Peyronie's disease
Peyronie's disease — causes, diagnosis, treatment methods
— Doctor, what should I do? — This patient is asking the same question as everyone else. — It somehow started happening gradually, I didn't even notice. And there was no injury, I know that after an injury...
— Please tell me, how would you rate your discomfort on a scale of 1 to 10?
— I didn't think I'd say this, but quite high... not just physically. I'm just not an old man yet, and I'm not satisfied with the aesthetics at all.
For many patients, this is true: the anomaly causes moral suffering, even if it does not inflict physical torment. Such an obvious and delicate physical imperfection like penile curvature is often an indication for surgery because only it can improve a man’s mental well-being.
Peyronie's Disease (ICD-10 code 48.6) — is a connective tissue disorder where dense plaques form on the elastic tunica albuginea of the penis, hindering its full expansion during erection. As a result, the organ becomes curved relative to its normal position. The anomaly develops gradually and can lead to difficulty in performing sexual intercourse, pain, discomfort, and urinary problems.
Peyronie's disease most commonly affects men — aged 50 to 60 years, but younger individuals can also suffer from it, with a probability ranging from 1.5% to 16.9%. Many patients with this condition develop erectile dysfunction, including psychological issues and depression. Severe cases may require medical assistance, even involving psychiatric intervention.
Pathogenesis of the disease
The exact causes of Peyronie's disease are not known. The hypothesis that seems most likely — is that connective tissue proliferates due to microtrauma of the tunica albuginea, which the man may not even notice himself.
Long-term inflammation leads to fibrosis — excessive proliferation of connective tissue and formation of foci.
I usually conduct a physical examination as usual. Contrary to what patients often assume, it doesn't exclusively involve palpation of the organ where the pathology is detected. Often, I have to palpate even peripheral organs — it depends, of course, on the disease.
— And what are these scars on your palms? — They are very small, but noticeable to an experienced doctor.
— Oh, those... it was surgery to excise scars. The problem wasn't serious, but I'm a jeweler, and finger dexterity is crucial for me, and the scars were hindering that. But I forgot what this condition is called.
Oh, but I remember perfectly well. There are studies proving a link between Dupuytren's contracture and Peyronie's disease. Both are disorders of connective tissue that start to grow uncontrollably and, as a result, restrict mobility in the affected organs.
Scientists are currently actively exploring the hypothesis of a genetic link between the likelihood of developing Peyronie's disease and Dupuytren's contracture — a fibrotic pathology of the fingers. A correlation has been found between these two anomalies:
● Palm pathology is found in 8–39% of patients suffering from Peyronie's disease.
● Fibrotic transformation of the penile tunica albuginea is observed in 4–26% of patients with Dupuytren's contracture.
Several other factors are noted to increase the risk of forming fibrotic plaques:
● High blood pressure
● Previous surgeries on pelvic organs
● Low testosterone levels in the blood
● Lipid metabolism disorders
● Erectile dysfunction
● Ischemic cardiomyopathy
● Autoimmune diseases
● Diabetes mellitus
It has also been proven that smoking and excessive alcohol consumption increase the likelihood of developing Peyronie's disease.
Two phases of the disease progression
Peyronie's disease can develop differently in different patient groups.
The first phase begins with acute inflammation, which patients experience as pain in the penis during rest or painful erections. As the pathology progresses, soft plaques form on the tunica albuginea of the penis, but penile curvature does not always occur. Painfulness is quite common in the early stage of the disease but tends to resolve in most men within a year.
The second phase — is chronic (fibrotic), characterized by the formation of hard plaques. For most patients, penile curvature remains stable (36–67%); for many, it progresses (21–48%). Spontaneous improvement is possible in rare cases (3–13%).
Diagnosis of Peyronie's Disease
At the initial consultation, the doctor gathers a detailed medical history, including information about symptoms, duration of the disease, the impact on the patient's quality of life, and their psychological state in relation to the anomaly. Physical examination involves not only inspection and palpation of the penis in the erect state but also examination of the hands for contractures.
If indicated, auxiliary diagnostic tests such as CT scans, MRI, and ultrasound with Doppler imaging may be used to assess vascular condition. For precise evaluation of penile curvature, intracavernous injections or vacuum pumps are utilized.
Treatment methods for Peyronie's disease
Surgical interventions, medical treatment, and their combinations are used. Medications are primarily indicated in the early stages of the disease, such as for pain relief.
Conservative therapy
Non-surgical treatment taken orally consists of a series of measures aimed at:
● Alleviating or eliminating pain (using non-steroidal anti-inflammatory drugs);
● Stimulating apoptosis (natural cell death) and reducing collagen deposition;
● Improving erectile function.
Injections into the plaque of various substances are also practiced: calcium channel blockers, collagen-splitting enzymes, interferon, botulinum toxin, hyaluronic acid. Conservative therapy is most effective when the curvature is not too significant, but on average, improvement is noted in only 34% of patients.
Injection therapy has prognostic value. Studies show that the better the response to such manipulations, the higher the likelihood of success in subsequent surgical intervention.
In addition to medications, other experimental methods are also used (there is not enough reliable data on their effectiveness):
● Extracorporeal shock wave therapy;
● Vacuum therapy.
One option for non-surgical correction of deformation — is traction therapy, which involves wearing an extender device that stretches the penis. The extender has proven effectiveness but is highly inconvenient (it needs to be worn for many months) and can only be used in the early stages of Peyronie's disease when plaques have not yet hardened.
Doctors place their greatest hopes in a multimodal approach, which involves combining several treatment methods. However, in most cases, despite reducing the severity of pain and making intercourse possible, the curvature of the penis is not sufficiently eliminated and continues to cause discomfort. Currently, the only radical solution to address this delicate issue is surgery.
Surgical intervention
— Does this mean it can be treated?— the patient asks cautiously.
— Yes. The procedure is similar to the one you already had for excising contractures in your hands. It's more complex, but we perform these surgeries routinely, and 99% of those operated on have had no issues afterward. Both aesthetic function and erection are restored, if there were any issues.
— I was thinking that only a prosthesis could save me... Are there any contraindications to the surgery?
— There are few. Of course, we'll need to run necessary tests beforehand, but if you don't have severe chronic conditions, chances are we're almost there...
The surgery is recommended only after six months of disease stabilization (9–12 months from onset) — if the patient complains of pain and inflammation at the time of consultation, symptomatic medical therapy will be prescribed initially. Surgery is performed when:
● Large-sized firm plaques are present;
● Conservative treatment is ineffective;
● Penile curvature is severe enough to impair functionality.
Physical and psychological comfort of the patient are also considered: if the situation causes distress, surgery can be performed at the patient's discretion. The final decision on its advisability is made by the doctor in consultation with the patient.
Many factors are important for choosing the microsurgical technique:
● Size and location of fibrotic plaques;
● Degree of penile curvature;
● Presence of complex deformities (twists, etc.);
● Size of the penis;
● Presence of erection problems.
There are several intervention options, each with its own characteristics and can be applied depending on the patient's needs and initial data:
Currently, in most cases, surgery is recommended because conservative treatment methods do not show satisfactory results.
Prognosis after surgery
Thanks to modern microsurgical technologies, the prognosis in the vast majority of cases is positive. Surgical treatment of Peyronie's disease is characterized by:
● Extremely low risk of complications or recurrence;
● High effectiveness both aesthetically and functionally;
● Low invasiveness, resulting in a relatively short rehabilitation period.
The use of special high-precision optical techniques guarantees the elimination of the anomaly for the patient without damaging adjacent tissues and blood vessels.
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