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Understanding Peyronie's Disease
A Treatment Guide for Curvature of the Penis
By Laurence A. Levine, Kristen W. Marzejon, Jack Kusler
Addicus Books, Inc.Copyright © 2007 Laurence A. Levine, M.D.
All rights reserved.
Defining Peyronie's Disease
Whether you have already been diagnosed with Peyronie's disease (PD) or think you might have it, you know that the disorder can take a physical and emotional toll. Since the disease affects a very personal and sensitive part of your body — the penis — you may find it difficult to or embarrassing to seek help from your primary care physician or a urologist. As a result, you may, like many other men, suffer in silence and never get a clear understanding of the disease.
Getting accurate information about Peyronie's disease and how it can affect you physically, psychologically, and sexually is the first step to improving your situation. And knowing where to go for help can lead you to the road to recovery.
1. How did Peyronie's disease get its name?
Peyronie's disease was named after François Gigot de la Peyronie, who held the title of First Surgeon to King Louis XIV of France and first wrote about the ailment in 1743. In his classic paper to the medical community, de la Peyronie reported on three men who had an unusual scarring of the penis, which caused deformity. He described the use of special waters coming from a renowned spa in the French town of Barèges to remedy this scar formation; his belief that the disorder was caused by sexually transmitted disease was inaccurate.
2. What is the medical definition of Peyronie's disease?
Peyronie's disease is considered "a wound-healing disorder." This means that injury or damage to the penile tissues, particularly within the outer penile tissues, activates a scarring process that goes well beyond the normal scarring process.
This excessive scarring can cause painful erections, a curvature of the erect penis, and other penile deformities. In some cases, these symptoms can make it difficult, or even impossible, to engage in sexual intercourse.
3. What are the symptoms of Peyronie's Disease?
Not every man will have the same onset of symptoms. The PD may develop slowly over time, or the symptoms may develop rapidly. Symptoms may include:
Hardened scar tissue in the penis
Pain during erections
Curvature or bend in the penis when erect
Narrowing of the diameter of the penis when erect
Shortening of the erect penis
The scarring may occur on the top or bottom of the penis; it can also occur on both sides of the penis.
4. What kind of penile deformities does Peyronie's disease cause?
There are a variety of penile deformities that can occur as a result of Peyronie's disease, including curvature, indentation, narrowing, hinging, hourglass deformity, and loss of length. The length, location, and orientation of the scar may have an effect on the type of deformity that occurs.
Penile curvature is the most common deformity and most often occurs in an upward direction. However, curvature can also occur in a downward direction or in a lateral direction, meaning the penis curves to one side or the other. Curvature can range from mild to severe. Indentation can occur anywhere on the penis and may lead to narrowing, which means that the shaft loses some of its diameter.
When indentations are severe, it can lead to hinging, in which the penis buckles or folds at the point of the indentation. Hinging can also occur when the penis takes on the shape of an hourglass due to a narrowing of the shaft. In this case, the penis will tend to fold or buckle in the narrowed area; this is known as an hourglass deformity. Shortening is a common problem and can be the most devastating emotionally. The shortening is typically in the one- to two-inch range, but some men may experience as much as four inches of shortening.
5. Do all patients with Peyronie's disease end up with the same deformity and side effects?
No. The way Peyronie's disease affects each man is highly individual. For instance, some men will develop a large scar but will have very little curvature; others will have what would seem to be very little scar tissue but will have severe curvature with indentation. In addition, up to 30 percent will develop calcification or bone in their scar. Shortening of the penis is common, and the loss of length tends to be due to the extent of scar tissue throughout the shaft of the penis. This is again reflective of the individual nature and behavior of the scarring process. There is also individual variability as to how rapidly the deformity develops as well as how long it takes for the scar to stop growing.
6. What is a Peyronie's plaque?
The scar that forms as a result of this wound-healing disorder is called a plaque. This is actually a misnomer, or an incorrect term. Plaque is commonly associated with coronary heart disease and is a mixture of fatty substances, cholesterol, and other substances that become deposited in the inner lining of the arteries. You may worry that having a Peyronie's plaque means you may be at higher risk for having or developing heart disease, but those worries are unfounded. The Peyronie's scar does not contain the same components as cholesterol-containing plaque. In fact, analysis of the Peyronie's tissue shows that it is basically a scar. For the purposes of this book, the terms scar and plaque will be used interchangeably.
7. How does the scar cause penile curvature?
Scar tissue that develops on the top of the penis will cause the penis to bend upward. Scarring on the underside of the penis will cause it to bend downward. To better understand this, consider this balloon analogy. If you place a piece of tape on top of the mid -portion of a balloon and then inflate it, the balloon will expand but not in the area that's taped. This results in an upward curvature in the balloon. This is what happens to the penis when excessive scar tissue is present. During an erection, the penis expands except where the scar tissue is located, resulting in curvature or other deformities.
8. What is the scar made of?
The plaque/scar of Peyronie's disease is in essence like any other scar and has multiple components. The two main components of a typical scar are the proteins collagen and elastin, the latter of which provides elasticity to tissues. A Peyronie's plaque is also made up of collagen and elastin, however, there is a much greater abundance of collagen than in a typical scar. In addition, both the collagen and elastin in a Peyronie's plaque are disordered, meaning that they do not behave the way they normally would in a typical scar.
Another component that is found in typical scars is collagenase, an enzyme that is released at the end of the normal scar-formation process. It breaks down the scar and remodels it down to the smallest possible piece of scar that will hold the tissues together. In the Peyronie's plaque, there is a low or nonexistent level of collagenase, which may explain why the plaque does not go away with time.
9. Does the size of the plaque affect the degree of deformity?
The size of the plaque does not necessarily correlate to the severity of the deformity. In fact, some men have large plaques but very little curvature. These men may experience loss of shaft length though. Other men who have smaller plaques may have more pronounced curvature. Some experts believe that they can predict the curvature by the length of the plaque. However, this rarely works, as men with extensive plaques on one side of the penis may also have involvement on the opposite side, which may result in counterbalancing the tethering effect of the plaque and thereby reducing the amount of curvature.
10. What kind of changes in the scar can I expect to see with time?
The scar can change in many ways, depending on the individual. It may thicken and spread, it may remain the same size, or in some cases, it may actually get smaller. It is not uncommon to find men who have mild Peyronie's disease who initially reported a nodule in the penis that gradually changed into a long, narrow cord extending sometimes from the head of the penis down into the base. This cord-like thickening process may be an indication of enlargement of the penile septum, which is the wall between the two erectile cylinders within the penis. The septum is where the bulk of the pressure is directed during sex. As a result of intercourse, gradual thickening of the septum can occur. Thickening of the septum may also occur as a result of the aging process. In the susceptible man, trauma during intercourse may trigger more aggressive Peyronie's disease with a new lump and further deformity.
Studies have suggested that during the active phase, 50 percent of patients will have worsening of their deformity, around 40 percent will stay the same, and less than 10 percent will have spontaneous resolution of curvature.
11. Do some men develop bone within their plaques?
Reports suggest that anywhere from 12 to 30 percent of men with Peyronie's disease will have varying amounts of calcification within their plaques. Most commonly, it is a stippled or spotty area in which small bits of calcification are scattered around rather than a solid area. However, in some men, the plaque can form a sizable, irregularly shaped solid bone that can be easily felt through the skin as a hard unbendable structure. This process is known as dysmorphic calcification, indicating that it is an abnormal type of bone formation. Currently, researchers believe that this is a variant form of Peyronie's disease since very few men develop the most severe forms of calcification.
12. Is it normal to feel pain from Peyronie's disease?
It's common for pain to be present shortly after an injury to the penis or during the very early stages of Peyronie's disease. During this time, the penis may be painful to the touch, erections may be painful, and attempting intercourse may be painful. The pain associated with Peyronie's disease is due to the inflammation and swelling that occurs within the tissues. This aggravates the pain receptors within the nerves of the penis. Stretching the penis, which occurs with erection, or placing any pressure on the erect penis, can activate the nerves and cause pain. The pain almost always goes away completely within several weeks to a few months.
The simplest treatment to ease the pain associated with Peyronie's disease is to take over-the-counter, nonsteroidal anti-inflammatory medications, such as ibuprofen and naproxen. In rare cases when pain is severe, your physician may give you a prescription for narcotic pain relievers, commonly known as painkillers. Prescription pain pills may be habit-forming and are associated with certain side effects, including drowsiness and a loss of mental alertness. On the other hand, painkillers may be used less frequently and cause less harm to the stomach lining than ibuprofen and naproxen.
There are additional treatments available for pain. Two types of treatment will be covered later in this book; they are injection therapy, in which drugs are injected into the scar tissue, and electromotive drug administration (EMDA), in which electricity is used to deliver drugs through the skin to the scar tissue. These treatments may diminish the local inflammation that causes the pain.
Studies have shown that these treatments can rapidly and permanently resolve the pain. There is also some evidence that pain resolution can be accelerated with shockwave therapy. This is a noninvasive therapy that directs a shock-wave, typically generated by a spark plug, to pass through the skin and focus on the plaque within the penis. However, shock-wave therapy can be expensive and it's probably best to use less costly treatments if you're simply trying to treat pain.
13. What causes Peyronie's disease?
To date, there are no clear-cut answers. However, it has been recognized for some time that Peyronie's disease tends to run in families, suggesting a familial association. There is also likely some underlying genetic abnormality that predisposes a man to be unable to heal injuries to the penis in a normal fashion. In the past, it was thought that Peyronie's disease might be caused by an autoimmune disease or by an infection, but these causes have not been confirmed. Likewise, at this time, it appears that PD does not occur due to the use of any medications.
In the past decade, there has been increased interest among researchers worldwide to try to understand what causes PD. Thanks to this increased interest, we should gain a better understanding of what is responsible for this penile scar formation.
14. How does Peyronie's disease develop?
Peyronie's disease typically develops in two stages: acute and stable. During the acute phase, which typically follows injury or trauma to the penis, it's common to experience a sensation of pain in the penis. The pain may be felt anywhere within the penis, but is often felt in the head, or glans, of the penis. You may feel pain when touching the penis or with an erection. The pain may worsen when attempting penetration during sexual activity. During this stage, you may notice a palpable lump or nodule on the penis but may not have any curvature. Either at this time or shortly thereafter, depending upon the aggressiveness of the plaque formation, the deformity occurs with curvature, shortening, and/or indentation. Once the pain subsides and the deformity stops changing for a period of time, the disease is considered to be in the stable stage.
There have been very few studies on the natural history of PD, meaning what happens if you do nothing to have the disorder treated. As mentioned earlier, it is believed that it will dissipate in about 10 percent of men; however, if the deformity completely resolves with disappearance of the scar tissue, it is unlikely that it was Peyronie's disease and was probably just a slow-healing wound within the penis. For the most part, if curvature is to improve spontaneously, it tends to occur within the first one to two years from the onset of the disease.
15. Does Peyronie's disease tend to develop suddenly or gradually?
The deforming process is most often gradual and can take months to develop. However, there is no routine time frame for the development of Peyronie's disease, and in some cases, the deforming process can happen very quickly, as in a matter of weeks. In some men, the scarring process can be so aggressive that it would seem the deformity occurs "overnight.". The majority of men will initially experience pain and a palpable nodule followed sometime later by curvature or some other penile deformity. The disease stabilizes anywhere from one to eighteen months after the curvature is noted.
16. If Peyronie's disease develops quickly, does that mean that the curvature will be more severe?
It is not necessarily the case that if you experience sudden and aggressive scarring that you will end up with a severely deformed penis. In fact, the rate at which Peyronie's disease develops does not appear to have much effect on the severity of the deformity.
17. When do I know that the deformity associated with Peyronie's disease has stopped progressing?
You will know that the Peyronie's process has stabilized and that it is unlikely that the deformity will get worse when there is no pain with the development of an erection and when the plaque and deformity have not changed for at least four to six months. These time periods have not been universally agreed upon and have been mostly based upon physician experience and the published literature in the medical journals. In some men, stabilization can be reached within several months, but in others, it may take up to eighteen months from the time of onset.
18. Can I develop Peyronie's disease without ever having injured my penis?
The current medical thinking is that Peyronie's disease does result from an injury to the penis. It is not known scientifically whether it may develop without an injury. The injury may occur to either an erect or flaccid penis.
Note: Up to 60 percent of the men I see in my practice are not aware of any injury that may have activated the Peyronie's disease. The other 40 percent recall that following the injury there was a period of pain, a palpable lump, and then deformity.
19. Can Peyronie's disease occur later ... perhaps a year after injury to the penis?
The straightforward answer to this question is "Yes." That is because it may be that the initial injury may not have actually triggered the Peyronie's, but a subsequent silent injury may have set the abnormal scarring process in motion.
Excerpted from Understanding Peyronie's Disease by Laurence A. Levine, Kristen W. Marzejon, Jack Kusler. Copyright © 2007 Laurence A. Levine, M.D.. Excerpted by permission of Addicus Books, Inc..
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
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Table of Contents
Part I Peyronie's Disease: An Overview,
1 Defining Peyronie's Disease,
2 Evaluation of Peyronie's Disease,
3 Peyronie's Disease and Sexual Function,
Part II Nonsurgical Treatment,
4 Oral Medications,
5 Topical Treatments,
6 Injection Therapy,
7 Stretching Therapy,
8 Combination Therapy,
Part III Surgical Treatment,
9 Plication Procedures,
10 Surgical Grafting,
11 Prosthesis Implantation,
12 Common Questions about Surgical Procedures,
About the Author,