An Hourglass-Shaped Penis Could Be a Result of Peyronie's Disease
You may have seen the TV commercials with the bent carrot.
"A bend in your erection might be Peyronie's disease," the narrator says in the ad for the collagenase injection Xiaflex.
A bent penis is the common visual presentation of Peyronie's disease, which is the result of an accumulation of scar tissue in the penis that leads to curved erections. However, Peyronie's doesn't always present with curvature. Some men see an indentation when their penis is fully erect, which gives the appearance of an hourglass-shaped penis.
Beyond the curvature
"When we think of Peyronie's, most commonly we think of curvature of the penis," said Laurence Levine, M.D., a professor of urology at Rush University Medical Center in Chicago. "We see the commercials with the bent carrot, and curvature probably is the most common presentation. It could be curving up, left, right or downward.
'If you are still able to be intimate with your partner and you don't mind the new shape, you may just want to monitor it to make sure it doesn't get worse.'
"Now, we're recognizing probably upwards of 50 percent or more of the time, there's also an indentation deformity. That indentation can be just one side, having a little notch in it, or it can be circumferential, resulting in the hourglass," Levine said.
Levine has seen more than 1,400 patients with Peyronie's during the past five years. At least half of them had an associated indentation, including hourglass deformity.
Peyronie's disease can result in a wide variety of irregular shapes. Some men present with both a curve and an indentation, while others may experience shortening. The danger with the hourglass shape is it can result in instability, or what's known as the "hinge effect," Levine explained.
When a man has penetrative sex, there's pressure on his erect penis and it should resist collapse.
"The penis is a column, and the strength of that column is directly related to the diameter," Levine said. "So if you have a narrow segment somewhere along the shaft, that's going to be the weak point."
This narrow segment could cause the penis to buckle or hinge at that point.
While Peyronie's is by far the most common cause of hourglass deformity, other potential causes include penile fracture or a tumor from penile cancer, which is very rare.
Assessing the hourglass-shaped penis issue
Helen Bernie, D.O., a urologist and the director of sexual and reproductive medicine at Indiana University Health, always performs a penile duplex Doppler ultrasound on patients. The scan measures arterial and venous blood flow, because often the penis may lie to the left or the right, or have an hourglass shape when it's not fully rigid. Bernie determines the treatment based on the shape or irregularity of the penis when the patient has a rigid, penetration-hardness erection.
Some men have an hourglass shape to their penis when it is flaccid or semi-erect. However, once they get a full erection, it goes away. This is not Peyronie's, because that disease only takes into account the shape of the erect penis.
Levine said if it straightens out or fills out once you have a full erection, there's nothing to worry about.
"That's not an indication that Peyronie's is developing," he said. "It may mean there's a relative inconsistency in the elasticity of the tissue. It may also mean there's potentially a little scarring there, which might not be Peyronie's.
"It may also reflect some kind of vascular irregularity in the penis," Levine added. "If it straightens out with respect to curve or indentation, who cares?"
Treating an hourglass presentation
Surgery is a treatment option for Peyronie's if the curvature is severe and the condition has entered the chronic (stable) phase—it follows the acute (active) phase—usually about a year after the onset of symptoms.
In cases of significant hourglass deformity, Bernie typically performs either plication with grafting or a plaque incision with grafting.
Plication involves cinching together excess tissue with a series of stitches, shortening the long side of the erect penis. Penile grafting procedures involve removing the Peyronie's plaque and replacing it with a material called a graft. Common types include Tutoplast and TachoSil.
These materials add support and strength to the shaft and work very well to fill in the divot or the indentation in the shaft, creating a nice, equal girth, Bernie explained. She most commonly uses TachoSil.
"It's a very easy graft to use and it helps fill in the indentation or deformity in the shaft very nicely," she said. "It doesn't require you to have to place sutures into it as Tutoplast does. Most men do really well with it. It also acts as a hemostatic agent, so it helps control any bleeding."
If it's a mild hourglass shape, Levine usually recommends trying traction therapy first. Traction therapy involves stretching the penis with a mechanical device. Levine recommends at least four to six months of daily use.
If that doesn't work, or a severe indentation results in the hinge effect, he usually recommends surgery.
As for Xiaflex, the collagenase advertised in the carrot commercial, Levine said there's no good evidence indicating it helps with an indentation or hourglass deformity.
"Surgery is usually the most effective and fastest way to get results, but this is an individual decision that you should discuss with your Peyronie's disease specialist," said Raevti Bole, M.D., a urologist and male infertility and andrology fellow at Cleveland Clinic.
Treatment when Peyronie's causes ED
When treating a case of Peyronie's disease, whether it's an hourglass, curvature or other irregularity, Bernie's first order of business is to assess the patient's erectile function. If the man has poor erectile function or severe erectile dysfunction (ED), they're a strong candidate for a penile implant. The implants come in two varieties—semi-rigid and inflatable—both of which are surgically placed.
If ED therapies such as PDE5 inhibitors (e.g., Viagra, Cialis) and intracavernosal injections fail, and if the patient has hourglass deformity, Bernie considers a penile implant because it would help correct the issue and improve erectile function.
She also looks at the location of the hourglass irregularity. If it's proximal on the shaft, meaning closer to the base, that could lead to instability when a man has an erection. As a result, a penile implant may be the best treatment option.
Penile implants are not a first-line treatment and require serious consideration by all parties.
Sometimes, not treating Peyronie's is the answer
Peyronie's is not cancerous and doesn't affect fertility, so some men choose to live with it.
"If you are still able to be intimate with your partner and you don't mind the new shape, you may just want to monitor it to make sure it doesn't get worse," Bole said. "However, if it's affecting your ability to have a relationship or feel confident about yourself, you may want to consider treatment. Having an open conversation with your surgeon is the first step towards getting back to your new normal."
The first step is a consultation with a healthcare professional, and video visits have become a viable option for most people. Visit Giddy telehealth to get connected.