We Have Questions: Peyronie's Disease Treatment
Peyronie's disease occurs when pieces of flat scar tissue, known as plaques, build up in the penis, causing it to indent, curve or bend when it is erect. The condition can also shorten the penis and inhibit erectile hardness.
Approximately 1 in 100 men in the United States have been diagnosed with the condition, but research suggests many more live with the disease. Peyronie's disease could affect more than 1 in 10 adult men nationwide, according to a 2016 study.
Although Peyronie's is not inherently harmful, it can substantially impact a person's sexual health and overall well-being. Many people with the condition have erectile dysfunction (ED), difficulty with penetrative intercourse and penile pain. Depression and diminished self-confidence are prevalent as well.
No cure for Peyronie's exists, but several surgical and nonsurgical treatments do.
Raevti Bole, M.D., M.A., is a urologist affiliated with Cleveland Clinic and the co-author of several studies on Peyronie's disease. We spoke with Bole to discuss who does and doesn't need Peyronie's disease treatment, what options are available and what patients can expect.
Editor's note: This interview has been edited for length and clarity.
What's the most common Peyronie's disease treatment?
Bole: That one's a little difficult to say because it depends on a few different things in terms of what type of treatment, if any. The first thing that we always ask is, is the patient even bothered enough that they want treatment? Because a lot of people will have Peyronie's but they're not actually bothered by it. They just want to make sure that it's not something like cancer or something that's necessarily going to get worse. And then they say, 'OK, well, you know, I'm still doing OK. My partner's not complaining and I'm just going to choose to continue to be like this.' And that's absolutely fine.
And then the second thing is, are they in the acute phase? Which is just that initial period during which that curvature might even be changing. Peyronie's disease could be getting worse, sometimes better.
Or are they in a stable phase? Stable phase means that at that point, you're very unlikely [to see] that curvature change at all. And that's where some other treatment options come into play. So, for example, if you're in your acute phase where things could still change, you're probably not going to be a good candidate to have something permanent done, like a surgery. But if you're in that stable phase, then you could be offered something like a surgery.
What else do you consider?
Other things that matter to us are, does the patient have ED? Because that's going to affect the type of treatment that we recommend if they have really bad ED. And then, finally, what does the curvature look like? We have to do an assessment of every curvature, and all those things together are going to affect the final treatment recommendation. It's not really like there's one that's most common.
In the acute phase, is it possible to reverse the damage or reduce it?
Generally, in the acute phase, you are trying to do things, number one, that aren't permanent, and number two, that might potentially reduce the final effect. There are certain things people have tried, and I don't know that we have really strong data to say, 'Yes, for sure this works and you'll completely reverse it.' I don't think there's any treatment out there that's that good. But often physicians will use penile traction therapy in that phase to try and limit some of the length you can lose and try to work against some of that curvature that you experience from Peyronie's disease.
You can also try the drug Cialis [tadalafil], which is called a PDE5 inhibitor. It's actually a drug that's taken for erectile dysfunction. But there are some new studies coming out that perhaps it might help prevent some of that curvature in Peyronie's eventually, but that's sort of newer data.
What type of curvature typically warrants treatment?
Every treatment that we have is best for a specific type of curvature and a specific patient goal. So if someone's got a 60-degree curve but they're not really bothered by it and they can still have the type of intercourse or intimacy that they want, you actually don't need to treat it. On the other hand, if someone comes in and they have a really mild curve, say 25 degrees, but they're really bothered by it, then we would talk to them about treatment.
So it isn't really so much about the numerical value of the curvature; it's more so whether someone is bothered enough [that] it's really affecting their self-confidence. It's affecting their ability to be intimate. Those are the things that we look at for treatment.
Before we recommend any kind of treatment, we need to know what we're working with [and] we always do an in-office assessment of the curve. And so we will induce an erection with medications in the office and then we measure it, we measure the size of the plaque. Does it have calcium in it? We measure the length of the penis. We measure if they've lost any volume, [girth changes], if it's gotten real narrow in one spot. We measure blood flow, and then that way we're on the same page with the patient. We can see what they're talking about and then we recommend a very individualized treatment from there.
Could you explain how traction therapy works?
Traction, I would say, is a low side-effect and relatively low-cost way to correct some of that curvature and then also correct some of that length loss that patients get with Peyronie's disease. The downside is that it takes time.
It is a stretching device that you have to put onto the penis. You wear it daily for a certain amount of time to mechanically stretch the penile tissue. And the stretching is done usually in the direction opposite the curve while the penis is flaccid, so without an erection.
There's a newer generation of devices that were developed. One of those was called the RestoreX device. And that one, you only have to wear it for an hour a day. That's still an hour a day that you're wearing this device, so it's not easy. And you have to do that for about three months in order to experience the improvements that they saw in the clinical trial.
The other thing to know is that it won't be perfectly straight. It does improve your curvature, that's been shown, and it does get you back some length, that's also been shown. But it's not going to get you arrow straight. It's not going to get you to what you looked like before Peyronie's disease. And then the other thing to know is that if someone has problems with erectile dysfunction, it doesn't help that. It's purely for curvature and for length loss if someone is experiencing that.
With erectile dysfunction, does Peyronie's cause it or is ED caused by something else?
Yeah, they occur frequently in the same populations. And it's thought that perhaps Peyronie's might contribute to the dysfunction of the mechanism that allows the penis to sort of track blood and keep it in there once you get an erection. They're very much intermingled.
What types of medications are used, both in the acute phase and beyond?
In that acute phase, if someone's having pain, which doesn't usually last long term, you can give them an oral anti-inflammatory. If someone's having trouble with erections—also with that newer data that I was talking about where we think potentially it might help prevent the curvature—you could try medication like Cialis to try and work on both of those things: the erection difficulties and the curvature. Also, it might prevent further bending and buckling of the penis during intercourse. So, potentially, that might reduce the little microtrauma that happens to the penile tissues causing the curvature in the first place. So there are some oral medications. There's not a whole lot of data to support anything else apart from those, but those are some of the ones that have particular uses in Peyronie's.
Then the next type of medication would be injectable—injections that are right into that scar tissue that's causing the Peyronie's. There are a few different types that are very common. One is called Xiaflex. That one, again, will not get you perfectly straight, but it does improve curvature. And it's only approved for certain degrees of curvature. For a very mild curve, it's not approved, or if you have a very severe curve, it is not approved for that. So there is a specific degree of curvature that was tested in the clinical trials that it is approved for.
And then also—this is one of the reasons that we do an initial assessment—a lot of experts feel like this injection works best in scars that don't have calcium in them. So that's something we assess in the office as well. The downside of the injections, though, is they're going to take time. It takes four cycles, two injections in each cycle, and then you have to wait six weeks in between each cycle.
As far as surgery goes, generally, what does that entail and who usually needs it?
Surgery is the most likely thing to get the penis as straight as possible. It's the only option that can actually give you back volume if someone has Peyronie's disease that's causing an indentation or it just got really narrow because of scarring. Even loss of length, surgery can help a little bit with those things more so than some of the other therapies. But it really depends on which surgery you're talking about. In general, these are same-day procedures. The patient goes under anesthesia for the most part. You don't generally have to stay in the hospital and then when you wake up and you go home, you can recover at home. So it's not necessarily as intensive, maybe, as people sort of perceive it to be.
Another consideration is that if a man has severe ED, you can also do a surgery to fix both ED and the Peyronie's. And that's usually done by implanting a penile prosthesis, which in and of itself will straighten out some of the curve. Then you can also do some additional steps to get the penis straighter than that.
The patients who prefer surgery are going to be the ones who are in that stable phase—we're not expecting them to get any worse—and then patients who want to be as close as possible to having a straight penis, patients who want a faster, more reliable result, and then people who have that volume loss or indentation. Then, also, people who need a prosthesis anyway, because their erections aren't going to be rigid enough for intercourse even if you were able to fix that curve.
Other than prostheses, what does surgery typically involve for Peyronie's?
It depends. There's one type where you essentially just put some stitches on the side of the penis that is longer, that doesn't have the scarring. You sort of pull it in the opposite direction. That's called plication.
There's another type of surgery where you sort of cut the scar tissue, and then sometimes, if you need to, you can put a little graft on top of it. Both of those have their pluses and minuses.
With the plication, you have the possibility of losing a little length, but you don't really affect the person's erection hardness. But with the grafting, you can get back a little bit of length, or at least restore to the side that's not curved, but you then have a risk of having worse erection hardness. So there are pluses and minuses for each approach.
Generally speaking, how much can treatments like injections and surgery and traction help? What should people expect and not expect from this?
I think a lot of people come in hoping that we can get them back exactly to how they were before. And it is important to know that none of these treatments will get you back exactly where you were before having Peyronie's disease. And that's just, unfortunately, the nature of the condition and the nature of the treatments that we have available. But what we can do is help to get back a fulfilling and satisfying sexual experience.
I think that the patients who benefit the most from treatment are going to be people who have realistic goals in mind. Our goal is to get it to where people can have functional erections, so erections that are hard enough for penetrative intercourse, if that's what they choose.
Will it look exactly like it was before? That's probably unlikely. Some people do have that result, but that's never something that we promise. But if the goal is getting back to feeling more confident about yourself, being able to have the type of intercourse that is satisfying to you, absolutely, those things we can help with.