Peyronie's Disease

Peyronie's (pay-row-NEEZ) disease is a condition of unknown cause. It 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.

François de la Peyronie, a French surgeon, first described Peyronie's disease in 1743. Early writers classified it as a form of impotence, now called erectile dysfunction. 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.

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 too. 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 during intercourse.

The goal of therapy is to keep the Peyronie's patient sexually active. Providing education about the disease and its course is often 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.

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 along the center of each chamber 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 its 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 chance 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. Some researchers theorize that Peyronie's disease may even be an autoimmune disorder.

Symptoms
Cases of Peyronie's disease range from mild to severe. Symptoms may develop slowly or appear suddenly, even 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. In the milder form of the disease, inflammation may resolve itself without causing significant pain or permanent bending. The plaque itself is not cancerous. A plaque on the top of the shaft (which is most common) causes the penis to bend upward. One on the underside causes it to bend downward. Sometimes 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.

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 are often willing to undergo treatments whose effectiveness has not been proven.

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. Steroids such as cortisone have produced unwanted side effects, such as the atrophy or death of healthy tissues.

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.

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 the 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.