Residency · Residency · Urology

Peyronie Disease: Evaluation and Treatment

Definition and Epidemiology

Peyronie disease (PD) is an acquired fibrotic disorder affecting the tunica albuginea of the penis, which leads to the formation of penile plaques, curvature, and frequently erectile dysfunction. It affects approximately 3-9% of adult men, although this prevalence is likely underestimated due to underreporting. The condition most commonly presents between the ages of 50 and 60 years. PD is often associated with other fibrotic conditions such as Dupuytren contracture, seen in 15-20% of patients, as well as plantar fibromatosis (Ledderhose disease). Additional risk factors include diabetes mellitus, hypertension, and a history of penile trauma or surgery.

Pathophysiology

The pathogenesis of Peyronie disease begins with repetitive microvascular trauma to the tunica albuginea during sexual intercourse. In genetically predisposed individuals, this trauma triggers an abnormal wound healing response characterized by excessive deposition of type III collagen and fibrin. Transforming growth factor-beta (TGF-beta) promotes fibroblast proliferation and myofibroblast activation, while matrix metalloproteinase (MMP) activity is decreased, leading to plaque formation that may calcify over time. This inelastic plaque restricts normal expansion of the tunica on the affected side, causing the penis to curve toward the plaque during erection. The direction of curvature depends on plaque location: ventral plaques cause dorsal curvature, dorsal plaques cause ventral curvature, and lateral plaques cause lateral curvature. A circumferential plaque can produce an hourglass deformity by creating an indentation.

Natural History

Acute (Active/Inflammatory) Phase

The acute phase of Peyronie disease typically lasts between 6 and 18 months. During this time, patients often experience penile pain with erections, which may also be present at rest. The curvature is progressive and changes as the plaque evolves. Approximately 12-15% of patients experience spontaneous improvement during this phase, but the majority either stabilize or worsen.

Chronic (Stable) Phase

In the chronic phase, pain usually resolves, and the curvature stabilizes, remaining unchanged for at least three months. The plaque may calcify during this stage. Erectile dysfunction can persist or worsen. Surgical intervention is generally considered only during this stable phase.

<image>Cross-sectional diagram of the penis showing tunica albuginea plaque formation in Peyronie disease with corresponding penile curvature during erection</image>

Evaluation

History

A thorough history should include the duration of symptoms and the rate at which they have progressed. It is important to determine whether pain is present or has resolved, and whether it occurs with erection or at rest. The degree and direction of curvature should be assessed, often through patient self-report or photographs. The impact on sexual function, including erectile dysfunction and difficulty with penetration, must be evaluated. Erectile function can be quantified using validated tools such as the International Index of Erectile Function (IIEF-5) or Sexual Health Inventory for Men (SHIM). Information about prior treatments and associated conditions like Dupuytren contracture or diabetes should also be obtained.

Physical Examination

Physical examination involves palpating the penile plaque to assess its location, size, consistency, and presence of calcification. Stretched penile length should be measured, and the examiner should look for concurrent Dupuytren contracture. Curvature cannot be accurately assessed without an erection.

Objective Curvature Assessment

The most practical method for assessing curvature is self-photography, where the patient takes pictures of the erect penis from above and the side. In-office erection testing involves intracavernosal injection of prostaglandin E1 (PGE1) to induce an erection, followed by measurement of curvature with a goniometer. Documentation should include the direction and degree of curvature, plaque location and size, and erectile function.

Penile Duplex Doppler Ultrasound

This imaging modality evaluates erectile function by measuring peak systolic velocity (PSV) and end-diastolic velocity (EDV). It also identifies plaque characteristics such as location, size, and calcification, which can assist in surgical planning. However, it is not required for all patients and is mainly reserved for those being considered for surgery.

Questionnaires

Validated questionnaires such as the IIEF-5/SHIM assess erectile function, while the Peyronie Disease Questionnaire (PDQ) provides a disease-specific evaluation of symptom bother, psychological impact, and overall disease burden.

Non-Surgical Treatment

Oral Medications (Limited Evidence)

Several oral agents have been used to treat Peyronie disease, though evidence supporting their efficacy is limited. Pentoxifylline, administered at 400 mg three times daily, has anti-fibrotic properties by inhibiting TGF-beta and may reduce plaque size and calcification, but the evidence is weak. L-arginine, a nitric oxide precursor, has limited data supporting its use. Vitamin E is widely used despite randomized controlled trials showing no proven benefit. Colchicine, an anti-inflammatory agent, has limited evidence and is often limited by gastrointestinal side effects. Potaba (aminobenzoate potassium) has some evidence for plaque reduction but is expensive and frequently causes GI intolerance.

Intralesional Injection Therapy

Collagenase clostridium histolyticum (CCH, Xiaflex) is the only FDA-approved medical treatment for Peyronie disease. It works by enzymatically degrading collagen within the plaque. The treatment protocol involves up to four cycles, each consisting of two injections spaced 48 hours apart, followed by six weeks of penile modeling and stretching. Clinical trials (IMPRESS) demonstrated an average improvement of 17 degrees in curvature. Indications include stable disease with curvature between 30 and 90 degrees and a palpable plaque. Complications are rare but can be serious, including penile fracture or corporal rupture (~0.5%), hematoma, swelling, and pain. Although withdrawn from the US market in 2020 due to manufacturer decisions, it remains available in some other countries.

Other intralesional agents include verapamil, a calcium channel blocker with proposed anti-fibrotic effects, typically given as 10 mg injections every two weeks for 12 sessions; however, evidence is mixed. Interferon alpha-2b, also administered intralesionally every two weeks for 12 sessions, has shown some efficacy in improving curvature and reducing plaque size but can cause flu-like side effects.

Penile Traction Therapy

Penile traction devices apply external stretching forces and are worn daily for durations ranging from 30 minutes to 2-6 hours. This therapy may reduce curvature by 10-20 degrees and can increase penile length, counteracting shortening caused by the disease or surgery. Most evidence supports its use as an adjunct to other treatments such as collagenase injections or surgery. The American Urological Association (AUA) guidelines suggest offering traction therapy as adjunctive treatment. Patient compliance remains the primary challenge.

<image>Demonstration of penile traction device application and patient-directed penile modeling exercises used as adjunctive therapy in Peyronie disease management</image>

Surgical Treatment

Indications

Surgery is indicated in patients with stable disease, defined as at least three months without pain or changes in curvature, whose penile deformity prevents satisfactory intercourse and who remain dissatisfied after an adequate trial of non-surgical therapies. The decision to proceed with surgery should be made collaboratively with the patient.

Surgical Options Based on Curvature and Erectile Function

Plication Procedures (For curvature <60-70 degrees with adequate erections)

Plication procedures involve shortening the tunica albuginea on the convex side opposite the plaque to straighten the penis. The Nesbit procedure excises an elliptical segment of tunica on the convex side, closing the defect to match the concave side. Tunical plication techniques, such as the 16-dot or Tunica Albuginea Plication (TAP) procedures, use sutures without excision. Variations include the Yachia technique, which involves a longitudinal incision closed transversely, and the modified Nesbit, which uses plication sutures. These procedures are simpler, carry a lower risk of erectile dysfunction, and avoid grafting. However, they cause penile shortening proportional to the degree of curvature and may result in palpable suture knots. Success rates for curvature correction range from 80-95%. Plication is best suited for patients with good erectile function, moderate curvature under 60-70 degrees, and no complex deformities.

Plaque Incision/Excision and Grafting (For curvature >60-70 degrees with adequate erections)

For more severe curvature, plaque incision or partial excision on the concave side is performed, followed by placement of a graft to cover the defect. Graft materials include autologous tissues such as saphenous vein, dermis, tunica vaginalis, or buccal mucosa; allografts like small intestinal submucosa (SIS/Surgisis), pericardium (Tutoplast), or cadaveric dermis (AlloDerm); and synthetic materials such as Gore-Tex, which are less commonly used due to higher risks of infection and extrusion. This approach corrects curvature with less penile shortening than plication but carries a higher risk of new-onset erectile dysfunction (10-20%), graft contraction, and numbness. It is best reserved for patients with good preoperative erectile function, severe curvature exceeding 60-70 degrees, hourglass deformities, or complex curvature patterns.

Penile Prosthesis (For PD with significant erectile dysfunction)

In patients with Peyronie disease and significant erectile dysfunction, implantation of an inflatable penile prosthesis (IPP) addresses both curvature and erectile function. Inflation of the prosthesis cylinders alone can correct curvature by 20-30 degrees. If residual curvature remains after inflation, manual modeling over the prosthesis can correct most of it. For residual curvature under 30 degrees, plication may be performed, while plaque incision and grafting are rarely necessary. This surgical option offers the highest patient satisfaction when both PD and erectile dysfunction coexist, as it simultaneously treats both conditions.

<image>Surgical decision algorithm for Peyronie disease based on curvature severity and erectile function, showing pathways to plication, grafting, or penile prosthesis</image>

Postoperative Management

Postoperative care includes applying a penile dressing for 24 to 48 hours and restricting activity, including abstaining from intercourse, for six weeks. Penile traction therapy may be used postoperatively to reduce recurrence and help regain penile length. Follow-up visits are typically scheduled at six weeks, three months, and six months. Patients should be counseled about the possibility of persistent or recurrent curvature, which occurs in 5-10% of cases, and the risk of new-onset erectile dysfunction, particularly after grafting procedures.

Clinical Pearls

Peyronie disease progresses through two distinct phases: an acute (active) phase characterized by pain and changing curvature, and a chronic (stable) phase marked by pain resolution and stable deformity. Surgical intervention should only be undertaken during the stable phase, defined as at least three months without pain and with stable curvature. Collagenase clostridium histolyticum (Xiaflex) was the only FDA-approved medical therapy and demonstrated meaningful curvature improvement averaging 17 degrees, but its availability is currently limited. Intralesional verapamil and interferon serve as alternative treatments, though with less robust evidence. Vitamin E, despite widespread use, has no proven benefit in randomized controlled trials. The surgical algorithm is straightforward: plication is preferred for moderate curvature with good erectile function; grafting is reserved for severe curvature with good erections; and penile prosthesis implantation is the best option when erectile dysfunction coexists with Peyronie disease. Plication is simpler and preserves erectile function but causes penile shortening, whereas grafting preserves length but carries a 10-20% risk of new-onset erectile dysfunction. Penile prosthesis addresses both curvature and erectile dysfunction in a single surgery and yields the highest patient satisfaction in this population. Penile traction therapy remains an underutilized adjunct that can improve curvature and penile length when used alone or in combination with other treatments.

References

• AUA Guideline on Peyronie Disease, 2015
• EAU Guidelines on Penile Curvature, 2024 Update
• Levine LA, et al. "Peyronie disease: current surgical management." Urol Clin North Am. 2019.
• Gelbard M, et al. "Collagenase clostridium histolyticum for Peyronie disease" (IMPRESS Trials). J Urol. 2013;190(1):199-207.
• Ralph D, et al. "AUA/EAU update on Peyronie disease." J Urol. 2019.
• Campbell-Walsh-Wein Urology, 12th Edition, Chapter on Peyronie Disease

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