West Coast Urology  –  Geelong   |   Hamilton    |   Colac   |   Winchelsea

A. PROF RICHARD GRILLS

DR KATHRYN MCLEOD

MR PATRICK PREECE

Urological Surgeons

Penile Curvature & Peyronie’s Disease

To download a PDF with information about ‘Penile Curvature and Peyronie’s disease’ please click:

  • It is named after Francois de la Peyronie’s who first described the condition in 1743.
  • It is a scarring condition that causes ‘plaques’ to form in the erectile chambers of the penis, making sexual intercourse difficult.
  • It affects 2-10% of men, typically between the ages of 40-60 (although it can occur at any age).
  • To varying degrees, these plaques can cause:
    • Penile curvature with erections
    • Penile shortening or deformity
    • Erectile dysfunction
    • Pain

 

  • The plaques and associated symptoms tend to evolve over a 6-month period or so (the ‘acute’ phase), before stabilising (the ‘chronic’ phase). Any pain that occurs in the early stages usually dissipates over time.
  • The exact cause of the plaques is uncertain, but may relate to repetitive microtrauma, and is associated with certain connective tissue disorders such as Dupytren’s contractures (a similar scarring process of the hands).

 

  • Risk factors for Peyronie’s disease include:
    • Diabetes and vascular disease risk factors
      • smoking, high cholesterol, high blood pressure, obesity
    • Family history
    • Penile trauma
    • History of pelvic surgery
      • Including radical prostatectomy (prostate cancer surgery), where plaques have been shown to develop in up to 10% of men

 

  • Very often however, Peyronie’s disease develops in men with no identifiable risk factors.
  • Unfortunately, Peyronie’s disease is an irreversible condition. No treatment can get rid of the scar tissue. Treatments aim to improve sexual function and any deformity.
  • Treatment is bespoke as it depends on the combination of bothersome symptoms that affect each patient (erectile dysfunction, curvature, deformity, shortening).


Do nothing

  • If erections remain strong, and the penile curvature does not interfere with the ability to have penetrative sex, the best solution for most men is to leave things be!


Medications

  • Although many things have been tried, there is no good quality evidence to suggest that any particular medication can stop, slow or reverse plaque formation.
  • Anti-inflammatories and regular paracetamol are useful in the early stages of the disease which may be associated with pain around the plaque.
  • Sildenafil (Viagra) or tadalafil (Cialis) can assist in achieving stronger erections in men who experience mild to moderate erectile dysfunction due to Peyronie’s disease.


Traction therapy

  • Traction therapy devices forcibly stretch the plaque. With diligent usage (ideally worn for at least one hour every day over 6 months), these devices can improve penile curvature (perhaps by 10-20 degrees) and also increase penile length by modest amounts (1-2cm).
  • Unfortunately, most men find the devices cumbersome and hard to fit in around their day to day lives.
  • Various traction devices are available and can be sourced online.

 

 

 

 

 

 

 

 

 

Vacuum Erection Device (‘penis pump’)

  • Similar to traction therapy, vacuum erection devices (VED) mechanically draw out the plaque using negative pressure which causes forcible engorgement of the penis.
  • The penis is placed inside a cylinder with a good fitting seal around the base. A pump expels the air, generating negative pressure and pulling blood into the penis to create an erection of sorts.
  • The VED should be cycled for 10-20 minutes, morning and night for 6 months, with studies showing comparable results to traction therapy. Curvature may improve by 10-20 degrees and the penis lengthened by perhaps 0.5-1.5cm.

  • VEDs can be sourced online. Two commonly recommended are:
  • Some private health insurers’ ‘extras’ policies partially fund VEDs. Ask your fund.

 


 

 

 

 

 

 

  • Some men also use VED to manage erectile dysfunction. A constriction ring can be fitted onto the base of the penis to trap the blood and cause a sustained erection once the VED cylinder has been removed.


Other treatments NOT routinely recommended

Creams

  • There are no creams that have been shown to reliably improve Peyronie’s disease.


Shockwave therapy

  • Some studies suggest that shockwave (ultrasound) therapy can improve pain associated with Peyronie’s disease, but doesn’t affect curvature or penile deformity.


Injectable therapy

  • Injections into the plaque with an enzyme medication called collagenase (‘Xiaflex’) can soften it slowly over time. However, Xiaflex is no longer available in Australia.
  • Xiaflex results were comparable to traction therapy/ VED with an average improvement in curvature of 30% (10-20 degrees). Potential complications of xiaflex included bruising, pain and rupture of the penis (‘penile fracture’).
  • Other injectables have been used for Peyronies disease (e.g. ‘verapamil’) however, studies have not shown them to be any better than placebo in correcting curvature.

There are 3 possible surgical solutions your surgeon may recommend for treating Peyronie’s disease:

  • ‘Nesbit’ procedure (plication surgery)
  • ‘Lue’ operation (incision and grafting surgery)
  • Insertion of an inflatable penile prosthesis

 

‘NESBIT’ PROCEDURE

  • Peyronie’s disease typically results in the penis having a shorter (scarred) concave side and a longer convex side.
  • The Nesbit procedure removes a small section of the wall (‘tunica albuginea’) and stitching it closed on the longer convex side, which shortens it a little to match the concave side, pulling the penis straighter.
  • It is most effective in men who still have reasonably strong erections with a penile curvature less than 60 degrees.
  • The main downside of the procedure is it will cause a degree of penile shortening; it is otherwise a very successful and durable operation.
  • Risks of the surgery include:
    • Infection, bleeding, penile shortening, worsening erectile dysfunction (perhaps 10%), persistent or recurrent curvature, altered sensation, palpable sutures or scar on the penis

 

‘LUE’ PROCEDURE

  • For extreme penile curvature (>60 degrees or so) a Nesbit procedure usually results in an unacceptable degree of penile shortening. For men who have good strong erections, a Lue procedure is usually recommended instead.
  • The plaque in incised and stretched out to create a space in which a ‘patch’ is inserted (typically a strong bovine collagen product). This relaxes the scared area of the penis causing it to straighten.
  • It can be a challenging operation as often the plaque sits underneath a thin layer of nerves and blood vessels which has to be carefully lifted off. Damage to these nerves can result in temporary or permanent numbness of the penis.
  • Risks of the surgery:
    • Infection, bleeding, erectile dysfunction (20%), numbness, persistent or recurrent curvature, palpable sutures or scar on the penis.
    • Dissatisfaction rates with a Lue procedure are around 20-30%, as complication rates are significantly higher with the Lue procedure compared to the Nesbit procedure.
    • The Lue procedure is an operation best suited to men where a Nesbit procedure is unsuitable and a man wishes to avoid a penile prosthesis.

 

  • Although not essential, circumcision is recommended as part of a Nesbit or Lue procedure for uncircumcised men, as 20-30% of men will develop foreskin troubles afterwards, such as phimosis (a tight foreskin) or oedema (swelling of the foreskin).

 

INFLATABLE PENILE PROSTHESIS

  • The inflatable prosthesis allows for a reliable ‘on demand’ erection that will help straighten out penile curvature.
  • It is a device that consists of two inflatable cylinders surgically inserted into the shaft of the penis. The cylinders are connected to a ‘inflate/deflate’ pump that sits under the skin in the scrotum and a fluid filled reservoir hidden in the pelvis.
  • When the cylinders are empty, the penis hangs in a flaccid state. By pressing the scrotal pump, fluid is pushed from the reservoir to fill the cylinders and cause an erection. A deflate button allows the erection to go down, returning fluid to the reservoir.

Read more about inflatable penile prostheses here.

  • There are pros and cons to each surgical option. Your surgeon will take into account your personal situation before making any recommendation.
  • As a general rule though, the two main factors that guide Peyronie’s disease management are the strength of a man’s erections and the severity of his penile curvature/ associated deformity.

 

 

STRENGTH OF ERECTIONS

SEVERITY OF CURVATURE/ DEFORMITY

Good

(No need for Viagra etc)

Moderate

(Uses Viagra etc)

Poor

(Viagra etc ineffective)

< 60 degrees

Nesbit

Nesbit

Penile prosthesis

> 60 degrees or Wasting/ hinge defect

Lue or penile prosthesis

Penile prosthesis

Penile prosthesis

 

  • 7-10 days prior to surgery you will have routine blood tests.
  • Please ensure good genital and groin hygiene in the lead up to the procedure. It is important you notify your surgeon if you develop any rashes or infections (e.g. jock itch) prior to surgery.
  • You will be freshly shaved at the beginning of the surgery to minimise the risk of wound infection.


Medications to stop 

  • Notify your surgeon if you take any blood thinners, medications for diabetes or medicationsthat weaken your immune system as these may need to be withheld in the lead up to surgery.
  • A Nesbit procedure typically takes 60-90 minutes whilst a Lue procedure takes up to 3 hours.
  • Both surgeries are normally performed through a circumcision type incision with the penile skin pulled down to expose the shaft of the penis. 
  • For uncircumcised men, your surgeon will clarify beforehand whether you wish to have a circumcision as part of the operation to minimise the risk of foreskin complications afterwards.
  • An artificial erection is created during the surgery to accurately evaluate the curvature as well assess the ‘end result’.
  • The penis is firmly bandaged and a catheter is sometimes left in overnight to drain urine.
  • The procedure can be performed as day stay or overnight surgery.

Wound care

  • All the stitches are dissolvable.
  • Any bandages and dressings on the penis can be removed after 48 hours.
  • Keep the wounds clean and dry for 48 hours after surgery. You can then shower as normal, but ensure the wound is dry afterwards (pat dry with a towel or use a hair dryer)
    • Avoid baths or long showers which may macerate or ‘soften’ the skin around the wound

Recovery

  • It is advisable to take a week off work.
  • Swelling, bruising and pain can last for several weeks.
  • It will take up to 6 weeks before complete healing occurs.
  • Constipation is common following surgery and is often exacerbated by the use of strong pain medication. To prevent/ treat constipation, maintain good fluid intake, high fibre foods and use laxatives as required.

Exercise and activity

  • Avoid any strenuous activity (including sex) for 4-6 weeks.
  • Patients are reviewed at the 6-week mark to assess the quality of their erections.

Driving

  • It is safe to resume driving only when you are off all pain medications, are moving around freely.

Medications

  • When you leave hospital you will be given:
    • Pain relief medication
    • Laxatives to prevent constipation

Follow up appointment

  • You will reviewed in the rooms 6 weeks after surgery to assess the quality of your erections.


If you did not receive an appointment when leaving hospital, please contact reception staff at West Coast Urology to make one.

  • Contact the rooms of your surgeon if you notice any of the following during the recovery period:
    • Worrisome bruising or bleeding
    • Fever
    • Worsening pain, increased swelling, redness or purulent wound discharge
    • The wound opening up
    • Difficulties with urination