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Peyronie's Disease - The Bent Penis

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Peyronie's disease is a condition where the internal tissue of the penis turns to scar tissue and the penis bends, sometimes dramatically, one way or the other. Unlike hypospadias, which is an accident of birth, Peyronie's is acquired during adult life. 

First described in the 18th century, Peyronie's is usually caused by the formation of a hard plaque of tissue on one side of the penis. Because this scar tissue is hard and inflexible, it causes the penis to bend when erect. But it does also come in other forms: according to "Sex, A Man's Guide" (published by Rodale Press, Inc), the penis may be hard at the base, but soft up top, or skinny in the middle like an invisible band has been fastened around it. And it can come on fast - a man may wake up one morning with his erection bent over. 

The cause of it is thought to be injury to the walls of the internal cavity of the penis, which results in bleeding and eventually scar tissue formation. The scar tissue is inflexible and tight, and sits in the shaft of the penis as a hard knot, causing it to bend. According to some estimates it affects as many as 1% of men. Sometimes the problem is minor, and a man may continue to have enjoyable sex. The real difficulties arise where the bend is so marked that normal intercourse becomes impossible. I should emphasize that this is very different to  the curve that almost all normal penises have, where they bend ever-so-slightly to one side or the other, or upwards towards or downwards away from, the body. You can see from this photo that we are talking about something very different:

Peyronie's isn't the same as chordee (see hypospadias information), where the penis bends over at the tip due to a congenital condition in which the space for the urethra is shorter than the penis body. It is just as much of a problem, though. Men can have enormous psychological difficulties with it, and sex is often affected. In some cases the problem goes away spontaneously; in others it doesn't. Treatment options are limited, but of course medicine is constantly coming up with new ideas, and it's worth checking with a urologist to find out what the latest knowledge in the field might be. There are some surgical procedures which can help in severe cases.

Treatment of Peyronie's Disease

Peyronie's disease is the result of an often painful inflammation of the wall of the erectile cylinders of the penis. Usually, this involves the formation of scar tissue, or plaque, along the top of the penis. The scarring causes the penis to curve upward or to the side. How physicians treat Peyronie's disease depends on the degree of difficulty the individual is having with side effects of the inflammation. The overall goals are to reduce the initial pain involved with the acute inflammatory phase, to decrease penile curvature when it is causing a functional problem with erections, and to restore normal erectile function where the patient has inadequate erections, usually in combination with a severe curvature deformity.

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Peyronie's disease: bent penis

Natural Course of the Disease

We have known for a long time that the acute inflammatory phase of Peyronie's disease may last up to 12 months. Therefore, conservative non-surgical management should be used for the first year. In the past we have correlated the acute painful phase with the acute inflammatory process; however, pain does not always have to be present for there to be progressive scarring. One retrospective review found up to 40 percent of Peyronie's patients experienced progressive problems with curvature and erectile dysfunction from the date the patient first came to the physician, usually complaining of painful erections or penile curvature. Up to 30 percent of the patients had spontaneous improvement of their symptoms during the ensuing 12 months. Also of interest in this particular study was the fact that there was no significant difference in outcome between those who were treated with drugs and those who received no treatment. During the first 12 months, while waiting for the acute inflammation to settle down, some patients that have used intracavernous injections or the vacuum constriction device for treatment of the erection portion of the problem have actually seen an increase in the penile curvature.

Medical Management

For a number of years, oral medications have been the popular treatment by urologists for patients when they first present with penile pain, plaque formation, curvature with erections, hourglass deformity or erectile dysfunction. The two most common oral agents are Vitamin E and potassium para-aminobenzoate (POTABA). The Vitamin E, at 400 IU twice a day, is inexpensive with no side effects. In some retrospective studies it appears to be successful in some patients. In like manner, results with POTABA have mostly been reported in a retrospective fashion. Up to two-thirds of patients get a significant decrease in penile pain, shrinking of the Peyronie's plaque, and decrease in the penile curvature over a six-month span of oral therapy. On the other hand, the POTABA is much more expensive, since 12 grams per day are required. Usually 24 tablets per day are taken at a dose of 500 mg. per tablet. The patient must balance the cost of the drug against the reports that 30 percent of the Peyronie's patients will see a spontaneous improvement without taking any medication. Nevertheless, most patients who are having painful erections or a significant curvature do want to try some type of therapy, and are usually started on either Vitamin E or POTABA.

A number of researchers have tried injecting the Peyronie's plaque with drugs aimed at decreasing the fibrosis early in the plaque formation stage. For example, Gelbard and associates did a careful prospective randomized study with the injection of collagenase directly into the Peyronie's plaque. They found no statistically significant decrease of penile curvature following these injections. Nor have intralesion injections of steroids resulted in any measurable, significant success. Levine and coworkers"' have injected calcium channel blockers into Peyronie's plaques, and have reported a decrease in the scar process and subsequent fibrosis in some patients. On the other hand, this technique failed to alleviate the curvature. Radiation therapy in low doses has been used on patients in extremely rare cases where the painful phase has been very protracted. However, these individuals need to be aware that radiation can cause additional damaging fibrosis inside the corpus cavernosum.

Surgical Treatment

Fortunately, the vast majority of patients with Peyronie's disease do not have deformity severe enough to require surgery, which should be reserved for those with the most severe deformities and erectile dysfunction. If surgery is considered, the inflammatory process needs to be stable, and in most cases the patient will have been monitored for at least 12 months from their initial symptoms.

The first of three groups of operative procedures involves either a plication procedure or the Nesbitt procedure. Individuals with mild to moderate curvature but no erectile dysfunction are candidates for these procedures. Since either procedure will cause a small degree of penile shortening, the patient needs to have adequate penile length. With the plication procedure, the surgeon makes an incision in the area of the penis opposite the curvature to do a counter-straightening procedure when the incision is closed in a transverse fashion. The Nesbitt modification is usually used for patients with more significant curvature. Again, these patients must have good blood flow and normal erectile function out distal to the Peyronie's plaque portion of the penis. In the Nesbitt procedure, an ellipse of the tunica albuginea is removed opposite the point of the greatest curvature. This incision is then closed with permanent, non-absorbable sutures. Most of these patients get a very good result and are able to return to normal sexual function.

The next surgical procedure involves either incision or excision of the Peyronie's plaque along with placement of a graft to cover the ensuing defect in the corpus cavernosum. Patients who are candidates for this procedure will have enough curvature to prevent intercourse but will otherwise have good erectile function. Often these patients will have the severe hourglass type deformity and a short penis. Since the previously discussed plication or Nesbitt techniques shortens the penis, the patient who has a short penis to begin with would not be a candidate for plication, but may be a candidate for plaque incision and grafting. Several different materials have been used over the years for the graft. Since 1974 Divine and Horton have used a dermal (skin) graft to cover the deformity left where the plaque is incised or excised. Lue reported using saphenous vein to create a vein graft patch. He has reported good success with this material. Synthetic materials, such as woven Dacron or Gortex have been used, but produce poor long term elasticity when compared with dermal or saphenous vein patches. Erectile dysfunction rates following plaque excision or incision and graft placement have been reported to be as high as 65 to 70 percent. Following this procedure some patients will have a decreased penile sensation, recurrent Curvature problems or progressive erectile dysfunction.

The last type of surgical procedure for the Peyronie's patient who has severe curvature involves penile prosthesis implants, with or without excision of the plaque. In the late seventies and early eighties it was fashionable to try a one-stage operation where the implant was placed and the plaque excised and a woven Dacron graft utilized to cover the excision. However, those patients had to remain hospitalized for up to a week and the post-op infection rate was significantly higher than the 2 percent infection rate associated with doing the penile implant procedure alone.

The Links

Mayo Clinic Information on Peyronie's Disease A good guide from one of the leading US medical establishments.

Peyronie's Society Highly recommended support and information group.

Basic information on penile anatomy can be found here.

Andrology Center An informative site written by an Indian specialist in male disorders. Good on many aspects of male sexuality.

Peyronie's Disease Help  A site devoted to the treatment of Peyronie’s disease with alternative therapies.