Peyronie's Disease

Peyronie's disease is a disorder in some men who have abnormal healing of scar tissue.The result is an abnormal degree of curvature of the penis. The disease was first documented by Francois Gigot de la Peyronie, a French surgeon and barber, in the mid-1700's. Symptoms of Peyronie's disease may include palpable plaques, erectile dysfunction, and pain. 

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What Causes Peyronie's Disease

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Peyronie's disease is caused by injury to the penis. The injury, as with most injuries to the human body, creates a small amount of scar tissue, known as a plaque. The plaque is composed of collagen, a structural protein in scars, and elastin. The injured part of the penis is called the tunica albuginea. The tunica albuginea in a connective tissue layer that forms the two blood collecting spaces on either side of the penis. 

 

How much force does it take to create the plaque? There is no generally accepted amount of force required or specific type of injury involved in the disease's development. Even a small amount of force can cause enough injury for plaque formation to begin. For example, even sexual intercourse can cause enough injury to build scar tissue. For some reason, the men with Peyronie's disease are merely predisposed to creating these plaques.

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How is Peyronie's Disease Diagnosed

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Peyronie's disease is typically diagnosed in a doctors office by through visual examination of the penis. A doctor reviews the man's medical history as well as conducting a thorough physical examination. The physician will likely ask questions regarding when the problem first occurred, such as, "was there an injury?" The doctor will also want to know how long the curvature has existed and how it has changed over time.

 

A patient being evaluated will likely be asked to complete a questionnaire, known as the Peyronie's Disease Questionnaire (PDQ). The questionnaire consists of 15 questions and the answers give doctors a way to measure the overall impact of the disease on your health. You can download a sample of the questionnaire using the link below.

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Peyronie's Disease Questionnaire (PDQ)

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A doctor may use medication in the office in order to evaluate the penis in an erect state. Typically, the patient is administered an injectable medication into the penis. When the penis is erect, assessment of things like the number of plaques, the degree of curvature, and other defects are easier to examine. 

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Rarely is it necessary to perform imaging or other diagnostic tests to diagnose Peyronie's disease. If a patient is considering surgical intervention, an ultrasound of the penis may provide the surgeon with information regarding the anatomical specifics for the patient.

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Treatments for Peyronie's Disease

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Considering whether or not to undergo treatment for Peyronie's disease is the decision of the individual patient. Patients with a mild curvature who have no issues with sexual function may choose to avoid any intervention. On the other hand, patients who have pain or have a substantial amount of difficulty having sex may be much quicker to undergo treatment.

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There have been no oral medications for the treatment of Peyronie's disease that have been approved by the FDA. There have been numerous studies that explored potential oral treatment for Peyronie's disease, but either the medications were shown to be ineffective or the risks of the medications were too great. Some available treatments for Peyronie's disease that have been found to be effective include penile traction devices, extracorporeal shockwave therapy, topical medications, and injections.

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Penile Traction Devices to Treat Peyronie's Disease

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Penile traction devices use a small amount of physical force in attempt to straighten the penis. Traction devices have been found to be effective in reducing the degree of curvature associated with Peyronie's disease. In addition, studies on penile traction devices have found that use of the devices also resulted in increased penis length and increased penis girth.

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No in-depth studies have been able to reveal the scientific mechanism for the effectiveness of penile traction devices. However, the current assumption is that the devices work by causing physical stress to the underlying scar tissue. As a result, a small amount of injury is created at the site of the scar tissue, which causes new tissue to form. 

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A study published in the Journal of Sexual Medicine in 2008 were able to reduce the penis curvature in patients with Peyronie's disease by an average of 33% with the use of penile traction devices. The study found that the average penis length of the patients was increased by up to 2cm (slightly more than 3/4 of an inch). The study also reported an increase in penis girth of up to 1cm. The patients used the traction devices for up to 8 hours a day for 6 months and reported no adverse events during the study.

 

The Journal of Urology published a randomized, single-blind, controlled trial in 2019 evaluating the effects of a penile traction device in sexual health outcomes for patients with Peyronie's disease. The men undergoing traction therapy used the device for 30 to 90 minutes a day for 3 months. In addition to a reduction in penis curvature of 11.7 degrees, the authors reported an average increase in penis length of 1.5cm. Like the previous study, the participants suffered no adverse events.

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Another randomized, controlled clinical trial was published in the Journal of Sexual Medicine in 2019 that evaluated the ability of a penile traction device to treat the penis curvature associated with Peyronie's disease. The study showed that the penile traction device was able to reduce the curvature of the penis by approximately 20%. The authors also reported a significant increase in penis length of 1.7cm to 2.3cm. 95% of the men who used the device experienced increase in penis length. The study participants used the device for around 39 minutes a day for 3 to 9 months. 

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Overall, penile traction devices appear to be a reasonable option for the treatment of Peyronie's disease. The devices are non-invasive and have no associated adverse events from any of the research done. Major medical societies have been reluctant to endorse or recommend penile traction devices, despite the reported safety of the devices.

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Extracorporeal Shockwave Therapy for Peyronie's Disease

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Extracorporeal shockwave therapy (ESWT) is a procedure that applies sound waves to the body to effect change in the tissue beneath the skin. ESWT was originally used by urologists to break up kidney stones (lithotripsy). Advocates of the procedure believe that by heating the tissue, physically breaking the plaque, and causing inflammation, ESWT should be able to effectively reduce the curvature in Peyronie's disease.

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There have been many studies that examined the ability of extracorporeal shockwave therapy in the treatment for Peyronie's disease. A meta-analysis published in the Journal of Sexual Medicine in 2021 determined that ESWT is not likely effective in reducing the penile curvature in Peyronie's disease. The authors of the study note, however, that ESWT may be effective at reducing the size of the plaque. Earlier studies published on ESWT reported an improvement in pain associated with the use of ESWT, but this doesn't appear to be a consistent finding.

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Topical Medications for Peyronie's Disease

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There have been a few studies that have evaluated the effectiveness of topical medications to treat Peyronie's disease. The only medication shown to be effective has been topical verapamil. Verapamil is a calcium channel blocker. The oral version of verapamil is prescribed for the treatment of high blood pressure and some types of arrhythmias. Verapamil has also been used by veterinarians to prevent intra-abdominal adhesions (scar tissue) when performing surgery in animals.

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A placebo controlled pilot study, published in International Society for Sexual Medicine in 2007, explored the application of different topical preparations for the treatment of Peyronie's disease. The researchers concluded that topical verapamil gel was effective in reducing pain and decreasing penile curvature in patients with Peyronie's disease. The study reported a decrease in curvature of 84% after 9 months of treatment with verapamil gel 15% twice a day.

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Penile Injections for Peyronie's Disease

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There are two different injectable medication treatments that have been studied for Peyronie's disease - verapamil and collagenase. Collagenase is the only medication that is approved by the FDA for the treatments of Peyronie's disease (sold as Xiaflex). Injected verapamil has been studied as a treatment for Peyronie's disease because of its effects on collagen production, but is not commonly used.

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Collagenase is an enzyme that is naturally produced by the bacteria clostridium histolyticum. The enzyme catalyzes the breakdown of collagen, a structural protein that is present in scars. Collagenase is injected directly into the penile plaque in order to dissolve the plaque. The treatment typically consists of one injection every six weeks for a maximum of 4 injections.

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The major drawback of using collagenase is the potential for corporeal rupture, which is the tearing of the tunica albuginea. The tunica albuginea is the connective tissue that forms the two compartments of the penis where blood is contained. Corporeal rupture  frequently requires surgical repair. Although rupture of the tunica is considered rare, critics have alleged that this potentially severe adverse event is underreported.

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A prospective, matched-pair, non-blinded, randomized clinical study published in Investigative and Clinical Urology in 2022 compared the effectiveness of verapamil with collagenase for the treatment of Peyronie's disease. The researchers concluded that collagenase was more effective and was associated with higher short-term patient satisfaction. 

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PRP/PRF to Treat Peyronie's Disease

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Platelet concentrates are being increasingly studied for the treatment of Peyronie's disease. Platelet rich plasma (PRP) and platelet rich fibrin (PRF) have been used by physicians to treat Peyronie's disease. The procedure involves the extraction, concentration, and re-injection of platelets and growth factors into the penile plaques to encourage healing of the scar tissue.

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A pilot study published in Progres en Urologie attempted to determine the tolerance an efficacy of PRP injections for the treatment of Peyronie's disease. The study participants were injected with PRP directly into the penile plaque once every 15 days for a total of 3 injections. The participants had an average improvement of penis curvature of 11.8 degrees. The researchers also reported significant improvement of all 3 domains of the Peyronie's Disease Questionnaire (PDQ) and an overall improvement in erectile function. 

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A prospective study that was published in Arab Journal of Urology in 2022 evaluated the effectiveness of PRP in the treatment of Peyronie's disease. The researchers reported an average improvement in the curvature of the penis of approximately 16 degrees as well as overall pain improvement in a significant percentage of patients. The patients in the study received an average of 6 treatments each over 12 months.

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Surgical Treatment for Peyronie's Disease

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Surgical treatment of Peyronie's disease is usually reserved for patients with a severe deformity for more than a year. Typically surgical patients have failed more conservative treatments for Peyronie's disease, such as the ones discussed above.

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Research on Peyronie's Disease

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Chatar Achraf, Pr Ammani Abdelghani & Pr El Anzaoui Jihad (2022) Platelet-rich plasma in patients affected with Peyronie’s disease, Arab Journal of Urology, DOI: 10.1080/2090598X.2022.2135284

 

Chung E, Wang J. Intralesional collagenase Clostridium histolyticum vs. verapamil injections in males with Peyronie's Disease: A prospective, matched-pair, non-blinded, randomised clinical study comparing clinical outcomes and patient satisfaction rates. Investig Clin Urol. 2022 Sep;63(5):563-568. doi: 10.4111/icu.20220145. PMID: 36068002; PMCID: PMC9448666.

 

Cilio S, Fallara G, Capogrosso P, Candela L, Belladelli F, Pozzi E, Corsini C, Raffo M, Schifano N, Boeri L, d'Arma A, Imbimbo C, Mirone V, Montorsi F, Salonia A. The symptomatic burden of Peyronie's disease at presentation according to patient age: a critical analysis of the Peyronie's Disease Questionnaire (PDQ) domains. Andrology. 2022 Nov 25. doi: 10.1111/andr.13352. Epub ahead of print. PMID: 36426559.

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Joseph J, Ziegelmann MJ, Alom M, Savage J, Köhler TS, Trost L. Outcomes of RestoreX Penile Traction Therapy in Men With Peyronie's Disease: Results From Open Label and Follow-up Phases. J Sex Med. 2020 Dec;17(12):2462-2471. doi: 10.1016/j.jsxm.2020.10.003. Epub 2020 Nov 20. PMID: 33223425.

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Levine LA, Newell M, Taylor FL. Penile traction therapy for treatment of Peyronie's disease: a single-center pilot study. J Sex Med. 2008 Jun;5(6):1468-73. doi: 10.1111/j.1743-6109.2008.00814.x. Epub 2008 Mar 26. PMID: 18373527.

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Schirmann A, Boutin E, Faix A, Yiou R. Tolerance and efficacy of platelet-rich plasma injections in Peyronie's disease: Pilot study. Prog Urol. 2022 Oct;32(12):856-861. doi: 10.1016/j.purol.2022.05.004. Epub 2022 Jun 28. PMID: 35778315.

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Ziegelmann M, Savage J, Toussi A, Alom M, Yang D, Kohler T, Trost L. Outcomes of a Novel Penile Traction Device in Men with Peyronie's Disease: A Randomized, Single-Blind, Controlled Trial. J Urol. 2019 Sep;202(3):599-610. doi: 10.1097/JU.0000000000000245. Epub 2019 Aug 8. PMID: 30916626.