What are the treatment options for Peyronie’s Disease?

There is very little evidence that medical treatment is effective during the acute phase of the disease. Traditionally patients have been offered with no proven success oral vitamin E, Tamoxifen, Pentoxyphilline, Potassium Paraaminobenzoate, Colchicine and Verapamil in the hope to slow the progression of Peyronie’s Disease. 
 

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There might be a rationale for stretching the penis during the acute phase of the disease in order to counter-effect the tunical shortening produced by the plaque. This can be achieved either by pharmacologically enhancing natural erections or mechanically, with the use of a vacuum or stretching device.

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Surgery represents the gold standard treatment for Peyronie’s Disease and its aim is to guarantee a penis straight and hard enough to allow the patient to engage in penetrative sexual intercourse.
Medical treatment consists in intraplaque injections of Collagenase Clostridium Histolyticum, which will be discussed in depth in a different section of this website, and in mechanically straightening the penis using a vacuum or stretching device.

The evidence of the effectiveness of the use of the vacuum pump or of the penile stretching device to mechanically straighten the penis is minimal. In the best-case scenario, the regular use of these devices may just slightly reduce penile curvature, which would be beneficial only in very selected patients.
The choice of the best surgical approach, apart from patients’ preference, should take in consideration the quality of erection and the degree of deformity and shortening.

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In patients with preserved erections, the curvature can be corrected either by shortening the longer side of the penis, which has not been affected by Peyronie’s Disease, or lengthening the shorter side incising the plaque and interposing a graft. Both procedures can be performed as a day case.
Various techniques, such as the Nesbit and Yachia plication, the 16 and 24 dot technique and the tunica albuginea plication (TAP) can be used to accomplish shortening of the longer side. These techniques are relatively simple and are not associated with any postoperative worsening of the quality of the erections. The main drawbacks are that they induce further penile shortening, with an estimated loss of 1 cm for each 30 degrees of curvature corrected, and that they do not allow to correct hourglass deformities. Therefore these techniques are not indicated in patients with severe shortening, curvatures of more than 60 degrees, as the length loss would be more than 3 cm, or complex deformities with narrowing. 

Although it is technically slightly a more challenging procedure than penile plications, plaque incision and grafting still represents a very reliable procedure that should be offered to patients with complex curvatures and narrowing. As it does not produce significant length loss, it is also indicated in these patients who have experienced a significant penile shortening and a curvature of less than 60 degrees if the loss of length expected with a plication type procedure would exceed 20% of the total penile length.

The main drawback of plaque incision and grafting is that up to 15% of patients may experience some worsening of the quality of the erection postoperatively. Patients with a pre-existent degree of erectile dysfunction should therefore be counselled against plaque incision and grafting.

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Postoperative stretching of the graft either by pharmacologically enhancing the natural erection or mechanically stretching the penis is paramount to prevent graft contracture, recurrence of the curvature and ultimately penile shortening.
Patients with erectile dysfunction not responding to medical treatment or with a degree of erectile dysfunction and a complex deformity and/or severe shortening should be offered penile prosthesis implantation. 

Both malleable and inflatable penile prosthesis have been used in patients with Peyronie’s disease with excellent results with up to 95% of patients and partners satisfied with the results of surgery. Apart from guaranteeing the axial rigidity necessary to engage in penetrative sexual intercourse, penile prosthesis implantation alone allows the correction of the curvature in almost all cases. Additional straightening manoeuvres may be required to achieve adequate curvature correction in the remaining patients.
Plaque incision and grafting in combination with penile prosthesis implantation may be required in a very limited number of patients who present with very large calcified plaques.

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Patients undergoing penile prosthesis implantation needs to be adequately counselled preoperatively that the aim of surgery is to guarantee a penis straight and hard enough for penetrative sexual intercourse and that the procedure will not restore the length lost because of Peyronie’s Disease and the long standing erectile dysfunction. 

Penile length restoration procedures involve the elongation of the corpora cavernosa with a circumferential graft simultaneously with the implantation of a penile prosthesis. 

These techniques are technically more challenging, time consuming and potentially associated with increased risk of complications, when compare with penile prosthesis implantation alone. These procedures should be therefore offered only to an extremely selected group of highly motivated patients who have experienced significant loss of length and who are prepared to take an increased risk of complications.