Peyronie 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.

Peyronie's disease often occurs in a mild form that heals without treatment in 6 to 15 months. But in severe cases, the hardened plaque reduces flexibility, causing pain and forcing the penis to bend or arc during erection.

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 occurring in 1 percent of men. Although the disease occurs mostly in middle-aged men, younger and older men can acquire it. About 30 percent of people 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 familial 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, Francois 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. Peyronie's disease can be associated with impotence; however, experts now recognize impotence as 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. A chamber (actually two chambers known as the corpora cavernosa) runs the length of the penis. The inner-surface membrane of the chamber is a sheath of elastic fibers. A connecting tissue, called a septum, runs along the center of the chamber and attaches at the top and bottom (see Figure).

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, and why similar conditions such as Dupuytren's contracture do not seem to result from severe trauma.

Treatment

Because the plaque of Peyronie's disease often shrinks or disappears 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 that have unproven effectiveness.

Some researchers have given men with Peyronie's disease vitamin E orally 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 collagenase, dimethyl sulfoxide, steroids, and calcium channel blockers directly into the plaques. None of these has produced convincing results. Steroids, such as cortisone, have produced unwanted side effects, such as atrophy, or death of healthy tissues. Perhaps the most promising directly injected agent is collagenase, an enzyme that attacks collagen, the major component of Peyronie's plaques.

Radiation therapy, in which high-energy rays are aimed at the plaque, also has been used. Like some of the chemical treatments, radiation appears to reduce pain, yet it has no effect on the plaque itself and can cause unwelcome side effects. Currently, none of the treatments mentioned here has equalled the body's natural ability to eliminate Peyronie's disease. The variety of agents and methods used points to the lack of a proven, effective treatment.

Peyronie's disease has been treated with some success by surgery. The two most common surgical methods 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.

Sources of More Information

American Foundation for Urologic Diseases

30 West Pratt Street

Suite 401

Baltimore, MD 21201

Tel: (203) 764-6518 or

(800) 828-7866

National Organization for Rare Disorders

P.O. Box 8923

New Fairfield, CT 06812-1783

Tel: (800) 999-6673

National Kidney and Urologic Diseases Information Clearinghouse

3 Information Way

Bethesda, MD 20892-3580

(301) 654-4415

The National Kidney and Urologic Diseases Information Clearinghouse is a service of the National Institute of Diabetes and Digestive and Kidney Diseases, part of the National Institutes of Health, under the U.S. Public Health Service. Authorized in 1987, the clearinghouse provides information about diseases of the kidneys and urologic system to people with such afflictions and to their families, health care professionals, and the public. The clearinghouse answers inquiries; develops, reviews, and distributes publications; and works closely with professional and patient organizations and government agencies to coordinate resources about kidney and urologic diseases.

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