What 'Success' Means for Peyronie's Surgery
"Anytime you're operating on someone's penis, the most important thing is setting expectations ahead of time," said Niels V. Johnsen, M.D., a urologist at Vanderbilt University Medical Center in Nashville. "Because no matter what we do, you're not going to be 18 again."
Johnsen was referring to surgery to correct Peyronie's disease, a buildup of scar tissue inside the penis that causes curved erections. It's not unusual for men to have some curvature in an erect penis, but anything more than 30 degrees is reason to see a doctor, and 60 degrees off vertical is considered severe, said Petar Bajic, M.D., a member of the American Urological Association and a urologist at the Cleveland Clinic who specializes in Peyronie's.
Researchers don't know how many men may have Peyronie's disease, he added.
"It's still emerging research," Bajic said. "We know that it can have some genetic component, especially a similarity with Dupuytren's disease [bending of the fingers]."
Like most diseases, Peyronie's is easier to address if it's detected early. Bajic said you should see a urologist immediately if:
- Your erections cause pain or discomfort.
- Your erections cause difficulty having sex.
- You have any visible indicator that your penis isn't as straight as it used to be.
- You've noticed that the curvature has shifted considerably and quickly.
What are your expectations?
Before surgery, Bajic likes to set expectations about "curing" the problem of Peyronie's.
"If the patient desires the penis to be as close to what he remembers it as possible, like when he was 20, we have to be clear: There's nothing that we can do to make it exactly like it used to be," he said.
Johnsen agreed and offered a useful analogy: "If you've ever broken a body part, which I have, you know, my physician has always said, 'We're gonna put you back together, but it's not gonna be the same.'"
Depending on the patient's goals, doctors have methods to address the problem caused by Peyronie's—or problems, plural, because scarring can cause multiple issues.
"That's why I want to know exactly what my patient expects, and then I present a whole menu of options," Bajic explained.
First, he suggests that patients get a penile Doppler ultrasound to collect information about the scar tissue composition and blood flow in the penis. These details can substantially help the urologist's decision about a treatment approach.
Bajic and Johnsen explained the first step many urologists try—assuming the Peyronie's is in a stable state—is injecting Xiaflex, a drug that can reduce scarring. The injection, in conjunction with the use of a form of traction to break up the scar tissue, can straighten the penis considerably, Bajic said.
What if I still need surgery?
There are many reasons why Xiaflex, traction and nonsurgical remedies may not be an option for a man with Peyronie's disease. Erections result from blood filling two cavities in the penis and Bajic has seen patients whose Peyronie's caused leakage, where scarring caused the valve that controls the closure of those cavities to remain open. This situation may require surgery or other methods of repair so the blood responsible for the erection can remain in the penis.
Urologists have several surgical methods to address the curvature, Johnsen said. One is to internally stitch tissue on the side of the penis opposite the scarring causing the curvature. This shortens the outside of the curve and straightens the penis. Again, Johnsen stressed, patients have to know about the expectations.
"That one, we have a great deal of confidence in," he said. "It's going to be functionally straight, and it has high success rates and is very unlikely to impact your erectile function or your sensation. But some men may feel like we're shortening their penis."
For this reason, Johnsen makes the possibility of shortening very clear to patients going into surgery, and if length is already a concern, alternatives are available. One is to cut out the scar tissue causing the curvature, which may not impact length but does pose "a non-negligible risk of erectile function worsening with that procedure," Johnsen cautioned. Still, patients could maintain their penile length while using medications or other solutions for ED.
Finally, Bajic and Johnsen always make it clear that surgery can cause a temporary loss of sensation at the head of the penis. This loss is more likely if erectile dysfunction was already a factor, Johnsen said. Address the ED and the sensation may return, but not in all cases.
Johnsen stressed that all of these methods have risks, but there's also more that urologists can do to help patients suffering from Peyronie's disease.
Will your penis be exactly the same as before the onset of scarring or when you were a young man? No.
As Bajic and Johnsen both said, Peyronie's surgery doesn't include a "resumption of youth" option, but this reality doesn't mean the surgery failed. With or without surgery, men suffering from Peyronie's disease can still enjoy a satisfying sex life.