effective on more than 50 percent of guys.14 Here too using the traction device at home can add some further improvement.15 Because it activates the immune system, this medication can cause mild fevers and chills, even though it is just injected into the plaque.16
Aside from traditional needle injections, other techniques can be used to get the interferon alpha-2b or the verapamil into the plaque. Iontophoresis is a technique that uses electrical current to push the medication molecules through the skin and into the plaque. It may be as effective as injections but it is not widely available.17 Just rubbing verapamil cream on the penis is not likely to be as effective since it’s not likely to penetrate into the plaque on its own.18 In my practice, I utilize a MADA air injector, which pushes the verapamil liquid so forcefully out its tiny tip that it actually penetrates the skin and goes partway into the plaque without a needle. This treatment is given as a series of several “pops.”
Figure 3 Injection therapy for Peyronie’s disease
Don’t let the prospect of a knife near your privates make you shrink from proper treatment. Although the nonsurgical techniques work for a lot of guys, they don’t work for everyone. Surgery can work for almost everyone, and it may be the only solution for some. Some surgeries are minimally invasive, while others involve a major remodel of the penis, renovating it with a penile implant. On the simpler side of the spectrum is penis plication. The concept is simple: Since the Peyronie’s plaque won’t expand on one side of the penis, the key to making the penis straight is preventing the other side from expanding by cinching it with some stitches. This technique is low risk and offers a quick recovery. The main downside is that there is some minor loss in length from the Peyronie’s plaque that this technique does not restore, as it instead straightens the penis to the new length. Moving up the ladder of options, we come to removal of a small piece of tissue opposite the side where the plaque is to shorten the opposite side. If the Peyronie’s disease has caused significant shortening, then an alternative surgical approach that restores length may be better.
The plaque can be incised or even removed. This tends to be done for more severe or complex cases. When the plaque is operated on, a defect in the lining of the penis chambers is repaired with a graft material that may come from the person’s own body, such as a piece of vein. Because this operation involves cutting through the lining of the chamber of the penis that fills with blood, there is a greater risk of problems with erections after surgery.
In men who already have poor erections, this operation may not be practical, and instead a penile implant is often recommended. Penile implant surgery with straightening at the time of the implant can provide reliable erections that are also straight. The details of penile implant surgery are covered in Chapter 12.
Figure 4 Surgical correction of Peyronie’s: penis plications
Figure 5 Removing or cutting the plaque
Source: Joel Gelman, MD, centerforreconsructivesurgery.org/peyronies-disease/surgery-graft/#.WiH.
It seems that stem cells may cure whatever ails you, and Peyronie’s disease is no exception. Although not a mainstream treatment, stem cell injections into the penis are showing promise in clinical trials.19 A few urologists around the country offer this therapy outside of clinical trials, but because it is new, these treatments lack long-term safety studies so you must research the reputation and credentials of any such physician you seek out. The therapy is typically administered as an injection directly into the plaque or the penis chamber itself, one or more times. The stem cells do not dissolve or chemically break down the plaque the way the other injection therapies do. Rather, they may activate cells within the plaque to remodel themselves and smooth out the plaque.
Sonic shock waves are being used in some clinical trials to treat Peyronie’s. Urologists have been using sound waves to break up kidney stones for many years, but then someone got the idea to try lower-energy sound waves on the penis. It turns out that this treatment stimulates blood vessels to grow and seems to help mild cases of erection problems. It decreases pain and decreases the size of plaques but may not decrease penile curvature.20 Unlike with kidney stones, the sound waves are not blasting the plaque into bits. Some trials may even combine the shock waves with stem cells for added bang.
Peyronie’s disease is a common condition, but not many doctors understand how to treat it. The treatment options have improved recently, with the introduction of Xiaflex injections as well as the use of home traction. The search for a remedy can be frustrating, but with patience, knowledge, and the right doctor, this condition can often be successfully managed.