Feb. 22, 2020
Peyronie's disease (PD) is a condition characterized by penile pain, curvature, shortening and sexual dysfunction. The condition itself is common ― some studies suggest that 8% to 10% of men have signs or symptoms of PD. This condition was once thought to be a condition primarily impacting middle-aged men, but Mayo Clinic specialists routinely see the condition present in patients as young as teenagers and in many patients in their 70s and 80s, as well.
The leading hypothesis is that PD is a wound healing disorder of the penis that occurs in genetically predisposed men in response to penile trauma. Ultimately, a scar (plaque) forms on the tunica albuginea of the penis, preventing the normal highly elastic tunical fibers from expanding in the affected area as the penis fills with blood during an erection. This disorder results in the classic changes to the shape and appearance of the penis, such as curvature.
"The majority of men who present with PD do not recall a specific episode of trauma, such as a mis-thrust during penetrative sexual intercourse," says Matthew (Matt) J. Ziegelmann, M.D., Urology, at Mayo Clinic in Rochester, Minnesota. "Rather, it may be that excessive pressures to the erect penis during sexual intercourse create what we term microtrauma, thereby setting off an inflammatory cascade ending in scar formation.
"Thankfully, PD is a benign condition, so it is the severity of the symptoms and the level of patient-bother that dictates whether any treatment is necessary. For men with less severe symptoms, simply knowing that something more serious such as malignancy is not present may be all that is necessary."
If the symptoms are severe enough that sexual activity is more difficult or even impossible, active treatment is indicated. The American Urological Association (AUA) recommends that a formal assessment of the erect penis be performed by the evaluating clinician. "While pictures may be useful, the most accurate way to complete the assessment is by creating an artificial erection in the office and measuring the deformity with a goniometer," says Dr. Ziegelmann.
Determining optimal treatment strategies
Over the last three centuries, a multitude of treatments have been used to treat PD, including approaches as esoteric as arsenic, mercury and electricity, as well as the common therapies employed today. There are three key points to emphasize when considering the optimal treatment strategy:
Whether or not the patient has adequate baseline erectile function
For those patients with severe baseline erectile dysfunction, treating the penile curvature alone is suboptimal. "While a discussion regarding the management of patients with PD and concurrent erectile dysfunction is beyond the scope of this article, suffice it to say several options, including surgical intervention, are used with high levels of patient satisfaction," says Dr. Ziegelmann.
Assess the duration of the PD symptoms
Historically, it was suggested that about half of all men with PD would get better over time with simple observation. This is clearly not the case, as only about 10% to 15% of men actually see symptom improvement during the first year. In contrast, 40% to 45% of men may actually see progression if they elect observation alone. "We term this the acute phase, which is often defined as the first six to 12 months after symptom onset," says Dr. Ziegelmann. "If we are considering more-invasive options ― specifically, surgery ― it is necessary to verify symptom stability prior to definitive intervention."
Determine what level of treatment invasiveness the patient is willing to consider
Signs, symptoms and corresponding treatment options
Despite the fact that surgical straightening through procedures such as penile plication or plaque incision and grafting are the most rapid and reliable way to correct penile deformity, many patients desire less invasive approaches, particularly during the first six to 12 months (acute phase).
"Many different oral agents have been studied with various levels of academic rigor. Unfortunately, at this time there is no strong evidence to support oral monotherapy, and the AUA guideline panel actually recommends against the use of common agents including vitamin E, aminobenzoate potassium and tamoxifen," says Dr. Ziegelmann. "In contrast, we frequently employ oral phosphodiesterase-5 inhibitors such as tadalafil due to the high coincidence of erectile dysfunction, particularly in patients with mild dysfunction. Various topical agents have also been studied, but the literature once again does not support a meaningful benefit for most patients, and topical agents are not a routine part of the treatment armamentarium for most urologists.
Penile traction therapy is an excellent option that can be used in both the acute and chronic phases of PD. Several different traction systems are available, and there is both basic science and clinical data to support traction therapy for PD. Traction devices place tension on the flaccid penis. The force is translated to the penile plaque and promotes remodeling via a biomechanical process known as mechanotransduction.
"Penile traction therapy is the only nonsurgical treatment that has been reliably shown to increase penile length in some patients. This outcome is particularly relevant given that many patients consider penile length loss to be the most devastating consequence of PD," says Dr. Ziegelmann. "Until recently, the available data suggested that penile traction therapy needed to be performed for three to eight hours daily for up to six months to achieve relatively modest benefits."
In 2019, Dr. Ziegelmann and fellow researchers shared outcomes from a randomized, controlled trial wherein patients used RestoreX, a new penile traction system, for 30 to 90 minutes daily for three months. Study results were published in The Journal of Urology.
In that study, more than 75% of patients in the treatment arm realized objective improvements in their penile curvature by an average 17 degrees (27% with 20-degree or more improvement), and 94% of patients realized improvements in their stretched penile length by an average 1.6 cm (29% with 2-cm or more length gain). "While these results may seem modest, for the man with PD who is severely bothered by length loss, any clinical gain is often quite meaningful," says Dr. Ziegelmann. "Adverse events with this device were transient and did not prevent any patients from completing the therapy.
"Finally, intralesional injections directly into the penile plaque with medications such as verapamil, interferon alpha-2β and collagenase clostridium histolyticum are excellent options to prevent progression and improve penile deformity. The AUA PD guideline, published in The Journal of Urology in 2015, supports all of these agents, and to date there has never been a rigorous head-to-head trial comparing outcomes among these agents. However, collagenase is the only FDA-approved agent and the most frequently administered agent in practice."
In a combined analysis of two randomized, placebo-controlled trials, published in The Journal of Urology in 2013, the average curvature improvement was 17 degrees with collagenase versus 9 degrees in the control arm.
"While this improvement may once again seem modest, in practice we see many patients who experience meaningful benefits with collagenase, and this outcome is supported by multiple published series," says Dr. Ziegelmann. "In some cases collagenase may prevent the need for surgery or make the surgical approach less invasive ― for example, allowing the patient to be a candidate for penile plication rather than incision and grafting.
"To conclude, Peyronie's disease is a common yet poorly understood condition. Surgery is the most definitive treatment, yet many patients desire a less invasive approach, and this preference is particularly relevant during the six to 12 months after symptom onset. Treatment options vary depending on patient preference, baseline erectile function and symptom duration.
"For those patients who desire nonsurgical approaches, oral therapies alone are unlikely to provide the patient with significant benefit, whereas penile traction therapy and intralesional injections are excellent options that result in modest yet often meaningful improvements in penile curvature for many patients."
For more information
Ziegelmann M, et al. Outcomes of a novel penile traction device in men with Peyronie's disease: A randomized, single-blind, controlled trial. The Journal of Urology. 2019;202:599.
Nehra A, et al. Peyronie's disease: AUA guideline. The Journal of Urology. 2015;194:745.
Gelbard M, et al. Clinical efficacy, safety and tolerability of collagenase clostridium histolyticum for the treatment of Peyronie disease in 2 large double-blind, randomized, placebo controlled phase 3 studies. The Journal of Urology. 2013;190:199.