Peyronie’s Disease

An aberrant wound-healing process in the tunica albuginea of the penis. Scar forms a fibrous inelastic plaque, which on erection causes curvature, shortening, narrowing or a hinge effect. Repeated sub-clinical micro-trauma in a genetically predisposed man is the accepted mechanism; only about 10% of patients recall an actual penile injury.

Prevalence estimates vary widely by method, but the best overall estimate is around 9-10% of adult men, and the true figure is probably higher because men are embarrassed to report it. Peak incidence is around 55-60 years of age, and prevalence rises with age alongside erectile dysfunction.

Associations to look for:

• Erectile dysfunction — often pre-dates the Peyronie’s, and shares the same vascular risk factors
• Diabetes — about 30% of men with Peyronie’s disease
• Obesity, hypertension, hyperlipidaemia, smoking
• Pelvic surgery — affects 16% of men after radical prostatectomy
• Dupuytren contracture and other fibroproliferative disorders (plantar fibromatosis, scleroderma)
• Clinical depression — diagnosed in up to half of affected men

Two phases

The acute inflammatory phase has penile pain and progressing curvature. Pain typically settles spontaneously within 12 months and the curvature then stabilises. Short duration (<12 months), ongoing pain and continuing change in deformity all suggest active disease.

The chronic phase is defined by resolution of pain plus stability of the curvature for longer than three months. This distinction drives management — definitive treatment is reserved for the stable phase.

History

Curvature is the commonest presenting complaint, followed by feeling a nodule. Over half report painful erection. Ask about the direction and degree of bend, penile length change, pre-existing erectile function, and family history of Peyronie’s or Dupuytren’s.

Set expectations early. Spontaneous resolution occurs in only about 12%; most men stay static or worsen. No treatment restores the penis to its pre-disease state.

Examination

A firm plaque or indurated area is usually palpable in the flaccid penis, often before the patient has noticed it. In two-thirds of men the plaque sits dorsally, so the curve is upward; lateral and ventral plaques are less common but more likely to obstruct penetration. Plaques on opposite sides, or in the septum, can produce shortening with a relatively straight penis.

The flaccid examination underestimates the angle — the degree of angulation is not fully appreciated, and patients tend to overestimate it themselves. More than half of patients overestimate their curvature, and home photographs are rarely sufficient; a urologist obtains an objective measurement after intracavernosal injection before any invasive therapy.

Investigations

None are needed in general practice; this is a clinical diagnosis. Screen for associated conditions instead — diabetes, cardiovascular risk, Dupuytren’s. A urologist may add duplex Doppler ultrasound with an intracavernosal vasoactive agent to measure blood flow, curvature and plaque calcification. MRI is very rarely indicated.

Differential diagnosis

• Congenital penile curvature — lifelong, ventral bowing without acute angulation, no plaque
• Chordee — ventral curvature associated with hypospadias
• Penile fracture — a pop, immediate pain and detumescence during intercourse, with swelling and ecchymosis
• Penile pain syndrome — local, referred or neuropathic pain without deformity

Management

Observation is reasonable when pain and curvature are minimal, sexual function is preserved, or the man is not sexually active. Many men come for reassurance rather than intervention.

Oral agents do not cure it. Pentoxifylline and PDE5 inhibitors are used off-label; low-dose PDE5 inhibitors are often reasonable in the acute phase given coexisting erectile dysfunction, but the anti-fibrotic evidence is poor.

Penile traction or a vacuum erection device may give up to 25% curvature improvement, but only with regular daily use over about six months in a highly motivated patient. Low-intensity shockwave therapy has only very minor benefit.

Intralesional collagenase clostridium histolyticum (Xiaflex) is the only non-surgical treatment with good evidence. TGA-approved in Australia since 2016, but not PBS-listed and very costly. Randomised trials showed an average 37% curvature improvement versus 17% with placebo — on a 60 degree bend that is only about 22 degrees, which should be spelled out to the patient. Results are poorer with calcified plaque, severe curvature, or hinge/hourglass deformity. Give it only through a specialist or a GP with men’s health expertise. Intralesional verapamil is also used off-label.

Surgery remains the gold standard and is indicated for stable, minimally painful disease where deformity prevents intercourse. A minimum of three months of stable pain-free disease is required first. The aim is a functionally straight erection — under 20 degrees — not restoration of the original penis. Options are tunica albuginea plication (Nesbit) for good rigidity with curvature under 60 degrees, plaque incision or excision with grafting for more severe deformity, and penile prosthesis where erectile function cannot be salvaged pharmacologically.

When to refer

Refer to a urologist if Peyronie’s is causing sexual difficulty or patient anxiety, if curvature continues to progress, or if the diagnosis is unclear.

See also erectile dysfunction and Ejaculatory & Libido Disorders.