Oblique Angles and Acute Phases: How Peyronie's Develops
While some male health conditions, such as benign prostatic hyperplasia (BPH) and prostate cancer, may call for a "wait and see" or "watchful waiting" approach, Peyronie's disease does not.
Peyronie's disease is a condition in which the buildup of scar tissue, or plaque, in the penis leads to curved—and sometimes painful—erections. The disease comes in two phases: the acute, or active, phase and the chronic, or stable, phase. Treating Peyronie's during the initial acute phase is recommended by urologists.
The acute phase, which can last up to 18 months, occurs when there is active inflammation in the erectile tissue of the penis and scar tissue is deposited.
"The two things that characterize active phase are either pain with erections or changes in the structure of the penis," said Bobby Najari, M.D., a urologist at NYU Langone Health in New York City. "Those structural changes can be curvature or indentation."
The structural changes can also be progressive during this phase, he said.
"Some people woke up and noticed their erection was curved in one direction, and it doesn't get any worse from there," he said, adding that this applies to about 40 percent of men with Peyronie's. Others notice structural changes in their erection, and over the course of weeks to months, those changes worsen. For instance, the curvature increases from 20 to 40 degrees.
Some men may feel palpable plaque as a lump, or nodule, on the penis and may experience erectile dysfunction (ED), according to Helen Bernie, D.O., a urologist and the director of sexual and reproductive medicine at Indiana University.
A man enters the chronic phase when their plaque stabilizes, and the penis is no longer changing or undergoing reformations. Men also will not experience pain with erections during the chronic phase.
Treatment options for the acute phase
Bernie said it's typically not recommended to perform surgical procedures for correction of Peyronie's during the acute phase.
"That's because that plaque is still remodeling or changing," she said. "You don't want to do a surgery and then the plaque changes again, and now you have a new curvature after you just tried to fix something."
A common treatment option for the acute phase is penile traction therapy, which creates tension or stretching of the tissues in the penis.
Traction devices have settings for either pulling the penis straight outward or bending the penis in a direction opposite of where the Peyronie's is pulling it, Najari said. Patients typically wear the traction devices for 30 minutes twice a day for up to six months.
Over time, the traction device can help guide the remodeling of the scar tissue so it goes in the intended direction.
"The scar is more elastic as a result," Najari said. "It's similar in concept to braces."
The American Urological Association's guidelines do not recommend any oral medications for the acute or chronic stages of Peyronie's.
About 40 percent of men experience pain with erections during the active phase, according to Bernie. This pain can be managed with over-the-counter anti-inflammatories such as ibuprofen or prescription-strength anti-inflammatories.
What are intralesional injections?
An intralesional injection is a medication a doctor injects directly into the penile scar tissue to help stop the progression of the curvature.
Collagenase clostridium histolyticum (Xiaflex) is currently the only medication approved by the Food and Drug Administration for Peyronie's. It's been approved for use in men with moderate to severe curvatures.
"It's basically an enzyme that cleaves or cuts abnormal collagen," Najari said. "That's a medication that I inject in the office directly into the scar tissue. It's a series of injections over the course of six months."
Another commonly used intralesional injection is interferon. It belongs to the class of proteins called cytokines, which are used for communication between cells to trigger immune system defenses.
"It decreases or can decrease the amount of collagen deposition," Najari said.
The blood pressure medication Verapamil, a calcium channel blocker that is believed to stabilize inflammatory cells, is also used as an intralesional injection for Peyronie's.
Importance of early intervention
In Najari's practice, the majority of men choose to intervene in the active phase with intralesional injections and traction devices.
"I think there is definitely value in intervening in the active phase to just try to stop it in its tracks and get you in the stable phase with as minimal disease as possible," he said.
The men who don't have intervention in the acute phase are typically those who are in the latter part of the phase, when it looks like those structural changes have started to slow down. Either that or they were in the lucky minority who noticed the curvature but it didn't progress over the course of the active phase, Najari said.
"Maybe they have pain, but at least the curvature isn't getting worse on its own," he said.
One of the biggest frustrations for Najari is when he sees a new patient who is already in the stable phase, and they were told during the active phase not to worry about it or not to see anyone until it stabilized.
"We had an opportunity to minimize the extent of their disease if they had just come in sooner," he said.
See a urologist
Bernie said one of the most important things men with Peyronie's can do is see a doctor.
"This is not something that you did," she said. "We believe Peyronie's disease is something that occurs in men who have a genetic predisposition to it. We have treatments, and they shouldn't feel ashamed."
In medical literature, Peyronie's affects up to 15 percent of men, however, Bernie said it's believed the incidence is much higher.
"It's underreported because patients don't know that they have it or they're not partnered or sexually active, and they choose not to see someone for that to have it treated," Bernie said. "Peyronie's disease can be debilitating on a man's psyche."