The Curved Penis

Peyronie’s is also known as Induratio Penis Plastica.

It’s caused by an inflammatory condition of the tunica albuginea, which is the fibrous membrane around the corporate cavernosa of the penile body. You can see this illustrated in the diagrams below.

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The Tunica Albuginea is represented above as the “Deep Fascia”.

Photos

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The Nature of The Problem

Basically the condition involves the growth of a series of plaques which form as a result of injury in the soft tissue of the penis.

The tunica albuginea may then become infiltrated by fibrous tissue and possibly calcified deposits. In either case, the inflexibility and rigidity of the abnormal tissue prevents the penis from expanding on one side during erection.

This causes a curved erection, and possibly other symptoms such as erectile dysfunction, indentation, shortening of the overall length of the penis, and possibly a loss of girth.

There is also another variation of the condition in which the damage causes the penis to take on an hourglass shape, due to the nature of the constriction inside the body of the penis. In fact, although the general view of Peyronie’s is that it produces a curved penis, it’s entirely possible for the scar tissue to produce either divots or indentations as well as curvature.

Now, it’s important to recognise that many men are born with a naturally curved penis, and this should not regarded as an abnormality like Peyronie’s. The reality is that individual anatomy varies, both in respect of the exact shape of the man’s penis and the woman’s vagina.

Often a couple need to accommodate each other’s specific anatomy by finding the sexual positions which suit them. Moreover, it’s fair to say that a slight curve on erection can enhance the comfort of both partners.Indeed, many women report that intercourse with a man who has a completely straight erection can be uncomfortable.

Peyronie’s disease is different to this normal range of variation: it produces a curve which is sometimes so acute that it may actually prevent sexual intercourse from taking place.

Causes

Knowing what causes the problem may well help the search for a cure: and that matters, because up to now, comparatively few treatments have been successful.

To start with, unlikely as it seems, apparently certain beta-blockers list Peyronie’s disease as a possible side effect. More on this later!

More importantly, we know that trauma or injury to the penis is often a cause of Peyronie’s disease, which may develop some time after the original injury. Unfortunately, many men with Peyronie’s disease are unaware of any injury that may have led to its development.

We shall examine this issue in more detail later, but it is possible that a major cause of the condition is minor injuries which pass unnoticed during sex, yet result in bleeding and tears in the lining of the penis, subsequently inducing fibrous tissue growth.

Perhaps a number of factors may be involved. It’s been known for some time that rupturing of small blood vessels inside the penis, which may occur during sex, athletic activity, or as the result of an accident, is often linked to the development of Peyronie’s.

In these cases, it’s possible that blood cells and other tissue debris is trapped inside the injury, thereby triggering an inflammatory response and the buildup of scar tissue.

On the other hand, not every man who has an injury to his penis is going to develop Peyronie’s disease.

And it may be that here is a genetic influence at work, because we also know that a significant number of men with Peyronie’s disease – in fact about one third of them – also develop fibrosis in other tissues, particularly in the hands and feet, most notably in the form of Dupuytren’s contracture.

And there is a higher incidence of Peyronie’s disease in genetically related individuals than would be expected by chance alone, which also suggests a genetic component.

So: we can say that Peyronie’s disease is caused by some kind of problem in the normal wound healing process in the tunica albuginea, which results in the formation of permanent scar tissue.

This scar tissue is inflexible, so that when the penis becomes erect, any area that contains the scar tissue will neither stretch nor bend, resulting in a curved erection, and often pain and discomfort.

However, to complicate matters further, in some men Peyronie’s disease develops gradually, and doesn’t appear to be linked to any kind of injury. This suggests that one of the factors at work may be an immune system disorder.

Diagnosis

Well, diagnosis is not difficult, because sometimes the curvature of the penis is very noticeable indeed.

However, other very definite indicators of Peyronie’s include the formation of scar tissue plaques which can be felt under the skin of the penis as either flat lumps or a band of significantly inflexible and hard tissue.

In addition, the presenting symptoms will usually include some kind of erectile difficulty, either problems getting in maintaining an erection, or significant curvature on erection.

Regrettably, shortening of the penis is also common, as is pain during erection, pain during orgasm, or pain when the penis is touched. Generally symptoms are progressive, but only up to a certain point when the curvature stops getting any worse.

Indeed, even the pain generally improves within one or two years of the onset of the condition, but the curvature tends to remain as a permanent feature of the man’s erection.

Whether or not medical treatment is advisable depends on the exact nature of the condition, and the degree of difficulty encountered in having sexual intercourse.

Now, as we all know, the inability to have sexual intercourse will have an impact on a couple’s relationship, though the nature of the impact depends on how significant and important sexual intimacy is to the couple concerned. But even so, it’s not hard to imagine that this condition is going to cause stress and anxiety for both the man and his partner.

Should it really be necessary to go the whole hog, as it were, and have some tests to identify exactly what is at play, both ultrasound tests and x-rays may be used to identify the presence of scar tissue, or check on blood flow to the penis.

Treatment

This can be a tricky issue, because unfortunately few of the treatments available seem to have much impact on Peyronie’s.

Indeed, there is a case for arguing that if the curvature is stable, and intercourse is both acceptable and relatively pain-free, treatment may not even be necessary.

While a number of medications have actually been used to try and combat Peyronie’s, none of them appear to be as effective as surgery.

The medications which have been used include Verapamil, Interferon, vitamin E and collagenase, among others.

Again, we will examine these in more detail later.

Surgery has been developed over a long period of time, and can be a reliable solution in certain cases. There are several approaches: in the first case, the surgeon will shorten the longest side of the penis, that is to say the side without any scar tissue. Clearly shortening the side that has no scar tissue so that it is the same length as the scarred side of the penis when it is erect, is going to shorten the overall length.

This would be an operation as indicated in men who have adequate penile length and perhaps not as much of a curvature as others. The procedure is known as the Nesbit plication; regrettably it can cause erectile dysfunction.

An alternative approach is to lengthen the side of the penis which has developed scar tissue.

When the surgeon employs this type of surgery, he will make cuts in scar tissue, or possibly break any calcified deposits, thereby allowing the elastic tissue of the tunica albuginea to stretch out, and the penis to become more straight when erect. Scar tissue may be removed, and either a graft of tissue or a membrane made of synthetic material may be implanted.

It’s a process that tends to be used when the man has a shorter penis, more severe curvature, or a complicated problem. Regrettably it runs a higher risk of erectile dysfunction.

Other Treatment Approaches

Other treatments have been developed over the years, but again their effectiveness is variable. These include radiation therapy, ultrasound therapy to break the scar tissue, and penile traction therapy, which means basically using a device to stretch the penis.

 

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Drug Treatment For Peyronie’s

I’m going to start this page by describing a new possibility for the treatment of Peyronie’s disease. This is because I want to emphasize that there’s always hope just over the horizon when it comes to the development of new medical treatments.

It’s certainly true that the drugs which have been used for many years as treatment for PD tend to have limited or variable effectiveness. They’re described lower down the page. But just as you might be tempted to give up hope, along comes an interesting report from the New York Times (originally printed in June 2002).

The paper described a new treatment using a drug called Xiaflex, which showed some promise as a therapeutic agent for the treatment of Peyronie’s. Now, the results weren’t absolutely startling, but they were significant: in two trials, injections of Xiaflex into the fibrous plaque of Peyronie’s reduced the curvature of the man’s erection significantly more than placebo injections.

Furthermore, the men gained significant emotional benefits from the treatment, feeling considerably better about the condition after they received treatment than they did before treatment. And while  the professor of urology at the University of North Carolina said the results were not overwhelming or dramatic, they are a major step forward compared to other current treatments.

So, for example, in one trial the average erect penile curvature in men treated with this new drug went from about 50° at the start of the study to about 30° a year later. That’s very meaningful in medical terms, although it should be pointed out that the control group – who did not receive the drug – also showed a decrease in curvature, albeit on a smaller scale.

So how does this new drug work? Well, it’s derived from an enzyme that breaks down collagen, which of course is a component of the plaques that form inside the penis with Peyronie’s disease. Treatment consists of a number of injections over the course of about a year, and while these injections can cause swelling and pain and bleeding, the objective is to break down the plaques by using the collagen-destroying enzyme. The enzyme that affects the plaques is called collagenase clostridium histolyticum (don’t bother following the link – it’s scientific stuff!), and is derived from a bacterium that causes gangrene in healthy tissue.

The major benefit of using this approach is that there are actually no other currently FDA approved medical treatments for Peyronie’s disease, which leaves surgery as the main option. As we’ve already seen, complications of surgery include penile shortening, which is hardly desirable outcome if your penis already happens to be on the short side.

And a medication that can be injected into the plaques of Peyronie in the doctor’s office is certainly an encouraging development. The company behind this new drug,Auxilium (click on the link for the latest news about the company) have found that the best results are obtained using a three treatment series consisting of of three injections in each series delivered over a week, and allowing six weeks between each series of injections.

In almost 100% of the (admittedly limited) sample who completed the initial study, a 25% reduction in deviation angle was achieved at the nine month follow-up visit. The subjective assessment of the investigating team was that 67% of men receiving treatment were very much improved. The minor side-effects of pain and bleeding at the site of the injections were not serious and resolved in time without medical attention. So, if you have a case of Peyronie’s disease, it could well be worthwhile asking your doctor about the possibility of Xiaflex injections.

Other Drug Treatments For Peyronie’s Disease

Older treatments for Peyronie’s disease included potassium paraaminobenzoate, also known as potaba.

This is an immunomodulating agent, the supposed effectiveness of which comes from it ability to combat the inflammatory reaction in the areolar tissue between the tunica albuginea and the corpus cavernosum. It is this inflammatory reaction that apparently generates fibrotic tissue with a high hyaluronic acid content and abnormal collagen fibres.

Potaba has been been used in a variety of conditions characterised by inflammation and fibrosis, including pulmonary fibrosis and scleroderma. But there have been comparatively few scientific control studies on potaba, which is rather surprising considering how widely used  it has been as a possible therapeutic agent for Peyronie’s disease.

Some studies have reported that Potaba generally seems to arrest plaque development, stabilize plaque size, end penile discomfort, and stabilize penile angularity, provided the potaba is administered for a minimum of three months. However, one of the problems is that it costs a great deal of money, a man must take it frequently, and it has the possibility of causing severe gastrointestinal side-effects.

In general, on the forums where Peyronie is discussed, the consensus view appears to be as follows, as expressed by one particular man: “I think the most one can expect from oral therapy is pain reduction/elimination and if you’re lucky, disease stabilization and perhaps mild improvement if you’re really lucky. I don’t think I’ve heard of more than a handful of guys experiencing any resolution in their condition from oral therapy alone.”

I’m fascinated there is so little scientific evidence about the effectiveness of drugs for Peyronie’s, and I think that rather suggests they don’t work particularly well. In the case of potaba, one of the other problems is that there are potential liver issues with it – in other words it potentially may affect your liver – which means you need to ensure you have your liver function monitored if you do decide to take it.

One commentator on the Peyronie forum observed: “Forget Potaba. It is “old school” Peyronie’s treatment. While it does work, it requires you to take dozens of tablets vs a few for . While Pentox does have side effects, Potaba’s are far more common and often more severe. Potaba is generally more expensive than Pentox. Potaba is generally less safe than Pentox as it can have bad effects on the liver. Potaba is less effective than Pentox.”

Which brings us onto Pentoxifylline as a treatment for Peyronie’s.

Pentoxifylline as a treatment for Peyronie’s.

One of the reasons that so many drugs have become a purported treatment for Peyronie’s disease is that it’s a very difficult condition to treat (and the net for therapies has been cast widely). Pentoxifylline, otherwise known as Pentox, was mentioned as far back as the February 2006 issue of Nature Clinical Practice Urology. Tom Lue from the University of California published a paper in this issue in which he suggested that Pentox might be a therapeutic agent for Peyronie’s disease.

Pentoxifylline has been used in humans to treat a number of inflammatory and fibrotic conditions, including cystic fibrosis and radiation fibrosis. The drug’s mechanism of action is not entirely clear, although it appears to block part of the pathway of inflammation, and prevents collagen from being deposited in the tissues. It also acts as a non-specific phosphodiesterase or PDE inhibitor. (Don’t worry if you have no idea what this means.)

Early work on one particular man with an hourglass deformity led to promising results. Further studies are underway, although the authors of this initial study made the observation that they haven’t used pentoxifylline with men who have chronic stable lesions or heavy calcification, because they assume these lesions are stable and won’t respond to pharmacologic treatment. The other problem, of course, in any pharmacological treatment program for Peyronies disease is that the condition often stabilizes anyway, and it can be hard to distinguish between the effect of medication and natural history of the disease.

A later report published by TF Lue and others in the Asian Journal of Andrology in 2011, discusses a study of 71 men with Peyronie’s disease. 62 of these men were treated with pentoxifylline for about one year: an improvement or stabilization of calcification was noted in 92% of men treated with pentoxifylline compared to 44% of men not so treated. Pentoxifylline users were much less likely to have any subjectively assessed worsening of their condition.

One of the difficulties faced by investigators in this field is that very few drugs have been found to be effective in controlling Peyronie’s disease, and almost all so-called cientific studies that have been conducted have been flawed, hampered by low patient numbers, or the lack of a control group, or the inability of other investigators to reproduce the results, and finally and perhaps most importantly, an inability to distinguish between the effectiveness of medical treatment and the impact of spontaneous improvement in the development of Peyronie’s disease.

But despite these difficulties, pentoxifylline appears to be gaining traction as the most popular treatment for Peyronie’s disease. It comes under a variety of brand names such as Trental, Pentox, Flexital. Like all other medications, it appears to have more effect in some men than others, although as is almost always the case, the effect appears to be more likely to stabilize the condition than to reverse it.

One of the most notable features of Peyronie’s disease is the development of fibrotic plaques within the tunica albuginea. Although evidence is lacking about how many men experience this problem, recent studies suggest that it might be around 3.2 to 5%, although in a population of men being screened for prostate cancer, the prevalence was found to be 9%. Naturally it’s a problem that many men are reluctant to admit to, so it may be that the exact proportion of men population suffering from Peyronie’s disease is not then be clear for some time to come. Even so, one autopsy study suggested that up to 22% of men had symptoms of Peyronie’s disease; whatever the exact number, there is clearly huge under-reporting.

Furthermore, because of the nature of this condition, and men’s reluctance to admit that they are suffering from, the progress and development — otherwise known as the natural history — of the disease is also controversial. While some studies suggest that up to 50% of men who have Peyronie’s will experience some degree of spontaneous resolution or improvement, other studies indicate that only about 10% of men report improvement. This lack of clarity is astounding in the condition has the potential to cause men so much emotional distress.

Perhaps even more surprising is the fact that the origin and cause of the condition is equally uncertain and controversial. Certainly conventional wisdom is that some kind of tearing or damage to the tunica albuginea results in the destruction of blood vessels, and inflammatory response, and conversion of the connective tissue into fibrosis. This in itself makes the tunica albuginea even more susceptible to further injury. Regrettably however, one study of 393 men who had had various forms penile trauma revealed that there was no increase in the number of Peyronie’s plaques among these men, which seems to strongly suggest that there are other factors at work and trauma alone. One of the most obvious factors that need to be taken into account when assessing men with Peyronie’s is whether or not they show signs of other fibrotic problems such as(Dupuytren’s contractures) and feet (Lederhosen syndrome).

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