Peyronie's Disease
Peyronie's disease, a condition of uncertain
cause, is characterized by a plaque, or hard lump, that forms on the penis.
The plaque develops on the upper or lower side of the penis in layers containing
erectile tissue. It begins as a localized inflammation and can develop
into a hardened scar.
Cases of Peyronie's disease range
from mild to severe. Symptoms may develop slowly or appear overnight. In
severe cases, the hardened plaque reduces flexibility, causing pain and
forcing the penis to bend or arc during erection. In many cases, the pain
decreases over time, but the bend in the penis may remain a problem, making
sexual intercourse difficult. The sexual problems that result can disrupt
a couple's physical and emotional relationship and lead to lowered self-esteem
in the man. In a small percentage of patients with the milder form of the
disease, inflammation may resolve without causing significant pain or permanent
bending.
The plaque itself is benign, or noncancerous.
A plaque on the top of the shaft (most common) causes the penis to bend
upward; a plaque on the underside causes it to bend downward. In some cases,
the plaque develops on both top and bottom, leading to indentation and
shortening of the penis. At times, pain, bending, and emotional distress
prohibit sexual intercourse.
One study found Peyronie's disease
in 1 percent of men. Although the disease occurs mostly in middle age,
younger and older men can develop it. About 30 percent of men with Peyronie's
disease develop fibrosis (hardened cells) in other elastic tissues of the
body, such as on the hand or foot. A common example is a condition known
as Dupuytren's contracture of the hand. In some cases, men who are related
by blood tend to develop Peyronie's disease, which suggests that genetic
factors might make a man vulnerable to the disease.
Men with Peyronie's disease usually
seek medical attention because of painful erections and difficulty with
intercourse. Since the cause of the disease and its development are not
well understood, doctors treat the disease empirically; that is, they prescribe
and continue methods that seem to help. The goal of therapy is to keep
the Peyronie's patient sexually active. Providing education about the disease
and its course often is all that is required. No strong evidence shows
that any treatment other than surgery is effective. Experts usually recommend
surgery only in long-term cases in which the disease is stabilized and
the deformity prevents intercourse.
A French surgeon, François
de la Peyronie, first described Peyronie's disease in 1743. The problem
was noted in print as early as 1687. Early writers classified it as a form
of impotence, now called erectile dysfunction (ED). Peyronie's disease
can be associated with ED; however, experts now recognize ED as only one
factor associated with the disease—a factor that is not always
present.
Course of the Disease
Many researchers believe the plaque
of Peyronie's disease develops following trauma (hitting or bending) that
causes localized bleeding inside the penis. Two chambers known as the corpora
cavernosa run the length of the penis. The inner-surface membrane of the
chambers is a sheath of elastic fibers. A connecting tissue, called a septum,
runs between the two chambers and attaches at the top and bottom.
If the penis is abnormally bumped
or bent, an area where the septum attaches to the elastic fibers may stretch
beyond a limit, injuring the lining of the erectile chamber and, for example,
rupturing small blood vessels. As a result of aging, diminished elasticity
near the point of attachment of the septum might increase the chances of
injury.
The damaged area might heal slowly
or abnormally for two reasons: repeated trauma and a minimal amount of
blood flow in the sheath-like fibers. In cases that heal within about a
year, the plaque does not advance beyond an initial inflammatory phase.
In cases that persist for years, the plaque undergoes fibrosis, or formation
of tough fibrous tissue, and even calcification, or formation of calcium
deposits.
While trauma might explain acute
cases of Peyronie's disease, it does not explain why most cases develop
slowly and with no apparent traumatic event. It also does not explain why
some cases disappear quickly or why similar conditions such as Dupuytren's
contracture do not seem to result from severe trauma.
Some researchers theorize that Peyronie's
disease may be an autoimmune disorder.
Diagnosis and Evaluation
Doctors can usually diagnose Peyronie’s
disease based on a physical examination. The plaque is visible and palpable
whether the penis is flaccid or erect. Full evaluation, however, may require
examination during erection to determine the severity of the curvature.
The erection may be induced by injecting medicine into the penis or through
self-stimulation. Some patients may eliminate the need to induce an erection
in the doctor’s office by taking a digital or Polaroid picture in the home.
The examination may include an ultrasound scan of the penis to pinpoint
the location and extent of the plaque and evaluate blood flow throughout
the penis.
Treatment
Because the course of Peyronie's disease
is different in each patient and because some patients experience improvement
without treatment, medical experts suggest waiting 1 to 2 years or longer
before attempting to correct it surgically. During that wait, patients
often are willing to undergo treatments whose effectiveness has not been
proven.
Experimental Treatments
Some researchers have given vitamin
E orally to men with Peyronie's disease in small-scale studies and have
reported improvements. Yet, no controlled studies have established the
effectiveness of vitamin E therapy. Similar inconclusive success has been
attributed to oral application of para-aminobenzoate, a substance belonging
to the family of B-complex molecules.
Researchers have injected chemical
agents such as verapamil, collagenase, steroids, calcium channel blockers,
and interferon alpha-2b directly into the plaques. These interventions
are still considered unproven because studies included small numbers of
patients and lacked adequate control groups. Steroids, such as cortisone,
have produced unwanted side effects, such as the atrophy or death of healthy
tissues. Another intervention involves iontophoresis, the use of a painless
current of electricity to deliver verapamil or some other agent under the
skin into the plaque.
Radiation therapy, in which high-energy
rays are aimed at the plaque, has also been used. Like some of the chemical
treatments, radiation appears to reduce pain, but it has no effect at all
on the plaque itself and can cause unwelcome side effects. Although the
variety of agents and methods used points to the lack of a proven treatment,
new insights into the wound healing process may one day yield more effective
therapies.
Surgery
Peyronie's disease has been treated
surgically with some success. The two most common surgical procedures are
removal or expansion of the plaque followed by placement of a patch of
skin or artificial material, and removal or pinching of tissue from the
side of the penis opposite the plaque, which cancels out the bending effect.
The first method can involve partial loss of erectile function, especially
rigidity. The second method, known as the Nesbit procedure, causes a shortening
of the erect penis.
Some men choose to receive an implanted
device that increases rigidity of the penis. In some cases, an implant
alone will straighten the penis adequately. In other cases, implantation
is combined with a technique of incisions and grafting or plication (pinching
or folding the skin) if the implant alone does not straighten the penis.
Most types of surgery produce positive
results. But because complications can occur, and because many of the phenomena
associated with Peyronie's disease (for example, shortening of the penis)
are not corrected by surgery, most doctors prefer to perform surgery only
on the small number of men with curvature so severe that it prevents sexual
intercourse.
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