Treatment of Peyronie's Disease

Peyronie's disease is a process where the patient's own body lays down scar tissue within the lining of one or both of the erectile bodies deep within the penis.  Replacement of the normal elastic tissue of the erectile bodies with inelastic scar tissue often causes penile curvature, loss of penile length and decreased penile girth.  Decreased sensation may also occur by encasement of the dorsal penile nerves in scar tissue. Peyronie's disease  begins with single or multiple foci of inflammation on the lining of the erectile bodies (tunica albuginea).  Patients often feel a deep seated discomfort during the period of acute inflammation.  This is often when they notice a nodule or "knot."  With resolution of inflammation after 1-3 months, the discomfort usually resolves.  This is often the time when patients first notice penile curvature.  Some patients notice their curvature to appear almost overnight.  Most, however, experience a gradual progression of curvature over 2-3 months.  The typical patient then notices stabilization where the curvature no longer changes.  Penile curvature occasionally improves spontaneously, but that is not the norm.  Most patients notice little change in their curvature over time once it has stabilized.  Pain may occur during erection due to the curvature, but once the curvature has stabilized, pain should not be present when the penis is flaccid.

Every patient has their own threshold where curvature becomes problematic for intercourse.  Many men have angulations of less than 20 degrees.  While somewhat disconcerting to some, curvatures in that range are considered normal and are not cause for intervention in our practice.  Intercourse is substantially impacted when curvature reaches or exceeds 30 degrees downward or 45 degrees to either the side or upward.  Upward curvature is the most common, but also usually has the least impact on intercourse.  We see a large number of patients with severe curvature, often about 90 degrees.  Severe curvature is sexually disabling and usually requires surgical intervention to restore sexual function.   The type of surgical procedure is dependent on the extent of curvature and the individual patient situation.

We perform four different procedures for treatment of Peyronie's disease.  Individuals with severe curvature (generally greater than 60 degrees, but often as much as 110 degrees) who retain good erectile rigidity can be treated by incision of the scar tissue and placement of a graft.  Those with less severe curvature can undergo a series of collagenase (Xiaflex) injections in the office or have an outpatient corporoplasty surgical repair.  Finally, if the patient has experienced both curvature and loss of erectile rigidity, then a penile implant is usually the best choice. We have extensive experience with each of those options. 

If Peyronie's disease makes intercourse difficult or impossible please schedule a consultation. 

Plaque Incision and Graft for Severe Penile Curvature

This photo shows a close-up of a dorsal neurovascular bundle being gently lifted off the underlying corporal body by a blue rubber loop.  The most demanding part of surgery for Peyronie's disease is usually dissection of the neurovascular bundles so they can be retracted out of the way.  This generous nerve bundle incorporates all the neurovascular structures.  Nerve function will be preserved.  The actual problem tissue is the corporal body underneath the nerve bundle where incision and grafting will take place.

The image above is the first of a series of three in a patient that has a severe right penile curvature from Peyronie's disease.  We have dissected and lifted the right neurovascular away from the underlying corporal body exposing the scar tissue.  A sterile marking pen is used to make the purple mark where the tissue will be incised.

The tissue springs apart when the corporal tissue is incised at the purple mark.  This adds functional length to the side which was shortened by the Peyronie's disease scar tissue. The underlying spongy erectile tissue tissue is seen in the center of the photo.  We avoid injury of this tissue.

Four ply SIS is the most common graft we use for Peyronie's disease repair.  This acellular material is supplied  in a sheet that can be cut to fit the corporal opening.

A four ply SIS graft has been sewn in to cover the opening in the corporal body.  We oversize the graft about 20% to allow for normal contraction during the healing process.

Corporoplasty Repair of Penile Curvature

This patient experienced Peyronie's disease causing an upward (dorsal) curvature.  We determine the exact location of the curvature by injecting saline into the corporal bodies.  A skin incision is then made.  We try to minimize the size of the skin incision while still providing good surgical exposure.  In this case the skin incision was limited to the underside of the penis along the old circumcision line. The point opposite the point of maximum curvature is marked by the single purple mark over the urethra in the center of the incision.  For a dorsal curvature we then make two marks for the incisions on each corporal body lateral to the initial purple mark.  Only one of the corporal marks can be seen in this photograph and consists of four dots.  This is the location of the incision for a Yachia corporoplasty.  The opposite corporal body will have a similar incision.  In this case each incision will be approximately 7mm long.

With this type of corporoplasty, the longitudinal incision is closed transversely.  No tissue is removed, just redirected.  Five small dark colored suture knots are seen here running up and down (transversely).  These sutures close the corporal body incision and secure the repair.  We use very long lasting absorbable sutures (PDS) for this repair.  The knots can be felt for several months, but eventually absorb. 

Collagenase (Xiaflex) Injection

Patients with mild or moderate curvature can be good candidates for collagenase injection (Xiaflex). This is an office procedure where an enzyme is injected into the Peyronie's plaque to break down the scar tissue.  The large multicenter clinical trial demonstrated that patients can expect an average 30% improvement in their curvature. There can be a wide range of response, however.  Some patients with more severe curvature can have marked improvement, while others may have little benefit. Collagenase (Xiaflex) can be injected up to four cycles of two injections each. Practically speaking, we follow the following schedule:

Cycle 1

Friday:  Office visit for injection of a small amount of alprostadil to allow us to assess the curvature and then inject the Xiaflex in the correct position.

Monday Afternoon:  Xiaflex injection

Wednesday:  Modeling procedure and patient instruction on how to properly stretch the scar tissue.  (The Wednesday visit is only done during the first cycle)

Cycle 2  (Six weeks after completing the first cycle)

Friday: Xiaflex injection

Monday Afternoon:  Xiaflex Injection

Cycles 3 and 4

Identical to cycle 2.  Each is at least six weeks after the preceeding cycle.

 Collagenase Syrenge