Penile Curvature (Peyronie's Disease)

What is Penile Curvature?

The word curvature describes any type of curving body part. It is common for an erect penis to curve slightly. Penile curvature, however, describes an erect penis with an abrupt curve that can cause pain and interfere with sex (Fig. 1). Some men were born with this condition (congenital penile curvature). In others, it develops over time. Penile curvature that develops later in life is called Peyronie’s disease.

What Causes Penile Curvature?

If you were born with penile curvature, your erect penis has always been bent. Usually, the penis is bent downwards, and this is noticeable as soon a young man becomes sexually mature. Congenital curvature is associated with other problems of the genital organs and is usually recognized during early childhood. If you develop penile curvature (Peyronie's disease), you may experience pain in your penis and/or be able to feel hardening of the tissue as the curve forms. Peyronie’s disease is considered a wound-healing disorder. At some point during sex or other activity, the penis has been injured, and the tissues do not heal properly. Excess scar tissue forms in the layer (tunica albuginea) that surrounds the spongy erectile tissue (corpus cavernosa) and becomes a fibrous plaque. Although usually described as rare, both types of penile curvature are likely more common than previously thought.

Risk Factors for Penile Curvature:

Congenital penile curvature is associated with other problems of the genital organs, usually recognized in early childhood. Peyronie’s disease (Acquired penile curvature) is associated with erectile dysfunction (low-quality erection makes the penis more likely to buckle) and Dupuytren’s contracture, which causes one or more fingers to stay bent into the palm of the hand.

Fig. 1: Curvature of the penis.

Diagnosis of Penile Curvature

In Peyronie’s disease, repetitive injury and trauma are believed to cause inflammation in the penis. The tissues surrounding the swelling bodies of the penis do not heal properly, causing the formation of a fibrous plaque (fibrosis). You can see an example of this plaque in Fig 1. In the beginning (acute phase), you might feel pain and nodules under the skin. Over the course of several months, you will notice curving of the penis and the formation of hard plaque (chronic phase). Although the pain will decrease and mostly disappear, the resulting curvature can cause painful erections and may prevent sexual penetration and intercourse.

Symptoms can include:

  • Pain in the penis

  • A ridge or hardening of the penis tissue that can be felt through the skin

  • Soft or painful erections

  • Decreased libido

  • Lowered self-esteem

  • Depressive feelings

After the initial first phase, the curvature stabilizes in about two-thirds of patients within several months. In a few patients (about 5%), Peyronie’s disease goes away without being treated.

Diagnosing Peyronie’s Disease

Initial evaluation- Your doctor will assess:

  • General health status

  • Current symptoms and their order of appearance

  • Presence of erectile dysfunction

  • Other associated risk factors

  • The hard plaques can usually be felt whether or not the penis is stiff.

To assess your penile curvature type and severity, your doctor may need pictures of your erect penis. You may provide them yourself. If you are not able to have a natural erection because of the stressful situation or erectile dysfunction, injected drugs can be applied.

Penile Doppler Ultrasound

Ultrasound may be used to show: Where the plaque is, whether there is calcium build-up in the plaque and how the blood flows in your penis. Prior to obtaining this ultrasound study, a penile injection will be performed to create an erection.

How is Penile Curvature Treated?

Diagnosis and treatment are similar for congenital penile curvature and Peyronie’s disease. There is no clear function or angle of curvature that demands treatment. Personal aesthetics, pain, and the inability to have sex are reasons for treatment. Prior to treatment, it is important to determine whether the disease is still active. This will influence medical treatment or timing of a surgery, if indicated. The disease is considered to be stable when the pain has gone away, and penile curvature has not increased for at least 3 months. This usually occurs 6-12 months after symptoms are first noticed.

Treatment Can Include:

  • Watchful Waiting: May be chosen if the penile curvature is not severe and is not increasing, there is no pain in the penis during sex, pain is mild during erections, and erectile function is good.

  • Penile Shockwave: During the acute phase, if penile pain is severe, focused Shockwave therapy applied to the penis can provide pain relief. This will not affect the curvature. If you are interested in this, be sure to talk to your physician.

  • Penile Injections: Clostridium collagenase histolyticum (CCH, also called Xiaflex). Xiaflex is a biological agent that a urologist injects directly into the plaque. It is the only FDA-approved injection therapy for the treatment of Peyronie’s disease. The enzyme digests the abnormal collagen deposits in the plaque to decrease the abnormal force exerted on the penis. Men in clinical studies had a roughly 34% improvement in their curvature and reported improvements in their distress suffered from the disease. Side effects of this therapy were usually mild and included temporary pain, bruising, and swelling. A few men in the clinical trials had a penile injury severe enough to need surgical correction. All of these men regained sexual function post-surgery. Of note, Xiaflex works over time and requires 2 injections per cycle over approximately 4 cycles, separated by 6 weeks each. Additionally, you will be instructed to avoid sexual activity for 4 weeks after the Xiaflex injections.

  • Penile traction: Aims to straighten the curvature by using a device that stretches the penis. There are several devices commercially available, but Restorex has the most available evidence. Penile traction requires discipline and commitment as it needs to be worn for 1 hour EVERY DAY. Studies have shown average improvements of 17 degrees (OR 28%) after 6 months of use. Studies have also shown some recovery of penile length, about 1.6 cm in average. This device is not usually covered by insurance plans and must be acquired out of pocket. The cost of this device as of November, 2022 is $525. For more information, please visit Restorex.com

  • Surgery: Usually reserved for men with significant, disabling penile deformities that make it hard to have sex. The type of surgery will depend on your condition. Most health care providers suggest putting off surgery until the disease has stopped getting worse, and the patient has been pain-free for at least 6 months. Surgery may correct the curvature of your penis, but it carries risks. Your doctor will consider: Your personal preference, Location of scar tissue, Severity of your symptoms, Response to medication in case of erectile function and Penile length

There are 3 types of surgery:

  • Penile Plication: This is the most straightforward surgical approach. Most often under a general anesthesia, the surgeon makes an incision on the shaft of the penis, to expose the fibrous coating of the penis where the plaque is. Usually, the surgeon gives the man an erection in the operating room using an injection medicine. Once the surgeon observes the degree of curvature, he or she will place several stitches opposite the curve to “pull” the penis against the direction of the curve. Once the sutures are tied down, the tissue bunches together against the curve. The main downside to the surgery is men can lose some length.

  • Penile plaque excision/incision and graft: This surgical option is far more involved. Depending on the location of the plaque, excision and graft surgery involves a similar incision to the plication surgery or an incision along the circumcision line. After the incision, the surgeon removes the plaque and places a patch. Risks of plaque incision and grafting include temporary or permanent penile numbness, reduced erection strength, scarring and shortening. In the right surgeon’s hands, however, this represents a powerful and effective treatment option.

  • Penile Implant: If a man suffers from both Peyronie's and moderate to severe erectile dysfunction, a penile implant with intraoperative modeling (or a combination of the surgeries above) is likely the best surgical option. Surgeons have been placing implants for over 40 years. An implant can correct the Peyronie’s deformity because the cylinders will act as beams to straighten the penis. Once the surgeon places the implant, he or she can hold pressure over the erect implant and bend the penis against its curve. With the cylinders in place, the penis has a good chance of holding straight once the man heals.

Possible Side Effects of Penile Curvature Surgery:

Failed procedures with the need for reoperation (the operation can fail for several reasons, including new plaque formation or active disease, shrinking of the graft, loosening of the sutures):

  • Penile shortening

  • Erectile dysfunction

  • Numbness

  • Risk of recurrent curvature

  • Palpable knots and stitches underneath the skin

For more information, you can view an educational video by clicking this link: https://youtu.be/czx5WvHtcYg or read further by clicking these links: https://jamanetwork.com/journals/jama/fullarticle/2774409