Many men who develop peyronie’s disease initially think something catastrophic has happened to them. The erection that was once straight becomes bent , sometimes severely bent , and a hard lump that can be easily felt is formed on the penis shaft . Most of the time there is pain. Sex becomes hard, then impossible. Confidence takes a dive. Many men suffer in silence for months or years without realising this is a recognised medical condition with effective treatment options.
Peyronie’s disease occurs when an abnormal scar tissue (plaque) forms in the tunica albuginea, the fibrous sheath that surrounds the erectile chambers of the penis. This plaque is inelastic . When the penis erects , the tunica expands and the affected side can not stretch equally . This pulls the erect penis towards the plaque and causes curvature . The condition affects between three and nine per cent of men and is far more common than most men or their doctors realise.
Peyronie’s is a benign, non-cancerous, fibrotic condition of the penis, characterized by the development of scar tissue (plaque) within the tunica albuginea, the tough fibrous envelope surrounding the two erectile chambers (corpora cavernosa) of the penis. During erection the tunica albuginea stretches evenly and the penis becomes rigid and straight. When a Peyronie’s plaque exists, there is an area of inelasticity, the segment of the tunica with the plaque cannot stretch as the rest of the tunica stretches and this causes the erect penis to bend, curve, or deform toward the side of the plaque.
Plaque can form on any surface of the tunica, dorsal (top), ventral (underside), lateral (side), or multiple sites at once. The most frequent presentation is an upward curvature secondary to dorsal plaques. Downward curving due to ventral plaques. Lateral plaques curve from side to side. Multiple or circumferential plaques can result in a characteristic hourglass or narrowing deformity, or in severe cases a hinging deformity, in which the penis bends at a sharp angle at the plaque site at the time of erection.
Peyronie’s disease is not rare, with an estimated prevalence of 3-9% in the general male population, higher prevalence in men over 50 years of age, diabetics and men with connective tissue disorders. It is vastly under-diagnosed because many men are reluctant to discuss sexual health problems with their doctor and many primary care doctors are not fully familiar with the condition. The psychological impact is profound; a large proportion of men with Peyronie’s disease experience depression, relationship difficulties and sexual avoidance, and a significant loss of self-confidence.
The exact mechanism of Peyronie’s disease formation is not fully understood but the current best evidence suggests abnormal wound healing within the tunica albuginea following micro-injury. The fibrotic response that would normally repair the injury instead becomes self-perpetuating producing an expanding plaque of collagen-rich scar tissue rather than normal tunica.
Penile Trauma & Micro-Injuries During Sexual Activity
The most widely accepted cause of Peyronie’s disease is repeated micro-trauma to the tunica albuginea during sexual intercourse, typically when the erect penis experiences buckling or bending forces (such as during vigorous or awkward sexual positions). A single major injury (equivalent to a ‘penile fracture’ that does not fully rupture the tunica) can also initiate the fibrotic cascade. Most men with Peyronie’s disease do not remember a specific injurious event, the trauma is usually minor, cumulative and unnoticed at the time. Instead of normal healing, the resulting inflammatory response becomes dysregulated and progresses to chronic fibrosis.
Genetic Predisposition & Family History of Fibrosis
Peyronie’s disease has a well-defined genetic component, and men with a family history of disease or related fibrotic disorders are at a significantly higher risk of developing the disease themselves. Genetic studies have found specific polymorphisms in genes involved in collagen metabolism, transforming growth factor-beta (TGF-β) signalling (the key molecular driver of fibrosis), and the fibrillin gene family. Younger men (<40 years of age) who have Peyronie’s disease are more likely to have a major genetic component. Genetic predisposition does not cause the disease by itself but determines the susceptibility of the individual’s tunica to develop dysregulated fibrosis when micro-trauma occurs.
Connective Tissue Disorders – Dupuytren’s Contracture & Ledderhose Disease
Peyronie’s disease is strongly associated with other fibroproliferative diseases, especially Dupuytren’s contracture (fibrosis of the palmar fascia of the hand, leading to contracture of the fingers) and Ledderhose disease (fibrosis of the plantar fascia of the foot). “20 to 30 percent of men with Peyronie’s disease also have Dupuytren’s contracture, and the co-occurrence is far too frequent to be coincidental. All these conditions share the same biological mechanism, dysregulated fibroblast activation and abnormal collagen deposition, and affect different anatomical sites in the same individual. Men with Peyronie’s disease who are also developing finger contractures or foot nodules should be aware of this systemic fibrotic tendency.
Diabetes & Cardiovascular Disease as Risk Factors
Men with diabetes mellitus are significantly more likely to have Peyronie’s disease than men without diabetes mellitus. Several studies have reported a two- to three-fold higher prevalence of Peyronie’s disease among diabetics. Diabetes interferes with normal wound healing, results in abnormal collagen cross-linking and changes fibroblast behaviour, all of which predispose to the dysregulated fibrosis that characterizes Peyronie’s disease. Hypertension and other cardiovascular risk factors are also independently associated with Peyronie’s disease, probably through their effects on microvascular circulation in the tunica. The combination of diabetes and Peyronie’s disease is particularly difficult because diabetic men are also at high risk for concurrent erectile dysfunction.
Post-Surgery or Post-Catheterisation Penile Scarring
Penile fibrosis can masquerade as Peyronie’s disease or be the cause of it . It can be triggered by urological procedures, particularly radical prostatectomy, in which the cavernous nerves and periprostatic tissue are manipulated, and prolonged or traumatic urethral catheterisation . Peyronie’s-like plaque formation after prostatectomy is reported in a small but significant proportion of men after radical prostatectomy and is thought to be related to ischaemic damage to the erectile tissue during the perioperative period combined with abnormal fibrous healing. Penile prosthesis surgery, trauma to the perineum, and prior penile surgeries may also lead to tunica fibrosis.
Idiopathic Peyronie’s Disease – No Identifiable Cause
No identifiable precipitating cause can be established in 20 to 30 percent of men with Peyronie’s disease. These represent idiopathic cases with spontaneous plaque formation, no history of trauma, no connective tissue disorder and no abnormal metabolic risk factors. The course of the disease in idiopathic cases varies, with some resolving partially or completely without treatment and others progressing to significant curvature and functional impairment. Idiopathic Peyronie’s disease may represent the extreme end of normal variability in fibrotic response in men genetically predisposed to abnormal collagen repair.
Symptoms of Peyronie’s disease vary from mildly inconvenient to profoundly disabling and change as the disease progresses through its stages. If these symptoms are recognized early and assessed early, the chances of successful management during the acute phase, when some interventions are most effective, are best.
Penile Curvature During Erection (Upward, Downward or Lateral)
The most recognisable and common symptom of Peyronie’s disease is the curvature of the penis during erection. The inelastic plaque does not allow the involved side of the tunica to expand normally during an erection, resulting in a bend of the penis toward the plaque. Mild curvature (less than 30 degrees) may be a concern for cosmetic reasons, but usually does not affect sexual function. 30 to 60 degrees of curvature is often uncomfortable or challenging during intercourse. A severe curvature (greater than 60 degrees) often prevents penetration. The direction of the curvature, upwards, downwards, to the left or to the right, depends on the position of the plaque in the tunica. The acute phase is defined by progressive worsening of the curvature over weeks to months.
Painful Erections Especially in the Acute Phase
Pain during erection is due to inflammation and swelling inside and around the developing plaque and is a hallmark of the acute inflammatory phase of Peyronie’s disease. The pain is usually felt in the area of the plaque and is usually described as a deep ache or sharp pain that gets worse as the erection becomes fully hard. As the disease progresses from the acute to the chronic phase, the inflammatory activity within the plaque decreases as it matures into stable scar tissue, and the pain usually improves or resolves, usually within six to eighteen months after onset. Pain resolution during erection is an important clinical sign of disease stabilization. Surgical treatment is usually delayed until pain has disappeared and the curvature has been stable for at least 3 months.
Palpable Hard Lump or Plaque on the Penis Shaft
Some men notice this before there is any significant curvature . The first physical sign is often a firm , sometimes tender , palpable nodule or plaque on the shaft of the penis . This is generally felt most easily during flaccidity . The plaque is usually much harder than the surrounding penile tissue, varies in size from a few millimetres to several centimetres in the longest dimension and can be single or multiple. In some men the plaque produces few or no symptoms and a limited degree of curvature. In others a small plaque in a mechanically critical location produces dramatic curvature in excess of that predicted by size of the plaque. Calcification of plaque , when calcium is deposited within the fibrous tissue , can make the plaque feel very hard and is more common in long-standing disease .
Penile Shortening or Narrowing (Hourglass Deformity)
One distressing result for many men with Peyronie’s disease is shortening of the penis. The plaque contracts and shortens, thus shortening the effective length of the involved segment of the tunica, pulling the erect penis shorter than its pre-disease length. This shortening is real and measurable, and it is important to counsel men about it honestly, both so they understand what has happened to their penis and so they can make informed decisions about surgical treatment, some of which may cause additional shortening. The hourglass deformity is most commonly associated with ventral or circumferential plaques. The plaque causes a circumferential constriction at a point on the penis, creating an indentation that resembles an hourglass shape. During erection, this creates a characteristic hinging deformity at the constricted segment.
Difficulty With Penetration Due to Severe Curvature
If the curvature is more than 45 to 60 degrees, sexual intercourse may be physically difficult or impossible. The bent angle of the erect penis makes penetration anatomically difficult, uncomfortable for both partners and in severe cases virtually impossible. Many men with significant Peyronie’s curvature avoid sexual activity altogether, often for years, before seeking treatment. Intimacy’s end has far-reaching consequences for relationship quality, for the emotional health of the partners, and for the man’s self-image. It is one of the most compelling reasons for surgical correction, because restoring the ability to have sexual intercourse restores something fundamental to many men’s lives.
Erectile Dysfunction Associated With Peyronie’s Disease
About 30 to 50 percent of men with Peyronie’s disease also have erectile dysfunction, and the link between the two is two-way. The plaque mechanically prevents the uniform expansion of the tunica that is needed for total rigidity. The psychological impact of the curvature, performance anxiety, loss of confidence, distress about appearance, creates a psychological overlay that further impairs erection. In some men, a venous leak develops distal to the plaque as a result of the fibrotic process. When erectile dysfunction coexists with Peyronie’s disease, it has a major impact on the choice of treatment because surgical correction of the curvature alone (plication or plaque incision and grafting) does not cure the accompanying ED. In such cases, a penile implant that simultaneously straightens the penis and provides rigidity may be the most appropriate single-procedure approach.
Penile Pain Even Without Erection in Severe Cases
Pain with erection is frequent in the acute phase but some men with severe or progressive Peyronie’s disease can have persistent pain even in the flaccid state especially at rest or pressure on the plaque site. This resting pain is a marker of active, intense inflammation within the plaque and of particularly aggressive disease progression. It may also be a sign of calcification . Calcified plaques can cause sharp pain when pressure is applied directly . Persistent resting pain requires early urological assessment and should not be dismissed or managed with self prescribed anti-inflammatory medication without appropriate assessment.
The single most important factor in determining the appropriate treatment strategy is understanding the stage of Peyronie’s disease. The two phases, acute and chronic, have basic different clinical features, different options of treatment and different prognosis.
Acute Inflammatory Phase (First 6 to 18 Months)
The acute phase of Peyronie’s disease begins at onset and is characterized by active inflammation in and around the developing plaque. During this phase the plaque is forming and evolving, it has not yet reached its final size, consistency or calcification status. Clinically the acute phase is characterized by pain on erection (or at rest in severe cases), progressive increase in curvature and sometimes rapid change in plaque size or distribution over weeks to months. During this time the disease is still progressing and a surgical correction cannot be reliably planned, the curvature that exists today may be very different from the curvature in six months. That is why surgery during the acute phase is generally not recommended, as the target is a moving one and surgery on actively inflamed tissue has higher complication rates.
In the acute phase medical and non-surgical treatments are preferred. The only FDA-approved treatment for Peyronie’s disease is intralesional injection therapy, or injections of collagenase clostridium histolyticum (CCH, Xiaflex) directly into the plaque. It is most effective during the acute phase when the plaque is still responsive to enzymatic dissolution. Adjunct oral treatments (colchicine, pentoxifylline, vitamin E) are occasionally used but have limited evidence. Evidence exists that penile traction therapy, using a specially designed external traction device to stretch the plaque on a daily basis, can reduce progression of curvature and preserve penile length during the acute phase.
Chronic Stable Phase (After 12 to 18 Months)
In the chronic phase of Peyronie’s disease the disease is stable, the plaque is mature, the curvature has not changed for at least three months (preferably six months) and pain with erection has resolved. Most men develop the chronic phase between 12 and 18 months after onset of the disease, although in some the transition is more rapid or more gradual. In the chronic phase the plaque is dense, fibrous and often calcified, it is no longer amenable to dissolution by collagenase injections and is unlikely to change significantly with further non-surgical treatment. This is the stage where surgical correction, plication, plaque incision and grafting or penile implant, becomes the treatment of choice for men with significant curvature or functional impairment.
Why Treatment Approach Differs Between Acute & Chronic Phase
The rationale for this phase-specific operative approach is simple: operating on a moving target is unreliable. When curvature correction surgery is performed during the acute phase while the disease is still progressing, the curvature may continue to change after surgery, sometimes worsening beyond the correction obtained from surgery or changing direction. Acutely inflamed tissue also makes it harder to work through the surgical tissue planes and increases complication rates. On the other hand, the non-surgical treatments (especially CCH injections) are much less effective in the chronic phase, when the plaque is fully developed and calcified, as the collagenase enzyme cannot penetrate and break down a heavily calcified plaque. Thus there is a need for fundamentally different management strategies for the two phases.
How to Know If Your Disease Has Stabilised
Stabilization in Peyronie’s disease is defined as: the complete resolution of pain during erection; no change in the angle of curvature for at least 3 consecutive months; and no change in plaque size or consistency on serial clinical examination. Patients monitor curvature stability at home by taking photographs of the erect penis (in a standardised position) every month, progressive photographs that demonstrate no change in the angle of curvature over a three to six month period are the most reliable evidence of stabilisation. Dr Vikas Singh clinically confirms stabilisation at follow-up appointments through standardised curvature measurement with a goniometer (angle-measuring device) during a pharmacologically induced erection, along with serial plaque ultrasound assessment.
When Penile Implant Is the Best Option for Peyronie’s
If there is also erectile dysfunction occurring at the same time and of moderate to severe nature, then penile implant is the best treatment option for Peyronie’s disease. That is when the erections are so poor that satisfactory intercourse is not possible even without the curvature problem. In this case, correction of curvature only (plication or PIG) does not restore sexual function due to the ED. On the other hand, a medication-only ED treatment does not address the curvature. The only thing that treats both at once is a penile implant. The ideal candidate for Peyronie’s disease implant surgery is a man with stable disease (chronic phase), curvature that makes intercourse impractical, and concomitant erectile dysfunction that has failed oral medication therapy.
How Implant Placement Straightens the Curvature
If the cylinders of a penile implant that are placed inside the corpora cavernosa are inflated, the cylinders expand evenly along the entire length of both corpora, including through and beyond the Peyronie ‘s plaque. The cylinders expand symmetrically, producing a straightening force on the inelastic plaque from the inside. In most cases ( especially those below 60 degrees of curvature ) , this mechanical expansion straightens the penis sufficiently as the cylinders fill. Modelling is a technique of applying manual force to the erect penis during the operation to achieve complete straightening. Modelling is systematically performed to achieve the best possible straight result before the patient leaves the operating room.
Simultaneous Modelling Technique During Implant Surgery
Intraoperative modelling (also known as the Wilson modelling technique) is performed at the time of penile implant surgery for Peyronie’s disease to maximize curvature correction. When the cylinders are full of normal saline and the penis is erect, the surgeon uses sustained controlled manual force against the plaque in the opposite direction to the curvature, gently bending the inflated penis against the plaque for 30 to 90 seconds. This controlled force stretches and partially disrupts the inelastic plaque fibres , the same principle used in manual stretching therapy , but applied with a much greater effect by the mechanical rigidity of the inflated implant . This modelling is repeated 2-3 times with clinical assessment of straightening after each manoeuvre until the best achievable result is obtained.
In most cases modelling works fine for curvatures up to about 60 to 70 degrees. There is a small risk of cylinder or tubing injury if excessive force is applied but this is minimized by careful controlled technique and assessment of cylinder integrity after each modelling manoeuvre by the experienced surgeon. If modelling alone achieves sufficient straightening, no further plaque surgery is required . The inflated implant cylinders maintain the straightened configuration while the plaque heals in the corrected position.
Combined Incision Grafting & Implant in Severe Cases
If modelling alone does not sufficiently correct the curvature , generally when the curvature is greater than 60 to 70 degrees , or in the presence of hourglass deformity or very dense calcified plaques , further surgical steps are performed at the time of the implant surgery . The plaque is incised (and where necessary partially excised) to release the contracture under the guidance of the inflated implant, which provides constant reference to the desired straight geometry. The defect created in the tunica is then repaired with a graft material (pericardial graft being the most common in this context) and the implant cylinders ensure that the grafted tunica heals in the expanded, straight configuration. The combined technique is technically difficult and increases the operative time, but gives excellent straightening results even in very severe deformities.
Patient Outcomes After Implant for Peyronie’s Disease
Outcomes data for penile prosthesis surgery in men with Peyronie’s disease and concomitant ED have been uniformly excellent. Major series report patient satisfaction rates of 90 to 96 percent, with high rates of curvature correction (typically residual curvature below 20 degrees, which most couples find acceptable) combined with reliable erectile function from the implant. The rate of satisfaction of the partner is just as high. The results of penile length are generally better than with plication surgery, as the expansion of the cylinder of the implant helps to recover some of the length that was lost to the Peyronie’s contracture. The primary issues for patients are the irreversibility of the procedure, the duration of the implant (usually 15 to 20 years before mechanical replacement may be needed) and realistic expectations of the degree of correction that can be achieved with the implant.
The surgeon who treats Peyronie’s disease must appreciate not only the technical aspects of the disease but also its profound personal and relational consequences, and be able to offer the entire spectrum of therapies, from medical management to complex combined surgical procedures. Why Central India’s patients trust Dr. Vikas Singh for the care of Peyronie’s disease:
But spontaneous resolution of Peyronie’s disease , or complete disappearance of the plaque and curvature without treatment , occurs in only about 5 to 15 percent of men . There is a partial improvement (reduction of the curvature angle) in 30-40% of the cases. Without treatment, about 50 to 60 percent of men have stable disease or progressive worsening. Given the low likelihood of spontaneous resolution and the potential for significant functional impairment and psychological distress, watchful waiting without any active intervention is only appropriate for men with very mild curvature (<15 to 20 degrees) not causing functional problems. All other patients can be triaged and treated in phases.
If you develop a new bend in the penis, feel a hard lump on the shaft of the penis, or have pain with an erection, you should be seen by a urologist promptly. By consulting early in the acute phase, you can access treatments that work best when the plaque is still active and responsive (collagenase injections, penile traction therapy) and allows monitoring of the trajectory of the disease. Patients often wait until the disease is severe before seeking help. As a result, they miss the window of early intervention and arrive at surgery correction with more severe deformity.
Intralesional collagenase clostridium histolyticum (CCH) injection therapy is the most evidence-based non-surgical treatment for Peyronie’s disease and the only FDA-approved pharmacological treatment for the disease. It is administered as a series of injections directly into the plaque over a period of several months in cycles, for men with stable disease or early disease, with curvature between 30 and 90 degrees. Published trials demonstrate CCH reduces plaque burden and decreases curvature by an average of 17 degrees, a significant but often incomplete correction. Penile traction therapy has evidence for maintenance of penile length and reduction of curvature progression in the acute phase with use of 3-8 hours daily . Evidence for oral treatments is weak and they are used only as adjuncts .
The impact of surgery on erectile function varies with the procedure performed. Penile plication is associated with a very low risk of causing or worsening ED as it does not involve the plaque directly and circumvents the cavernous nerves. The principal trade-off is loss of penile length. The risk of de novo or worsened erectile dysfunction from stretching of the cavernous nerves and disruption of tunica biomechanics after plaque incision and grafting is 10 to 15 percent. This risk is greater in men with pre-existing borderline erectile function. Penile implant surgery, by definition, provides reliable erectile function through the device, making it the preferred treatment for men with concomitant ED. Each surgical candidate is discussed in detail about the choice of procedure and implications for erectile function prior to a decision being made.
Penile shortening is an important and often misunderstood component of surgery for Peyronie’s disease. It is important to understand that the disease itself often causes the penile shortening that surgery will not correct. Plication surgery adds additional shortening , usually 1 to 2 cm for every 15 to 20 degrees of curvature corrected . Plaque incision and grafting can be used to release the contracture and patch the defect, and restore some of the shortening associated with the disease. Surgery of penile implants with modelling usually restores part of disease related shortening using corporal dilation but does not restore the length completely to pre-disease [1]. All patients are offered a frank discussion of the anticipated penile length outcome for the procedure chosen based on their pre-operatively measured stretched penile length.
Most often surgical correction of the Peyronie’s disease curvature is very durable. Published series report long term maintenance of straightening in 80-90% of patients at five to ten years and recurrence of curvature after plication is not common. Recurrence rates after plaque incision and grafting are also low , usually less than 10 percent in experienced centres . It is important to note, however, that Peyronie’s disease itself, as a biological condition, does not disappear after surgery. Theoretically, if a genetically susceptible man to fibrosis continues to get penile microtrauma, a new plaque could develop at a different site. The surgery does not address the fibrotic propensity itself, but the deformity itself.
Peyronie’s disease does not directly affect the production, quality or quantity of sperm, or hormone levels, and so does not cause male infertility on a biological level. But severe curvature of the Peyronie’s can make sexual intercourse difficult or impossible and so prevent natural conception if penetration cannot be achieved. Assisted reproductive techniques (intrauterine insemination or IVF) may be of benefit as a bridge for men with Peyronie’s disease who are trying to conceive while awaiting surgical correction of their curvature. Penile implant surgery does not impact the quality of the sperm or the ejaculatory function.
The price of the Peyronie’s disease treatment varies widely and depends on the treatment you choose. The least expensive options are nonsurgical therapies, including collagenase injection therapy, penile traction devices, and oral medications. The cost of surgical intervention will depend on the type of operation. Plication is the least complex and least costly surgical option. The cost of plaque incision and grafting includes graft material and additional operative time. The biggest expense with penile implant surgery is the implant device itself (the three-piece inflatable implant is the most expensive device). Check with your insurance company to see if Peyronie’s disease treatment is covered.
Yes, the main goal of treatment for Peyronie’s disease is to restore satisfactory sexual function. This goal is achieved in most patients who have adequate surgery. Most men who have good erectile function pre-operatively will return to satisfactory sexual intercourse within six to eight weeks of surgery after plication or plaque incision and grafting. Sexual activity is usually resumed at six to eight weeks after penile implant surgery, once the device is activated and the surgeon has ensured adequate healing and function. Partner satisfaction with Peyronie’s surgery is high, and most partners are very accepting of residual curvature, as long as it does not interfere with intercourse. In fact, many couples report a marked improvement in their sexual and emotional relationship after successful treatment.
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