Peyronie's disease is an acquired fibrosis of the tunica albuginea producing penile curvature, deformity, pain, and often erectile dysfunction and distress. It follows abnormal wound healing after (often unrecalled) microtrauma, and management is staged — support and intralesional/traction therapy in the active phase, surgery once the deformity is stable.
Pathophysiology and Risk Factors
An inflammatory disorder of the tunica in which a scar fails to remodel (TGF-β1 is central). Risk factors (mnemonic IT DRAG A Crooked Wand): Infection, Trauma, Diabetes, Radical prostatectomy (11–16%), increasing Age, Genetic predisposition, Autoimmunity, Collagen disorders (Dupuytren contracture, Ledderhose disease, tympanosclerosis), and aberrant Wound healing. Hypogonadism worsens severity; PDE5 inhibitors are not associated.
The tunica's outer longitudinal layer is thinnest at 3/9 o'clock and absent ventrally (5–7 o'clock) — the commonest site of prosthesis extrusion, and the reason most plaques (60–70%) and curvature are dorsal. The penis deviates toward the plaque (the opposite of a penile fracture, which deviates away from the injury); a circumferential plaque causes an hourglass deformity.
Natural History
- Active (acute) disease — changing symptoms with pain (the defining feature), lasting up to 18 months.
- Stable (chronic) disease — clinically unchanged for ≥3 months.
Pain resolves spontaneously in ~90%, but curvature improves in only 12–13% (worsens ~45%, stable ~42%) — so deformity rarely self-corrects. The differential includes congenital curvature, a thrombosed dorsal vein, penile fracture, and (rarely) penile cancer.
Diagnosis
History and examination are mandatory; examine the penis on stretch and record a baseline stretched penile length. Before any invasive treatment, document the erect deformity objectively — the intracavernosal-injection (ICI) test ± duplex Doppler ultrasound is the gold standard (home photographs are an alternative). Ultrasound also identifies plaque calcification (extensive calcification predicts a poor response to non-surgical therapy). Routine labs and MRI are not needed.
Non-Surgical Treatment
- Active phase: NSAIDs for pain. (ESWT is a conditional option for pain only — it does not reduce curvature and may worsen it.)
- Stable phase:
- Penile traction — the first-line non-invasive option (wear ≥3 h/day); reduces curvature and increases stretched length and girth.
- Intralesional injection with modelling — collagenase (Clostridium histolyticum, Xiaflex) degrades collagen I/III for curvature 30–90° with intact erections and a single non-calcified dorsal/lateral plaque (IMPRESS I/II: ~17° vs 9° improvement); it does not treat pain or ED, can rarely cause corporal rupture, and was withdrawn in Canada/Europe in 2020. Verapamil (weak evidence) and interferon-α2b (modest; flu-like effects) are alternatives; corticosteroids are not recommended, and PRP/stem-cell therapy lacks efficacy data.
- Oral agents (CUA may consider; AUA does not endorse): colchicine, CoQ10, potassium para-aminobenzoate, pentoxifylline. Vitamin E and tamoxifen are not recommended.
Surgical Treatment
For stable disease (≥1 year from onset, ≥3–6 months stable) with deformity compromising intercourse, or after failed/declined non-surgical therapy. Counsel about residual/recurrent curvature, penile shortening, reduced rigidity, and transient sensory change; the goal is a functionally straight penis (<20° residual).
| Procedure | Best for | Trade-offs |
|---|---|---|
| Plication (tunical shortening — Nesbit, Yachia, 16-dot) | Simple curvature <70°, minimal hourglass, adequate length | Shorter and simpler, preserves rigidity; causes penile shortening; recurrence ~10% |
| Plaque incision/excision + grafting (tunical lengthening — pericardial or porcine SIS grafts, never synthetic) | Complex curvature >70°, large plaque, hourglass | Restores length but higher risk of reduced rigidity; needs strong pre-op erections (poor for ventral curves) |
| Penile prosthesis (inflatable, ± manual modelling/grafting) | Refractory ED with deformity, or profound instability | Gold standard when ED coexists; commonest complaint is length loss; modelling's main risk is urethral injury |
Self-Test
1. List the risk factors for Peyronie's disease. Infection, trauma, diabetes, radical prostatectomy, increasing age, genetic predisposition, autoimmunity, collagen disorders (Dupuytren's, plantar fasciitis, tympanosclerosis), and aberrant wound healing (mnemonic IT DRAG A Crooked Wand).
2. In untreated disease, how does the curvature evolve? Pain resolves in ~90%, but curvature improves in only ~12–13%, worsens in ~45%, and stays stable in ~42%.
3. Which oral agents are supported, may be considered, or are not recommended? Supported — NSAIDs for pain; may be considered (CUA) — potassium para-aminobenzoate, colchicine, CoQ10, pentoxifylline; not recommended — vitamin E, tamoxifen, procarbazine.
4. Which intralesional agents are recommended vs not? Recommended — collagenase, verapamil, interferon-α2b; not recommended — corticosteroids, botulinum toxin, PRP.
5. Which curvatures suit plication vs grafting? Plication for simple curves <70° with adequate length; plaque incision/excision + grafting for complex curves >70°, large plaques, or an hourglass deformity.
6. What is the gold-standard surgery when Peyronie's coexists with refractory ED? An inflatable penile prosthesis (± manual modelling or grafting).