About Peyronie's disease
Peyronie's disease, sometimes referred to as a curved penis, is a benign, but disabling condition of the penis whereby scar tissue develops in the normally very elastic deep tissue of the penis. This disease probably results from minor episodes of trauma that cause internal bleeding with resultant scar tissue formation. The deep corporal bodies (corpus cavernosa) normally are very stretchable, yet also very strong tissue that is resistant to bending and breaking. Probably what happens is that as men age, the firmness of the erections diminishes slightly, thereby putting the penis at risk for buckling type injury.
The onset and progression of Peyronie's disease is variable from patient to patient. In some patients, the onset is rapid, and the resultant curved penis may become severe in a matter of days. Other patients may notice first a firm plaque in the penis and then slowly begin to develop curvature associated with an erection. This is the same disease process and probably varies based on the amount of initial trauma. Most patients experience penis pain in the plaque region at the initial onset of the disease, and then later in the course of the disease progression, the penis pain is usually only associated with erections. A painful plaque in the absence of an erection indicates that the disease process is still active. Many men experience difficulty with voiding associated with morning erections because of the bend of the penis, and in rare cases, the plaque can actually compress the urethra. Most men notice some changes in firmness of their erections which may result directly from the disease process (venous leak) or may simply result from the fact that an erection is painful and not enjoyable. Another possible factor is a psychological component causing erectile dysfunction (impotency) because of the obvious focus on the penile deformity. There is no association between the curved penis caused by Peyronie's disease and cancer of the penis.
Treatment options for Peyronie's disease
According to Charles Secrest, MD, "I have a very definite philosophy and approach when it comes to surgical reconstruction for Peyronie's disease: Never shorten the penis unless it is absolutely necessary. My first-line surgery for all men who present with severe, stable, disabling curvature of the penis caused by Peyronie's disease is to excise the offending plaque and reconstruct the penis with an autologous dermal graft. Not only am I not shortening the penis, but I am adding back length that was taken away by the scar tissue. The plaque is removed, and the defect in the penis naturally expands. I measure the defect in the tunica albuginea and then harvest a graft that is 50% larger than the expanded, measured area. The graft is taken from over the iliac crest in the lower outer portion of the abdomen. This is your tissue that I am implanting back into your penis. This technique was originally developed in the mid 1970s by Drs. Devine and Horton at Eastern Virginia Medical Center in Norfolk, VA. This is where I trained in fellowship under Dr. Jordan's careful watch, and I have remained true to this philosophy and surgical approach for over 25 years now. While it is true that some men with extreme curvatures and various defects require some form of minor plication, I will always try to correct the deformity with a graft first."
Peyronie's disease affects about 2% of all men. Obviously, not all of the patients have surgery, and in fact, only approximately one out of three patients eventually requires an operation for penile straightening. Once the diagnosis is made, patients are placed on vitamin E with a standard dose of 400 milligrams twice daily. No other form of treatment have been proven to help consistently with the disease process and there are really no good controlled studies involving Vitamin E. Many men will experience spontaneous softening of the Peyronie's plaque with resultant straightening of the penis over time. The disease is not considered stable until the plaque has been present for at least one year and the curvature stable for six months.
There have been many different operations for correcting this disease that results in a curved penis. We have had good results (92% success rate) with an operation that involves excising the Peyronie's plaque (scar tissue) and reconstructing the penis with a dermal graft. This is also a complicated reconstructive procedure that requires loupe magnification (microscope) and very delicate dissection. Sometimes we combine the use of dermal graft with a Nesbit tuck procedure (tunicaplication). The Nesbit tuck involves making small elliptical incisions on the opposite side of the curvature and then closing these incisions, thus shortening the side opposite the curve.
All patients who are considered for surgical intervention will undergo a blood flow study of the penis to determine if there is an underlying abnormality. The most common associated problem is a venous leak. A venous leak occurs because blood leaks out through the scar tissue in the penis and the erections then become less rigid. There was also an association between Peyronie's disease and arteriosclerotic changes (hardening of the arteries) that bring blood into the erectile bodies of the penis. In patients who we find severe problems with erectile function, we will consider implantation of an inflatable penile prosthesis at the time of surgery. Usually, however, this also involves removing the scar tissue and performing a dermal graft. Some patients with severe curvature require two operations: one to correct the curved penis and a second operation for implantation of prosthesis.
Duplex doppler ultrasound of penis
The duplex doppler ultrasound of the penis is a procedure to evaluate male erectile dysfunction. Duplex ultrasound is combined with an injection in the penis to create an artificial erection. The single test can evaluate both the early and late states of an erection. The technique utilizes a special Doppler ultrasound device that uses a system that assesses the blood flow direction and provides a way to evaluate the volume of flow into and out of the penis.
The technique is fairly simple. It is done by first taking a picture of the flaccid penis. We include all layers of the penis including the corporal bodies and the spongiosum, which is the spongy layer that surrounds the urethra. There we took for dense areas that may represent a plaque called Peyronie's disease. We also look for the calcifications that can indicate scarring or early blood vessel changes consistent with atherosclerosis such as those found in the heart. We then induce an erection by injecting a medication into the penis. We check the ultrasound at varying time intervals during the erection. Using this technique, we are able to look at the varying time intervals during the erection. Using this technique, we are able to look at the arteries of the penis and measure the flow of blood. Poor arterial dilation indicates poor blood flow in response to the injection. This is compared to data on the normal peak flow velocity and how fast the blood pressure should rise in the artery supplying blood to the penis. We are also able to visually evaluate the erection and document the function of the veins and any evidence of venous leakage. Blood that flows too quickly out of the penis may be a sign of a venous leak.
The blood flow test is particularly useful in patients with Peyronie's disease because it not only assesses how much blood flow is present, but how much bending there is and the presence of other lesions. I generally recommend this test on all patients who are undergoing a penile implant or corrective surgery. This provides factual information to work with prior to proceeding with the surgical procedure.
All patients experience pain following this operation. Again, this is a very involved reconstructive operation that takes three to fix hours to perform. As the tissues heal, there is usually associated discomfort that may last for several weeks and even up to six months following this operation. Because we are operating around the very delicate nerves that supply sensation to the body and head of the penis, most men experience temporary numbness of the skin or glans penis (head of the penis) after this operation. Usually, however, the sensation will return following several months of healing. Some men have permanent loss of sensation to part of all of the penis. Another potential with the surgery is recurrent curvature following the cooperation. This is probably associated with severe contraction of the dermal graft. However, another problem is that some men cannot have erections after surgery and therefore, the graft never has a change to expand and soften properly. Men who cannot have adequate erections following this operation are usually instructed to purchase a vacuum erection device. This serves as physical therapy and will greatly help with the healing process. patients are instructed to stretch the penis daily using the vacuum device, but are not supposed to use the constricting rings that come in the kit. This serves as excellent physical therapy even for men with normal erections. Also, patients who develop severe scarring and contraction of the graft post-operatively with associated pain may benefit from ultrasound deep heat treatment which is performed by a physical therapist. Bleeding, infection, and chronic swelling are other potential complications common to all surgery.