Peyronie's Disease: Curvature, Erectile Dysfunction, and What the Evidence Supports

Peyronie's disease is a wound-healing disorder in which fibrous scar tissue forms within the tunica albuginea, the tough fibrous sheath surrounding the erectile chambers of the penis. The result is curvature, indentation or shortening during erection, often with pain in the early stage. It is more common than most men expect, and it frequently occurs alongside erectile dysfunction.

This article covers what the condition is, how it relates mechanically to erectile dysfunction, what the treatment options are, and what men with penile curvature should consider before using any external device.

How common it is

Mulhall and colleagues assessed 534 men attending prostate cancer screening centers in the United States, using both self-report and physical examination. Peyronie's disease was found in 8.9% — a group of men who had presented for an unrelated reason and who were not seeking help for penile curvature. Published in the Journal of Urology in 2004, the study also identified significant associations between Peyronie's disease and aging, hypertension, diabetes and self-reported erectile dysfunction.

Looking from the other direction, a study of men presenting with erectile dysfunction found Peyronie's disease in 7.9% of them, with significant associations between the condition and both longer duration and greater severity of erectile dysfunction.

At least 20% of men with Peyronie's disease have erectile dysfunction, and in some series the figure is considerably higher.

What happens in the tissue

The tunica albuginea is a layered sheath of collagen that surrounds the two corpora cavernosa. It has two functions during an erection: it contains the expanding tissue, and it provides the surface against which the draining veins are compressed. That compression is what holds blood inside the penis.

In Peyronie's disease, a plaque of disorganized scar tissue forms within this sheath. Electron microscopy of these plaques shows loss of the normal collagen architecture, with excessive deposition of collagen types I and III and disordered fibrin and elastic fibers. The affected segment loses its elasticity. During an erection the healthy tissue lengthens and the scarred segment does not, which produces the characteristic bend toward the plaque.

The trigger is generally thought to be repetitive minor trauma to the erect or semi-erect penis — often unremembered — followed by an abnormal healing response in susceptible men. It is not caused by sexual activity being unusual or excessive.

Why it causes erectile dysfunction

Two mechanisms operate, and research has established that both contribute.

Veno-occlusive dysfunction. Scarring impairs the ability of the tunica to expand and to accommodate the increased blood inflow of an erection. Where the sheath cannot expand and stiffen normally, the small venules perforating it are not compressed properly, and blood escapes. This is venous leak arising at the level of the tunica, and it is the same failure of retention described in Venous Leak and Erectile Dysfunction Explained.

Impaired arterial inflow. Fibrosis affecting the wall of the cavernosal vessels can reduce inflow independently.

A penile duplex ultrasonography study published in The Journal of Sexual Medicine in 2011 examined which of the two predominates and found that both veno-occlusive dysfunction and poor cavernosal arterial inflow were associated with erectile dysfunction in men with Peyronie's disease, and that both contributed. Multivariate analysis has shown a strong correlation between plaque size and the development of erectile dysfunction.

The practical consequence is that a man with Peyronie's disease and erectile dysfunction may have a retention problem, an inflow problem, or both — which is why assessment matters before treatment is chosen. The distinction is covered in our article on arterial versus venous causes.

The two phases

Peyronie's disease progresses in a recognized pattern, and the phase determines what treatment is appropriate.

The acute or active phase typically lasts six to eighteen months. Pain during erection is common, and the curvature changes over time. Because the deformity is still evolving, surgical correction is generally not undertaken during this phase.

The chronic or stable phase follows, when pain has usually resolved and the curvature has stopped changing. Stability for at least three months is the usual threshold before surgical options are considered.

Spontaneous improvement occurs in a minority of men. Most are left with some degree of stable deformity.

Treatment options

The American Urological Association publishes a separate guideline for Peyronie's disease, distinct from its Erectile Dysfunction Guideline. Treatment is a matter for a urologist, and the options below are described so that the conversation is easier to have, not as a basis for self-treatment.

• Intralesional collagenase clostridium histolyticum. An enzyme injected into the plaque to break down collagen, approved for men with stable disease and curvature above a threshold angle. Administered in a course of injections by a specialist.
• Other intralesional injections, including verapamil and interferon, are used with varying evidence.
• Traction therapy. Mechanical lengthening devices worn for defined periods daily, with evidence supporting modest improvement in curvature and length.
• Surgery. Plication of the longer side, plaque incision or excision with grafting, or placement of a penile prosthesis where erectile dysfunction is severe and unresponsive to other treatment.
• Treatment of associated erectile dysfunction, which is managed on its own merits alongside the curvature.

Oral therapies including vitamin E have generally not performed well in controlled trials. Any treatment marketed as dissolving plaques without clinical evidence should be treated with skepticism.

Curvature and external devices

Men with penile curvature frequently ask whether a constriction device is appropriate. The honest answer requires separating two questions.

A constriction device does not treat Peyronie's disease. It acts on blood retention, not on scar tissue, and there is no evidence that it changes the course of the condition or reduces curvature.

On the question of use, the relevant considerations are practical and worth raising with a urologist before proceeding:

• A ring is sized to the circumference at the base of the penis. Where a plaque or indentation is located near the base, the fit may be uneven, and a device that sits well on one side may not on the other.
• Significant curvature can change how a device seats during erection, and it may shift or apply pressure unevenly.
• Devices should not be used during the acute phase while erections are painful, and pain during use is a reason to stop.
• Men with a penile prosthesis, which is one surgical outcome for Peyronie's disease with severe erectile dysfunction, are a separate case and should follow their surgeon's guidance.

Where any constriction device is used, the wear-time limits and warning signs in our guide to using a constriction device safely apply, and sizing is covered in our guide to choosing the right size.

What this means practically

If you have noticed a bend, an indentation, an hourglass narrowing or a loss of length during erection, see a urologist rather than waiting. Assessment during the active phase establishes a baseline, and pain in the early phase is treatable. Photographs of the erect penis from above and from the side are standard for documenting the deformity and are genuinely useful to the clinician.

Ask whether your erectile difficulty, if you have one, has been assessed separately from the curvature. The two are related but are not the same problem, and the retention mechanism described above is often the part that goes unexamined.

Peyronie's disease has a documented psychological impact, and distress is a recognized part of the condition rather than an overreaction to it. It is a reasonable thing to raise with your doctor alongside the physical findings.

Key takeaways

• Peyronie's disease was found in 8.9% of 534 men attending prostate cancer screening, most of whom had not sought help for it.
• It was present in 7.9% of men presenting with erectile dysfunction, and at least 20% of men with Peyronie's disease have erectile dysfunction.
• Scarring of the tunica albuginea impairs its ability to expand, so the veins perforating it are not properly compressed — producing venous leak at the level of the tunica.
• Duplex ultrasonography studies show both veno-occlusive dysfunction and impaired arterial inflow contribute to erectile dysfunction in Peyronie's disease.
• Treatment depends on whether the disease is in the active or the stable phase; surgery is generally deferred until the curvature has been stable for at least three months.
• Constriction devices do not treat Peyronie's disease. Where curvature affects fit, discuss use with a urologist first, and do not use a device while erections are painful.

References

• Mulhall JP, Creech SD, Boorjian SA, et al. Subjective and objective analysis of the prevalence of Peyronie's disease in a population of men presenting for prostate cancer screening. Journal of Urology. 2004;171(6 Pt 1):2350–2353.
• Kadioglu A, Tefekli A, Erol B, et al. Prevalence of Peyronie's disease among patients with erectile dysfunction. European Urology. 2006;50(2):235–248.
• Chung E, Yan H, De Young L, Brock GB. Penile duplex ultrasonography in men with Peyronie's disease: is it veno-occlusive dysfunction or poor cavernosal arterial inflow that contributes to erectile dysfunction? The Journal of Sexual Medicine. 2011;8(12):3446–3451.
• Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's Disease: AUA Guideline. American Urological Association, 2015.

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