Peyronie’s disease

Marc Darrow, MD, JD.

Why is your penis bent? Your doctor may have explained to you that your penis is bent because you suffer from Peyronie’s disease. This disease occurs when plaque (you can feel this as a hard lump) or scar tissue develops under the skin of your penis. When you have an erection, the bend is more noticeable.

Your doctor may ask you if you recently had an injury that required catherization, or if you suffered from genital trauma through injury. Sometimes strong, vigorous sexual activity can injure the penis.

Your doctor may ask you about or check you for Dupuytren contracture, a thickening of the skin of the palm of the hand that causes your fingers to bend inward. People with plantar fasciitis may be predisposed to Peyronie’s disease as a result of a common underlying scaring disorders.

Your doctor may want to check hormone levels if low testosterone is suspected. There is conflicting evidence to suggest a low testosterone connection. An October 2020 study suggested: “There was no significant correlation between penile plaque dimension or penile curvature degree and testosterone levels.” (1) While a team of Japanese urologists did find a correlation in their 2023 paper in the International journal of urology (2) suggesting: “(Average) curvature in 15 patients with a low testosterone level was 80°, significantly higher than those with a normal testosterone range (50°). (Analysis) indicated total testosterone, follicle stimulating hormone, and C-reactive protein as significant factors correlated with severe penile deformity, among which total testosterone was most relevant.”

 

You are not alone. Sometimes a man, or their partner, will feel powerless or frustrated by ineffective treatments of Peyronie’s disease.

You are not alone. Sometimes a man, or their partner, will feel powerless or frustrated by ineffective treatments of Peyronie’s disease. This frustration is discussed in a March 2024 paper in the The French journal of urology.(3) In this paper, urologists asked 55 patients and 41 partners questions about Peyronie’s disease and how it impacted their lives.

  • The average age of the patient was 51.8 years old and they had suffered symptoms of Peyronie’s disease for 15 months. The level of sexual desire was lower in 86% of those surveyed despite penetrative sex being possible in 87%.
  • Patients described penile deformation (96%), erectile pain (80%), erectile dysfunction (40%), penile pain at rest (26%) or sleep disorders (60%).

The partners

  • Most of partners felt powerless or frustrated.
  • Couple relationship was deteriorated in 40%.
  • Penile deformation bothers 61% of partners.
  • Partners researched the disease in 51% of cases for more information with partners feeling they were involved in the treatment management stage in 66% of cases.

Surgery may not universally lead to satisfactory outcomes. Which patients decided on surgery?

A December 2023 study in the Journal of Sexual Medicine (4) writes: “Despite the existence of conservative therapies for Peyronie’s disease, surgery is commonly utilized for the treatment of bothersome curvatures due to its potential effectiveness, although it carries intrinsic risks and may not universally lead to satisfactory outcomes.” In this study of 343 patients with an average age of 57 years old, their willingness to undergo surgery for Peyronie’s disease was assessed. Overall, 161 (47%) experienced penetration difficulties and 134 (39%) reported erectile dysfunction.

  • All the patients in the study were offered conservative treatments, either medications or injections.
  • Tunical shortening (the penis on the longer side of the “bend” is shortened or lengthening procedures (a common complaint of men before and after surgery is the shortening of their penis)) were offered as an alternative to conservative treatments, when indicated.
  • Penile prosthesis (penis implants) was offered to those with concomitant erectile dysfunction.
  • Hourglass deformity in 48 patients (14%) and penile shortening in 157 (46%) were reported.
  • As for previous treatments, 128 (37%) received tadalafil once daily; 54 (16%) and 44 (13%), intraplaque verapamil (Verapamil is a calcium channel blocker typically used for  high blood pressure. Verapamil has also shown that it can stop the progression of Peyronie’s disease scar formation) and collagenase injections (to break down hard collagen in the penis that prevents the penis from straightening); and 30 (9%), low-intensity shock wave therapy.
  • Only 126 (37%) patients were open to surgery for Peyronie’s disease when suggested. These were patients of younger age, more severe curvatures, and difficulty in penetration.

Clinical implications: “The need for effective nonsurgical treatments for Peyronie’s disease is crucial, as is comprehensive patient counseling regarding surgical risks and benefits, particularly to younger males with severe curvatures.”

Collagenase injections (to break down hard collagen in the penis that prevents the penis from straightening)

Currently,  collagenase clostridium histolyticum (Xiaflex) is the only FDA-approved medication for Peyronie’s disease. Researchers have noted that collagenase injections may work better when used in conjunction with penis traction (wearing a penis brace or sleeve) and modeling, the bending of the penis in the opposite direction of the bend.

A June 2023 study in the Research and reports in urology (5) however suggests “the current literature (research) continues to show the use of collagenase clostridium histolyticum is not effective in Peyronie’s disease patients with volume loss, indentation, or hourglass deformity.

A February 2024 study (6) determine change in the point of maximal curvature (POMC) during Collagenase Clostridium histolyticum (CCH) injections for Peyronie’s disease (PD).  Six hundred and eighteen men underwent more than one series of Collagenase Clostridium histolyticum (CCH)

  • Among 189 men who were satisfied or completed 8 Collagenase Clostridium histolyticum (CCH) injections, the average improvement in penile curvature was -27.5° (40.9%).
  • Overall, 55.6% had changes in point of maximal curvature of more than 1 cm (about 2/5th of an inch), 23.6% more than 2 cm (about 4/5th of an inch), 8.9% more than 3 cm (over an inch), and 3.8% more than 4 cm (Over an inch and a half).

Penile traction devices

A November 2023 paper (7) studied the effects of penile traction device in men with Peyronie’s disease on penile curvature, penile length, and erectile dysfunction,. Utilizing the data from five previously published studies on patient outcomes, the researchers here assessed penile length, penile curvature, and erectile function following treatment.

The researchers found: “There is a significant positive effect on the curvature degree, while there is no significant effect on penile length and erectile function. . .  The current evidence suggests that penile traction devices can be a safe and effective treatment option for men with Peyronie’s disease to reduce penile curvature.”

Platelet Rich Plasma Injections

Platelet Rich Plasma Therapy or sometimes referred to as PRP is a regenerative / biologic therapy that uses the healing factors of your blood to rebuild and repair damaged tissue. In the case of Peyronie’s disease, PRP injections are thought to help repair damaged blood vessels and connective tissue, as well as address scar tissue formation in the penis causing Peyronie’s disease.

As discussed in a February 2023 paper in the Research and reports in urology (7) “PRP is believed to exert regenerative effects at sites of tissue injury by releasing various cytokines (messenger cells that stimulate growth of immune and blood cells) and growth factors that promote angiogenesis (artery repair and development of new arteries to bring blood to the penis) and connective tissue regrowth.”

PRP treatments are derived from you. We collect a small amount of your blood, similar to the blood taken for standard blood work, and then take it over to a centrifuge where the blood is spun. The spinning helps separate out the blood’s platelets from the red blood cells. The collected platelets and the healing factors within are then injected into the injured area to stimulate healing and tissue regeneration.

An October 2022 study (8) assessed three injections of PRP, given 15 days apart in 17 patients with Peyronie’s disease. The Peyronie’s Disease Questionnaire (PDQ) and the measurement of the angle of curvature of the erect penis were assessed before treatment and then 1, 3 and 6 months after treatment. Erectile function was assessed by different questionnaires.

  • Three months after treatment, all three Peyronie’s Disease Questionnaire (PDQ) patient reported outcomes  suggested significantly improved. The angle of curvature of the penis was significantly decreased and erectile dysfunction scores also suggested significant improvement.

The doctors of the study wrote: “Our initial experience suggests that PRP injections for Peyronie’s disease are safe.” They also suggested more research was needed to confirm their findings.

Another October 2022 study (9) evaluated the effects of repeated injections of platelet-rich plasma (PRP) for the treatment of Peyronie’s disease in 65 patients. The patients were divided into two groups.

  • The first group with a curvature between 25 and 35° and the second group between 35 and 45°.
  • Patients in both groups received an average of 6.1 injections of PRP during the 12 month study period.
  • Penis angle was significantly improved in both groups . Pain during sex decreased from 70.7% to 34.25%, and 55.5% of patients had easier sexual intercourse.

Low intensity extracorporeal shockwave therapy and platelet-rich plasma

A December 2023 paper (10) examined low intensity extracorporeal shockwave therapy and platelet-rich plasma in acute phase Peyronie’s disease. (The acute phase of Peyronie’s disease is a worsening of symptoms and curvature that can last for months.)

In total, 159 patients were assessed.

  • Seventy-seven who a used combination of vitamin E 600 mg/day plus colchicine (gout treatment for high levels of uric acid) 1.5 mg/day plus oral daily 5 mg tadalafil (for erectile dysfunction) in group 1
  • Eighty-two who received low intensity extracorporeal shockwave therapy +PRP combination therapy plus oral daily 5 mg tadalafil in group 2.
  • All patients were visited at the 3rd and 12th months after the treatment. The conclusion: There was a statistically significant improvement in the mean plaque size, penile curvature degree, IIEF-5 (Erection quality score) and VAS (0-10 pain) scores in the low intensity extracorporeal shockwave therapy and platelet-rich plasma group after the treatment.

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References

1 Can O, Özbir S, Atalay HA, Çakır SS, Culha MG, Canat HL. The relationship between testosterone levels and Peyronie’s disease. Andrologia. 2020 Oct;52(9):e13727.
2 Mitsui Y, Yamabe F, Hori S, Uetani M, Aoki H, Sakurabayashi K, Okawa M, Kobayashi H, Nakajima K, Nagao K. Significant inverse association of testosterone level with penile deformity severity in Japanese males with Peyronie’s disease. International Journal of Urology. 2023 Jan;30(1):36-42.
3 Thach S, Pommier B, Soulier V. The impact of Peyronie’s disease on couples. The French Journal of Urology. 2024 Apr 1;34(4):102595.
4 Capogrosso P, Pozzi E, Russo GI, Hatzichristodoulou G, Cocci A, Falcone M, Martinez-Salamanca JI, Fernández-Pascual E, Candela L, Schifano N, Dehò F. Patients’ attitude with surgery for Peyronie’s disease: results from a multicentric European study. The Journal of Sexual Medicine. 2024 Jan;21(1):54-8.
5 Khooblall P, Bole R, Lundy SD, Bajic P. Expanded Utilization of Intralesional Therapies for Treatment of Peyronie’s Disease. Research and Reports in Urology. 2023 Dec 31:205-16.
6 Larson H, Warner J, Savage J, Kohler T, Ziegelmann M, Trost L. Changes in Point of Maximal Curvature During Collagenase Clostridium Histolyticum Injections for Peyronie’s Disease. Urology. 2024 Feb 1;184:122-7.
7 Almsaoud NA, Safar O, Alshahrani ST, Alwadai R, Alkhaldi SM, Almurayyi M, Alrweili HH, Assiri HM, Al Jubran A, Hakami B, Alzahrani MA. The effect of penile traction device in men with Peyronie’s disease on penile curvature, penile length, and erectile dysfunction: a systematic review and meta-analysis. Translational Andrology and Urology. 2023 Nov 11;12(11):1673.
8 Reddy AG, Dai MC, Song JJ, Pierce HM, Patel SR, Lipshultz LI. Peyronie’s disease: an outcomes-based guide to non-surgical and novel treatment modalities. Research and Reports in Urology. 2023 Dec 31:55-67.
9 Ledesma BR, Velasquez DA, Egemba C, Molina M, Ibrahim E, Costantini-Mesquita F, Deebel NA, Han S, Reis IM, Saltzman R, Ramasamy R. A phase 2 randomized, placebo-controlled crossover trial to evaluate safety and efficacy of platelet-rich plasma injections for Peyronie’s disease: clinical trial update. International Journal of Impotence Research. 2024 Feb 29:1-5.
10 Achraf C, Abdelghani PA, Jihad PE. Platelet-rich plasma in patients affected with Peyronie’s disease. Arab Journal of Urology. 2023 Apr 3;21(2):69-75.
11 Karakose A, Yitgin Y. A new alternative approach to management of acute phase Peyronie’s disease: low intensity extracorporeal shockwave therapy and platelet-rich plasma. Minerva Urology and Nephrology. 2023 Dec 13.

 

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