What are the treatment options for Peyronie’s Disease?
Medical treatment is aimed at reducing pain and the progression of Peyronie’s Disease and it is not very effective.
The use of PDE5i may represent the only effective medical treatment as they prevent the deposition of scar tissue at the level of the plaque. Furthermore, PDE5i promote the regular stretching of the plaque and may minimize the degree of contracture and shortening.
Although spontaneous reduction of the deformity secondary to Peyronie’s Disease can occur, it is relatively rare.
Treatment should be offered only once Peyronie’s Disease has stabilized and only if penile shortening and/or the quality of the erection render penetrative sexual intercourse difficult or impossible.
Patients need to be aware that the aim of surgery is to guarantee a penis straight and stiff enough to allow resuming comfortable penetrative sex.
While in the past surgery was the only effective treatment for Peyronie’s Disease, now patients can benefit also from injections of Collagenase of the Clostridium Histolyticum directly into the plaque.
Vacuum pump and penile stretching device used in isolation are instead ineffective and may have a role only in combination with surgery and/or injections.
Injections can be beneficial in a selected group of patients that present with a dorsal and dorsolateral curvature and it is not licenced for ventral curvatures due to the risk of urethral injury. The injections “chemically” softens the plaque and in combination with regular modelling and penile stretching can help to restore part of the length lost due to the scarring process and correct the curvature.
One injection should be performed every 4 weeks and the deformity should be reassessed after 3 injections. If significant deformity persists, more injections cycles can be performed.
Usually patients require just 3 injections to achieve adequate results. In general, a cycle of 3 injections usually leads to an average reduction of the curvature of around 30 to 50%. Patients need to be aware that treatment will not produce a perfectly straight penis but will downgrade the deformity.
In particular, a patient with 60 degrees of dorsal curvature should expect a reduction in curvature of up to 30 degrees, leaving a residual curvature of around 30 degrees, which is compatible with comfortable penetrative sexual activity. As a common rule, patients with soft/non-calcified plaques can expect to achieve a more significant reduction of the curvature.
Injections are a very simple and safe office based procedure and side effects are very minor and usually solve spontaneously in a few days.
Surgery represents the best treatment option for patients with Peyronie’s Disease. Patients need to be fully counselled that the aim of surgery is to guarantee a penis straight and hard enough to allow the patient to resume penetrative sexual intercourse with confidence. Unfortunately surgery will never be able to bring back the same size and shape of penis that the patient had before developing Peyronie’s Disease.
The type of surgical approach depends on the characteristics of the curvature, on the degree of shortening and on the quality of erections.
If the erections are well preserved, according to the degree of the curvature, patients can be offered either plication (=shortening) of the longer side of the penis, which has not been affected by Peyronie’s Disease, or plaque incision and grafting (=lengthening) of the shorter side (the one affected by Peyronie’s Disease). Both procedures can be performed as a day case and the patient is usually able to resume sexual activity 6 weeks postoperatively.
Plication (shortening) of the longer side of the shaft can be achieved with various techniques. The most commonly used are the Nesbit and Yachia plication, the 16 and 24 dot technique and the tunica albuginea plication (TAP).
All plication techniques do not involve the use of grafts and therefore are not associated with worsening of the quality of the erections postoperatively.
The main disadvantage of plication techniques is that they produce further penile shortening and that they are not suitable for the correction of hourglass deformities. As a common rule, patient can expect to loose 1 cm of length for each 30 degrees of curvature corrected and as a consequence plication techniques are contraindicated in presence of severe shortening, curvatures of more than 60 degrees.
Plaque incision and grafting represent a very reliable procedure, although it is quite more complex than plication surgery. This technique is indicated in patients with complex curvatures and narrowing or with significant penile shortening and with preserved erectile function.
The main risk associated with plaque incision and grafting procedures is around 15% of patients may experience some worsening of the quality of the erection postoperatively and therefore patients with a pre-existent degree of erectile dysfunction should be strongly discouraged to undergo this procedure as they are likely to become completely impotent.
Postoperative rehabilitation in these patients is paramount to minimize shortening and to reduce the risk of recurrence of the curvature.
Postoperative rehabilitation entails stretching the graft either by encouraging the natural erections with the administration of PDE5i or by stretching the penis either manually or with the use of a stretching device.
Patients with erectile dysfunction that does not respond to medical treatment or with a degree of erectile dysfunction and a complex deformity and/or severe shortening of the penis should instead be offered penile prosthesis implantation and penile straightening.
Both semirigid (malleable) and inflatable penile prosthesis can be used in patients with Peyronie’s disease and erectile dysfunction with very satisfactory results. In particular, up to 95% of patients and partners are satisfied after penile prosthesis implantation. Penile prosthesis implantation guarantees the rigidity necessary to engage in penetrative sexual activity and allows the correction of the curvature in almost all cases. If a penile curvature persists following implantation of the prosthesis, additional straightening manoeuvres may be required to guarantee an adequate curvature correction.
A very limited number of patients with very complex deformity or with large and calcified plaques may require plaque excision and grafting in combination with penile prosthesis implantation.
As previously discussed in case of plaque incision and grafting and plication procedures, even patients undergoing penile prosthesis implantation need to be thoroughly counselled preoperatively as they need to have realistic expectations. Patients need to be aware that the aim of penile prosthesis implantation is to guarantee a penis straight and hard enough for penetrative sexual intercourse and that the procedure will not restore the length lost due to Peyronie’s Disease and the long standing erectile dysfunction.
Penile length and girth restoration procedures involve the elongation and expansion of the corpora cavernosa with the use of a circumferential graft or performing multiple relaxing tunical incisions simultaneously with the implantation of a penile prosthesis. These procedures are quite complex and are associated with an increased risk of complications and therefore should be offered only to patients who have experienced significant loss of length.
Why Choose Giulio
Giulio is a veteran surgeon with 15 years of experience in the field of Andrology and Reconstruction. He is also one of the largest penile prosthesis implanters in Europe, as well as the surgeon who performs the largest number of procedures for the correction of complex cases of Peyronie's disease. He has been invited to lecture and perform surgery in 21 different countries, in 6 different continents.
Penile prosthesis implants last year
Complex Andrological procedures every year
Phalloplasties over his career