Peyronie’s Disease: Surgical Treatment and What the Future Holds
Peyronie’s Disease (also known as Chronic Inflammation of the Tunica Albuginea (CITA), is a connective tissue disorder involving the growth of fibrous plaques, or scarring, in the soft tissue of the penis. It affects up to 10% of all men. Specifically, scar tissue forms in the thick sheath of tissue surrounding the dilatable spaces of the penis which fill with blood and become distended with erection. The condition causes pain, abnormal curvature, erectile dysfunction, indentation, and shortening of the penis. While among CITA’s symptoms is not bladder control problems, because of its interference with normal sexual intimacy and the dysfunction that accompanies it, at NAFC we are prepared to address it and help to refer callers to further information and clinical experts.
Diabetes, high blood pressure, and cigarette smoking seem to be more common among men with Peyronie’s disease. Invasive procedures, like prostatectomy (removal of the prostate) may also increase the risk of developing Peyronie’s disease. However, studies aiming to draw causal links between such factors and CITA remain inconclusive to date. Doctors do not know why some men develop Peyronie’s disease and others do not. It is generally believed that it is a wound-healing disorder that prevents tissues in the penis from healing properly and that the disease is activated by injury to the penis. The injury can be a significant trauma or the accumulation of minor ones — like those that occur during normal sexual intercourse.
For many, the disease does change over time but it does not go away. It usually occurs in two phases — the acute (or active) phase when the most changes in the penis occur and the pain is most acute and the chronic (or stable) phase when the pain may subside substantially and changes cease to occur. In rare cases, Peyronie’s disease resolves on its own within 12-18 months without any form of medical treatment.
Recommended Nonsurgical Intervention
A variety of treatments have been used, but none has been especially effective. Reported success rates from invasive surgery tend to average 50-60%, and in about a third of the cases the condition returns after a number of years. Some of the country’s recognized experts in studying and treating CITA include Dr. Tom Lue of UCSF Medical Center, Dr. Lawrence Levine of the University of Chicago, and Dr. Cully Carson at UNC-Chapel Hill. Dr. Levine, and a member of the Medical Advisory Board of the Association of Peyronie’s Disease Advocates (APDA), recommends the following approaches among viable nonsurgical intervention and treatment:
“First is a combination of oral pentoxifylline 400 mg three times a day and L-arginine 1000 mg twice a day. Although these drugs have not been shown in any large-scale multi-center trials to be effective, there is some evidence that they may reduce the likelihood of progression of scarring and may have some beneficial effects on scar remodeling and resolution. These drugs
are relatively inexpensive, non-toxic, and tend to be well tolerated. This combination of drugs should be taken for about 6 months.
The second approach is injection therapy. It is my preference to use verapamil, as it is less expensive and has fewer side effects than interferon. In our experience in over 1700 patients, we found 50%-60% of patients had a reduction in curvature of at least 10 degrees. Verapamil is typically recommended to be injected in the office every 2 weeks for 6 treatments, at which point reassessment is made. If no improvement is noted, then no further therapy is indicated. If there is improvement of curvature, girth, pain, or erection, then it is reasonable to continue with the
standard protocol, which includes 12 injections over 6 months. This approach is typically covered by insurance. Verapamil injection should not be considered as a cure, but has been shown to be beneficial. Verapamil may help stabilize the disease and prevent progression of the deformity. When no treatment is given at all, the deformity gets worse in up to 50% of patients.
The third approach is external traction therapy. I prefer external traction devices, as they provide prolonged forces on the penis which activate the chemical processes that result in scar remodeling, elongation of the penis, and correction of deformity. I have not seen beneficial effects with vacuum therapy. It is important to use traction therapy carefully, which includes wearing the device for at least 3 hours per day at 2-hour intervals. This means it cannot be worn during extended periods of sleep for fear of injury to the underlying tissue. In over 300 patients treated with traction therapy, I have personally not seen any adverse side effects. Two men have had temporary abrasions of the skin on the edge of the glans penis, but there have been no negative effects on erectile function or sensation.
Initial evaluation at our medical center using this three-approach protocol demonstrated that approximately 60% of patients had measured improvement of at least 10 degrees, and that in those men who were responders, the average curvature reduction was 24 degrees. In men who used oral and injection therapy without traction therapy, only 50% had measured improvement, with an average curvature improvement of less than 20 degrees (1).
Essentially, there are three types of surgical procedures: 1) Plication, 2) Grafting, and 3) Implants (2).
Plication involves pinching the tissue together on the outer side of the curvature. It is one of the least invasive procedures, promising long-term results with low rate of recurrence requiring a second surgery. It is less likely to cause erectile dysfunction than grafting procedures, and has a track record of high patient satisfaction with its cosmetic results. Many patients achieve near-complete correction of the curvature. The unfavorable side effects can be a slight penile shortening, loss of elasticity and impotence (the inability to achieve or maintain an erection).
For men with more severe curvature, grafting is often recommended. The procedure involves replacing or expanding scarred penile tissue with healthy tissue (called grafts). Scar tissue, or plaques, are not usually removed in the surgery unless they are calcified. With many patients, some curvature is likely to remain present. The unfavorable side effects, like plication, involve penile shortening, loss of elasticity, and impotence. There is also scarring likely in the vicinity of the graft.
The implantation of bendable or inflatable plastic cylinders is still another option but considered by many urologists to be a last resort. These are typically desired by men for whom erectile dysfunction is a chief concern and where plaque formation is extensive. Shortening of the penis still occurs and other unfavorable side effects are possible, including infection, damage to penile tissues, decreased penile sensation and the occurrence of numbness, and implant malfunction.
Certainly there is excitement about Xiaflex, a form of injectable collagenase which is currently in phase III clinical trials. It is likely we will not know the results of those trials until late 2011 or early 2012. XIAFLEX® (collagenase clostridium histolyticum) is a prescription medicine currently on the market to treat adults with Dupuytren’s contracture when a “cord” can be felt. Over time, the thickening of this cord in your hand can cause one or more fingers to bend toward your palm, so that you cannot straighten them. XIAFLEX® helps to break down the cord that is causing the finger to be bent. XIAFLEX® should be injected into the cord by a healthcare provider who is experienced in injection procedures of the hand and treating people with Dupuytren’s contracture. The drug is marketed in the U.S. by Auxilium Pharmaceuticals, Inc. (3)
Still another possible intervention in the future is BOTOX injections. Currently, there is a clinical trial at Baylor College of Medicine in Texas. Little is known of results in patients enrolled in the trial to date.
The point, as with bladder and bowel control problems, is to seek out an expert and engaged in shared decision-making in choosing a course of treatment. A man’s sexual partner needs to be involved in the discussion, as appropriate, and be familiar with the benefits and risks of each treatment option. The APDA can be especially helpful with this process.
(1) http://www.peyroniesassociation.org/treatment/apda-medical-advisory-board-position-statement-on-treatment/#, retrieved November 28, 2011.
(2) http://www.peyroniesassociation.org/treatment/treatment-comparison/, retrieved on November 28, 2011.
(3) http://www.xiaflex.com, retrieved November 28, 2011.