Peyronie's disease

What Peyronie's disease is

Peyronie's disease is the formation of fibrous scar tissue, called a plaque, in the tunica albuginea — the tough sheath that surrounds the erectile tissue of the penis. Because scar does not stretch in the way that normal tissue does, the penis bends towards the plaque during an erection.

It affects an estimated 3–9% of men, and it is far more common than the number of men who seek help for it. Many men live with it for years before mentioning it, often assuming that nothing can be done or that it is somehow their fault. Neither is true.

Symptoms

• A bend or curve in the erect penis — usually upwards, but it can be to either side or downwards
• A palpable lump or firm band along the shaft
• Pain during erection, particularly in the early phase
• Narrowing, indentation or an hourglass appearance
• Loss of length
• Difficulty getting or keeping an erection, or instability during intercourse
• Difficulty with or inability to have penetrative sex

Distress, low mood and relationship strain are extremely common and are a legitimate reason to seek treatment in their own right.

The two phases

Peyronie's disease has an active (acute) phase, usually lasting six to eighteen months, in which the curvature is changing and pain is often present. It then enters a stable (chronic) phase, where the curve has settled and pain has usually resolved.

This distinction drives the treatment plan. Surgery is generally reserved for stable disease, because operating on a curve that is still evolving risks an incomplete result. Deciding which phase you are in is one of the main purposes of the consultation.

Causes and associations

The most widely accepted explanation is abnormal healing after minor, often unnoticed, injury to the erect penis during intercourse. Some men are predisposed:

• Family history of Peyronie's disease
• Dupuytren's contracture of the hand, or plantar fascia thickening in the foot
• Diabetes, high blood pressure and high cholesterol
• Erectile dysfunction, which increases buckling injury during sex
• Previous prostate surgery or pelvic trauma
• Smoking

How I assess it

Assessment establishes the direction and degree of curvature, whether the disease is active or stable, the quality of your erections, and how much the problem affects you. This involves history, examination of the plaque, and objective measurement of the curve — usually from photographs you take at home of a natural erection, or by inducing an erection in clinic with an injection. Penile duplex ultrasound is used where erectile function needs assessing at the same time, because that materially changes which operation is appropriate.

Treatment

Not every man needs treatment. If the curve is mild, sex is comfortable and satisfactory, and the disease is stable, observation is entirely reasonable.

Where treatment is wanted, the options depend on phase, degree of curvature and erectile function:

• Oral and topical treatments — of limited proven benefit, but sometimes used in the active phase
• Pain control and reassurance during the active phase, since pain almost always settles by itself
• Traction therapy and vacuum devices, which may help maintain length in selected men
• Intralesional injection therapy, where an agent is injected directly into the plaque over a course of treatments
• Plication surgery — shortening the longer, opposite side to straighten the penis. Reliable and simple, but shortens the penis somewhat. Best suited to good erections and less severe curves.
• Plaque incision or excision with grafting — releasing the scar and patching the defect. Preserves length better and handles severe curves and hourglass deformity, but carries a higher risk of erectile dysfunction and numbness.
• Penile prosthesis, with straightening at the same time, where there is significant erectile dysfunction that does not respond to medication. This treats both problems in one operation.

Choosing between these is a genuine decision, not a formula, and it depends on what matters most to you — length, straightness, or reliability of erection. I will set out the trade-offs of each honestly.

My practice

I specialise in surgical andrology and genito-urethral reconstruction and run one of the country's largest tertiary referral andrology practices at Guy's Hospital, for which I received a UK National Clinical Impact Award in 2022. I am a past National Chair of the BAUS Andrology section and Director of the Andrology Prosthesis Centre at Guy's.