Historically, few men have wanted to talk to their doctors about a common problem that strikes one in 10 men over age 50: a deformity that causes a bent and painful penis.
But if you have been watching TV over the past year, you have probably seen an advertisement featuring a bent carrot. The carrot is a not-so-subtle way of introducing the condition Peyronie’s disease (PD), which causes a painful deformity of the penis than can have devastating effects on a man’s sex life. Endo Pharmaceuticals developed the ad campaign to raise awareness of PD and to introduce an injectable medication called Xiaflex (collagenase clostridium histolyticum) that can treat it.
PD has been around for a long time. It was first described and named by the French physician Francois de la Peyronie in 1743. Even though it is a common condition, it has remained a bit of a secret kept by men and their urologists. PD can occur at any age but is most common after age 50. It is a type of scar tissue that forms a thick lump, called a plaque, under the skin of the penis. The plaque forms on the elastic covering of the tubes that expand to cause an erection.
The penis has two tubes that fill with blood, the corpus cavernosum, and an elastic sheath, the tunica albuginea. If a man has PD, part of the tunica albuginea does not stretch, so the erection becomes painful and bent.
PD has two stages. During the acute or active stage, a man will notice that erections are becoming painful. Along with the pain, a lump develops that can be felt beneath the skin, and there is a curving of the erect penis.
The most common deformity is an upward bend. If the penis has a bend of 30 degrees or more, sexual intercourse may not be possible. Many men will suffer from stress, anxiety, and erectile dysfunction due to the deformity.
Some men may also have a kink or hourglass deformity. In most men, the curvature gets gradually worse during this phase. Improvement occurs in about 10 percent of cases.
After about one year, the plaque becomes fixed and hard and is no longer painful, but the deformity remains. This is called the chronic stage. Without treatment, the deformity is permanent.
The main theory is that PD is caused by injury to the tunica albuginea. The injury is thought to trigger formation of a scar made up mostly of a connective tissue protein called collagen. The injury may be due to a hard bend, squeeze, or stretch of an erect penis during sex. It may also be caused by repeated minor traumas, called micro traumas, that cause a small amount of bleeding and inflammation. An example would be frequently trying to have intercourse with a soft erection.
However, many men have no history of trauma, and some men who have trauma never develop PD, so there may be other factors.
PD may be a symptom of abnormal wound healing called a connective tissue disease. A similar connective tissue disease is Dupuytren’s contracture, in which a collagen plaque forms in the palm of the hand, or plantar fasciitis, which causes collagen to thicken in the arch of the foot. Studies show that about 20 to 25 percent of men have both Dupuytren’s and PD. Other conditions may also increase the risk of PD, including low testosterone, diabetes, and smoking.
PD can be diagnosed by the symptoms and a physical exam. The plaque can almost always be felt under the skin. No diagnostic tests need to be done, but if a man is being examined by a urological surgeon, the penis may be injected with a medication to cause an erection. This allows the surgeon to see the deformity and measure the bend in the penis, which is important for planning treatment. Sound wave imaging may also be done while the penis is erect.
Treatment of PD depends on the stage, symptoms, erectile function, penile size, and the patient’s wishes. In the acute phase, waiting, watching, and pain management are sometimes the best treatment. Some men will get better, and some will end up in the chronic phase without pain and a deformity not severe enough to require treatment.
Before Xiaflex, the only reliable treatment was surgery. Although there are many nonsurgical options, including traction and vacuum devices to stretch the penis, no other treatments have shown consistent results in clinical studies. Erectile dysfunction medication may be used for men with ED, and an over-the-counter pain medication, like ibuprofen, may be used for pain, but there is no other oral medication that helps.
Xiaflex is the brand name for clostridium histolyticum, which is a mixture of proteins derived from bacteria that will break down collagen. It is injected directly into the plaque. Two large studies found that men with chronic deformities due to PD benefited significantly from this treatment, with about a 34 percent improvement in their deformity. Xiaflex is approved for men with a stable bend in the penis of more than 30 degrees but less than 90 degrees. The treatment involves a series of injections over 24 weeks. Each cycle of injections is followed by stretching exercises to “remodel” the penis.
Although Xiaflex has improved nonsurgical treatment, surgery is still the most reliable way to treat PD and gives the best long-term results. If the deformity has been present for at least one year and has not responded to any other treatments, three surgical procedures may be considered. In most cases, a successful option can be found.
PD is a complex condition. There is no one-size-fits-all treatment, but PD can be managed. If you or your partner develops signs and symptoms of PD, do not suffer in silence. Start by telling your primary care provider. You should be referred to a urologist for treatment, and if you need surgery, a urologist who specializes in sexual health.
