Advances in Treatment for Peyronie's Disease

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Early diagnosis of Peyronie's disease is critical to treatment efficacy. The iteration of proven treatments has increased the likelihood of nerve preservation, penile function and pain relief.

According to Ajay Nehra, MD, senior urologic surgeon and director of Men's Health and Male Reconstructive Surgery at Massachusetts General Hospital, these treatments are most effective when the condition is diagnosed early and treated by experts knowledgeable about its management. But patients usually delay seeing a physician about Peyronie's disease.

"More often than not, men are hesitant in presenting themselves for treatment. Usually it is the spouse that facilitates it," says Dr. Nehra.

Based on his experience and decades of multidisciplinary specialized urology practice, he says that patients ultimately seek care due to concern over the progressive development of notable curvature of the penis, pain or discomfort during intercourse or inability to have intercourse.

The disparity of understanding of Peyronie's disease among urological specialists can lead to a treatment gap, exacerbating patients' fears that the condition will persist indefinitely. To reduce this gap, Dr. Nehra led a multicenter expert panel which, in 2015, published the first-ever set of Peyronie's disease treatment guidelines for the American Urology Association.

Characteristics and Progression

Peyronie's disease is an inflammatory erectile dysfunction disorder that develops subsequent to injury, forceful intercourse or microfracture. It affects approximately 10% of men in the U.S., and most often presents in middle age.

Typically, the condition presents as a painful, inadequate erection in which the penile shaft is subject to bending and forms weak or stress points in tunica albuginea. This gives rise to the recruitment of macrophages and fibrin, which leads to the formation of scar tissue, loss of elasticity and a deforming curvature.

A progressive disorder, Peyronie's disease typically moves through three phases—acute, middle and chronic, characterized as active and stable states—and can result in significant tissue rigidity over a time course of 12-18 months. Some cases resolve on their own, but that is unusual.

Treatment Options

Optimal outcomes from treatment of Peyronie's disease are associated with care from urologic subspecialists skilled in its diagnosis, timing of appropriate interventions and clinical and surgical command of the full range of therapeutic options, aftercare and recovery. Practitioner expertise is especially critical in advanced cases that require surgery, when preservation of nerves is required to correct curvature and restore erectile function.

Initial conservative medical measures include administering oral anti-inflammatory medications and other agents to allow comfortable, gentle stretching exercise of the sheath to break down scar tissue to correct the curvature. The goal of these measures is to help the patient maintain an erection by restoring some tissue suppleness that allows the penile shaft to straighten.

According to Dr. Nehra, two viable treatment options for effective correction of Peyronie's disease include injectables and surgery.

Injectables

Agents injected into the plaque of collagen deposits can dissolve lesions and restore shaft suppleness.

In patients with mild curvature, characterized as curvature less than 30 degrees, minimally invasive injectables administered in the physician's office to disrupt scar tissue may be effective. They are the common first-line treatment in carefully selected patients.

In patients with curvature less than 30 degrees, a series of three injections of an agent that destroys collagen may be given in office visits over a period of 48 hours and supplemented by a regimen of stretching and tissue massage manipulations between office visits. This collagen-disrupting agent is approved by the U.S. Food and Drug Association and requires insurance pre-approval. The 48-hour, three-injection cycle may be repeated up to four times. Choosing an experienced physician who prioritizes a thorough pretreatment medical history and exam is essential because certain patients may be vulnerable to serious side effects, such as penile corporal rupture.

Surgery

Dr. Nehra explains that multiple surgical approaches to correct advanced, chronic Peyronie's disease have been refined and validated over the years. In appropriately selected patients, surgery typically provides relief when performed by experienced practitioners at high-volume centers of expertise.

Surgical procedures straighten the shaft to correct curvature. If surgery alone does not restore erectile function, oral medications prescribed to treat impotence may be effective. Recovery lasts two to four weeks and centers on controlling pain and doing gentle exercises to manipulate tissues and restore function. Follow-up is essential to monitor for potential complications once sexual activity resumes.

"People need to know Peyronie's disease is entirely treatable, but that early care is essential," Dr. Nehra says. "Our goal is to preserve nerve and penile function, eliminate pain and optimize sexual function."

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