Peyronie’s disease and treatments
The Birmingham Prostate Clinic specialises in Peyronie’s disease treatment. Peyronie’s disease is a condition which affects the penis, usually causing painful erections, lumps in the penis and a bend in the erection.
Although it can be progressive, it is not a malignant (cancerous) condition and it is not life-threatening.
What causes Peyronie’s disease?
The cause is not known for certain. A likely explanation is that it is an unusual reaction to injury to the penis, although most men with Peyronie’s do not recall having a specific injury. However the penis is subjected to varying degrees of stress and strain during penetrative sexual activity, and these relatively small injuries may result in some men developing the disease.
Who gets Peyronie’s disease?
The disease affects approximately one man in every hundred, perhaps even more. It is commoner in older men, but all ages can be affected. There is an association between Peyronie’s disease and the hand condition Duypetren’s contracture, which causes one or more fingers to bend into the palm. About one in ten men with Duypetren’s contracture have Peyronie’s. However no-one knows why some men get Peyronie’s disease and others don’t; it appears to be a matter of chance.
What happens in the disease?
Not every case of Peyronie’s disease is the same, but men usually first complain of painful erections or a bend in the erection, or both. Sometimes they notice lumps in the shaft of the penis, although these lumps may not be obvious initially. The symptoms may come on suddenly or slowly.
The symptoms usually get worse over a few months, but then stop progressing. The time course is very variable, but in most cases the disease stops progressing after 6 to 18 months. In a few unfortunate cases the disease continues to progress relentlessly, but this is rare.
When the disease stops progressing, the erections cease to be painful. The lumps in the penis may become harder and more obvious, and the bend in the erection stops getting worse. Sometimes the bend actually improves, although unfortunately this is unusual.
What causes the bend?
The penis is made up for the most part of two big bundles of blood channels (or sinusoids) called the corpora cavernosa, or more simply known as the erectile tissue. These run along the whole length of the penis and on the inside have the appearance of a very fine honeycomb. At rest, when the penis is flaccid, they are empty. When a man gets an erection, large amounts of blood flow into the erectile tissue, filling the blood channels which increases the penile size and gives the penis its rigidity.
In Peyronie’s disease the fibrous lumps block part of the erectile tissue, preventing the affected area from expanding. The rest of the penis is free to expand, so the erection becomes bent, with the lump at the apex of the bend.
More often than not the lumps are on the top surface of the penis, so the bend is usually in an upwards direction, towards the stomach; but it may be sideways or downwards.
Does Peyronie’s disease cause impotence?
Impotence is the lack of rigid erections, or the inability to maintain a rigid erection. Men with Peyronie’s disease are perhaps more likely to have less rigid erections although the association is not completely clear cut. Impotence and Peyronie’s disease are both conditions which are more common in older men, so any associated impotence may be simply be part of the aging process. Additionally, impotence may be psychological, particularly if the erection is painful, or if intercourse is difficult or impossible because of the bend. Sometimes, however, the amount of fibrosis in the penis is so great that no blood can get past the fibrotic area to the tip of the penis. In these cases the base of the penis may be rigid, but the tip is floppy.
How is Peyronie’s disease treated?
Unfortunately there is no guaranteed cure for Peyronie’s disease. Lots of treatments have been tried, but none of them have been proven in controlled trials to be successful. This means that for most people in the initial stages of the disease, it is simply a matter of waiting for the disease to stop progressing after about 6 to 18 months.
Once the disease has stopped progressing, it is perfectly possible to operate to straighten the erection, should that be necessary. The operations are discussed below.
Over the years a multitude of drugs have been tried in an attempt to cure Peyronie’s disease, or at least minimise the amount of deformity the disease causes. Many men wish to try these various drugs in the hope they may get some benefit, but in most cases treatment doesn’t work. The most popular is Vitamin E, which is readily available from chemists and health food shops, and some prescription drugs are reported as being helpful but none has been proved to be of definite benefit in clinical trials.
ESWT (Extra-corporeal Shock Wave Treatment)
ESWT has gained some popularity in recent years, but like drug treatment, has never been proven to be effective. The technology used is the same as is used to shatter kidney stones (lithotripsy). Multiple shock waves are fired at the lumps within the penis, breaking them up. Three treatments are usually given over a period of a few weeks. ESWT seems to be most beneficial to men who have a lot of pain with their erections but the effect on the bend is less impressive. Recently there has been some concern that in some cases the treatment actually makes the disease worse.
Operations for Peyronie’s disease
Who needs an operation, and when should it be performed?
The only reason to operate is to straighten the erection. Only men whose erection is so bent that they can’t have satisfactory sexual activity should undergo surgery. Surgery won’t improve potency (unless a prosthesis is inserted, see below), and it won’t remove penile lumps.
Surgery should not be performed until the disease is stable. This means that the pain has gone and that the bend has not got worse for at least three months.
What operations are available?
There are three principle operations for Peyronie’s disease, the Nesbit procedure, the Lue procedure, and in the most severe cases, insertion of a penile prosthesis.
The Nesbit procedure
Nesbit’s operation is the easiest and most straightforward operation to perform for Peyronie’s disease, but it has one major drawback, it causes shortening of the erection. Shortening is approximately 1cm per 30 degree bend of the penis. However, providing men are thoroughly assessed and this drawback is discussed, it is rarely a major problem after surgery.
For the majority of men, the Nesbit procedure is the best choice. The principle of the operation is to remove some tissue from the long side of the bent penis, thereby shortening the long side of the bend and straightening the erection.
The operation is performed under general anaesthetic and takes 40 to 60 minutes. The incision is made near the end of the penis, all the way around the shaft, a few millimetres from the glans. The skin of the penile shaft is rolled back and the long side of the corpora cavernosa is shortened, either by removing some tissue or simply with internal stitches. At the end of the operation, the foreskin is usually shortened to match the length of the penis, although many surgeons prefer to perform a full circumcision which seems to heal with fewer problems. As with any operation, wound infection can be a problem and the foreskin, if left behind, can become very swollen after surgery. Otherwise complications are rare and men usually go home the day after surgery, or even the same day.
The Lue procedure
The Lue procedure does the opposite of the Nesbit’s; it makes the short side of the bend longer. In theory at least, this maintains the length of the erection, but the operation is a lot harder to perform and has a higher risk of complications. Shortening of the erection can still occur, the risk of impotence after surgery is greater that with Nesbit’s operation and there is a risk of damaging the delicate nerves which go to the end of the penis, resulting in the glans of the penis being numb.
The Lue procedure is performed through the same incision as the Nesbit’s operation, and again it is often preferable to perform a circumcision at the same time. A cut is made in the short side of the bend to allow it to be lengthened. However, as the bend is usually in an upward direction the nerve supply to the tip of the penis, which runs along the corpora cavernosa at the very site where the cut needs to be made, has to be moved out the way.
This delicate manoeuvre can take up to an hour. Once it has been done, a cut is made in the corpora cavernosa and a graft or patch is inserted to increase the length of the penis on the short side. The graft can either be a piece of artificial material or a segment of the patients own vein, taken from his thigh. The whole procedure takes over two hours, patients are in hospital for at least 24 hours after surgery and may have a bladder catheter inserted for the first few hours.
Penile prosthesis insertion
Penile implant surgery is only used when Peyronie’s disease is associated with very severe impotence, which can’t be treated by other means such as drugs. The operation has many drawbacks, but can restore satisfactory erections in selected cases. It should be considered as a last resort.
Why can’t the lumps be removed?
Removing the fibrotic lumps from the penis leaves a defect (a hole) in the erectile tissue which can’t be repaired, resulting in a very high risk of impotence.
Which is the best operation?
Most men will be best served with a Nesbit’s operation, but if the bend in the erection is severe or if the penis is relatively short to start with then a Lue procedure may be best. There are no hard and fast rules, and each case should be considered individually. The best way to do this is to give an injection of a drug into the penis in clinic to produce an artificial erection.
Can Peyronie’s disease recur after surgery?
It is rare for the disease to recur or progress after it has initially stabilised, but occasionally it does so. Very occasionally, a second operation is needed to deal with a further penile bend.
- Peyronies disease causes lumps in the penis, a bend in the erection and often painful erections.
- We don’t know what causes it.
- The disease usually progresses over a period of several months, then stops getting worse. The pain settles, but the lumps and the bend remain.
- No drug or treatment has been shown to reliably reverse this process.
- Once the disease has stopped progressing the bend in the erection can be straightened by surgery. There are, however, risks of side effects and complications from surgery.
This information was written by Mr Mike Foster, a Birmingham Prostate Clinic consultant urologist specialising in Peyronie’s disease treatment. Mr Foster sees 50 new patients with Peyronie’s disease every year, with referrals from throughout the Midlands.