Peyronie's disease is a common malady affecting men mostly between the ages of 40 and 60. When penile curvature and erectile softening are present and the erectile dysfunction does not respond to Viagra a penile implant will strengthen and usually straighten the penis. If curvature persists after implant placement ‘modeling’ the erect penis will successfully achieve straightening in most patients. Plaque incision and grafting or a Nesbit procedure are rarely necessary to straighten the penis but will afford excellent results when employed. A thorough explanation of the pathogenesis of Peyronie's disease and effects of the disease and treatment on penile size will help avoid some of the disappointment seen when a shorter erection occurs.
Peyronie's disease, or the development of a plaque like scar, in the tunica albuginea of the corpora cavernosa was thought to be uncommon and of unknown cause in most instances. It was first described in 1743 by the French physician Francois Gigot de la Peyronie.1 It certainly has plagued men before and after that original description. Numerous causes have been suggested but trauma to the erectile body especially in the aging penis seems to be the most likely etiology and consistent with clinical findings.
The tunica albuginea of the erect penis in young men has plentiful elastic tissue and has the ability to be bent or strained with resiliency and the ability to readily spring back to its original shape. As a man ages, however, elasticity in the tunica is lost and if continued vigorous sexual activity occurs, the less resilient and pliable tunica when subjected to aggressive force and pressure will sustain minor tears. An inflammatory response ensues, the development of scar tissue follows, and as scar tissue is deposited a non-stretchable plaque develops in the elastic covering of the erection bodies. As scar replaces the elastic tunica, the ability of the penis to stretch is limited and a shorter erection noted. In addition the scar tethers the erection towards the side to which it is located and a curved erection occurs. The scar may be so prominent that it inhibits blood flow to the end of the penis distal to the area of the scar and a relatively firm erection at the base of the penis with distal flaccidity may develop. In the early stages of plaque formation pain may be prominent caused by the inflammatory response, which occurs with healing of the tunica albuginea. With time the scar formation is complete, the inflammatory response subsides, and the pain tends to abate.
The time from the beginning of inflammation and the development of scar to stabilization of the curved erection can vary from 6 months to 2 y. Some patients have noted that the curvature becomes less prominent as time goes on. This may be due to the development of scar tissue in another location in the tunica albuginea which counter balances the scar which caused the original curvature. It is unlikely that once the scar has infiltrated the tunica albuginea it will revert to elastic erectile body covering.
Textbooks relate that this problem occurs in about 1–2% of the population usually beginning past the age of 40. However, the incidence is probably much greater than this as the scar may not be disabling or patients may be reluctant to discuss sexual problems and do not present for treatment. The disease tends to peak in the late 40s and early 50s. In the younger patients the tunica is pliable and less prone to such injury. In older patients the erections, if they work at all are not quite as firm. The older patient is unable to use his erections as aggressively, and tunical injury is less likely. When younger patients below the age of 40 present with penile curvature careful questioning usually reveals that a penile fracture had occurred with resultant scar formation. One should not confuse Peyronie's disease with congenital penile curvatures which are usually either ventral due to a shortened corpus spongiosum or lateral due to disproportionate growth of the erectile bodies.
Medical treatment of Peyronie's disease has been disappointing. Vitamin E,2 Potaba,3 colchicine,4 as well as a number of other medications have been tried and despite initial glowing reports success has not been substantiated with time. These medications have been designed to reduce the inflammatory response and unfortunately by the time the patient presents for treatment inflammation and scar formation are well underway or possibly even complete. These medications will not dissolve scar and return the now fibrotic tunica to its original elastic, pliable state. Recent reports of intralesional injection of verapamil5 or collagenase6 have noted positive results. However, these require a number of injections over a period of months and the long-term durability of this technique needs substantiation. Over 80% of patients with Peyronie's disease will relate that the erection is curved. In many the curvature is not that prominent that it would interfere with intercourse. Curves less than 30° are usually manoeuvrable for satisfactory intercourse. When the curvature is greater than 45° it is usually uncomfortable for the patient or his partner during coitus and in some cases with severe curves vaginal penetration is impossible. About 70% of the curves are in the dorsal direction where the penis is in an exaggerated bend towards the umbilicus. Less common is the development of soft erections associated with Peyronie's disease. It is reported that 15 to 20% of men with Peyronie's will have erections too soft to achieve penetration during intercourse. However, as men age the incidence of softer erections increases in general. This is due to hardening of the arteries and other possible concomitant disease processes which may contribute to diminished penile blood flow.
If the patient has adequate firmness to his erection and the curve is present but is not prohibiting intercourse or uncomfortable for the patient or his partner then no treatment is indicated. The etiology, natural history, and possible problems associated with Peyronie's disease should be discussed with the patient. If the erection is adequately firm but curved to the point where it is not easily usable for intercourse then a straightening procedure can be performed. There are two types, the Nesbit procedure in which ellipses of tunica are removed from the convex surface of the curve with closure of the defect created7 or plaque incision/excision with grafting over the exposed spongy tissue once the penis has been straightened.8 The advent of sildenafil has revolutionized the treatment of Peyronie's disease. Prior to its arrival in 1998 the treatment of soft and curved erections was placement of a penile prosthesis. However, many men with Peyronie's disease will respond to sildenafil and the erections may now be adequately firm for intercourse. Instead of a penile implant a straightening procedure, as described above, has been very adequate in restoring a patient to successful intercourse. Prior to the advent of Viagra intracorporal injections of papaverine, phentolamine, and prostaglandin E-1 had been used in many patients to restore erectile firmness. This treatment has not been well accepted in patients with Peyronie's disease due to the fact that areas of plaque that are usually dorsal are difficult to penetrate with the needle used to place the medicine within the corporal bodies. In addition, propagation of the scar has been blamed on the medication or trauma of the needle piercing the tunica albuginea. Vacuum erection devices have been impractical in cases of significant Peyronie's as the curved penis will hit the side wall of the plastic cylinder before sufficient turgor for intercourse is achieved. If intracorporal injections or a vacuum erection device are used a straightening procedure will be necessary if the curvature is significant. In the patient with Peyronie's disease with significant curvature in whom Viagra is unsuccessful in restoring adequate erectile turgor and duration a penile prosthesis has been the best alternative.
In Peyronie's disease the elastic tunica albuginea of the corpora cavernosa has been injured and been replaced by elastic scar tissue or plaque. During initial placement of a penile prosthesis in these patients it is usually easy to dilate through the spongy tissue to the subglandular area and to the ischeal tuberosities with narrower dilators. As larger dilators are passed, stretching of the tunica may be difficult. Cavernotomes or the Otis urethrotome may be helpful in broadening the caliber of the corporal bodies in this situation and in some instances it is prudent to use narrow girth cylinders. A finger in glove like fit of the cylinders in the corporal bodies gives as good rigidity as wider cylinders would afford. The three piece inflatable prosthesis cylinders give better flexibility in sizing. The cylinders which do not expand distally (CX, CXM, alpha-1, and alpha narrow) should be used. Cylinders which expand distally (Ultrex) tend to exaggerate the curvature as they afford considerable distal pressure which does not allow the end of the corporal body to shift over the end of the cylinder.9 The size of cylinder placed should be that which corresponds to the measured length of the corporal body. One should not attempt to place a cylinder larger than the length of the corporal body in an attempt to lengthen the penis. Such a choice will only tend to exaggerate the curvature, cause additional discomfort, and give an ‘S’ like configuration to the erection. Inflating a three-piece type of cylinder will frequently straighten the curve due to the intrinsic rigidity of these non-distally expanding cylinders. If significant curvature persists the technique of modeling the penis popularized by Wilson and Delk may be used.10 The currently available cylinders of American Medical Systems have a dacron/lycra middle layer, which prevents aneurysmal deformities. The bioflex material of the Mentor cylinder has a similar function and both of these types of cylinders give very good intrinsic rigidity. The cylinders are inflated to full rigidity and the tubing clamped after corporotomy closure. The penis is forcibly bent in the direction opposite to the curve and held for 90 s. During this manoeuver pressure should be held against each corporotomy to minimize the chance of disruption of the suture line. A cracking feeling may be appreciated as the scars of the Peyronie's plaque are ruptured. A running closure of the corporotomy seems more likely to rupture during modeling than if interrupted sutures are used. After 90 seconds the clamps are removed and additional fluid added to the cylinders. This is now possible because of some expansion of restricted corporal space by the modeling manoeuver. Clamps are then reapplied, corporotomies once again protected, and the modeling procedure repeated for another 90 s. The intervals of 90 s are arbitrary but have been successful in the majority of manoeuvers. Using a fixed amount of time reinforces the principal that repeated long intervals of modeling are more successful than abrupt short bursts of pressure applied in the direction opposite to the curvature. Two modeling sessions should be all that is necessary and a residual curvature of 20° or less should be considered acceptable and should not cause any disability during intercourse.
If angulation greater than 20° persists after modeling, incisions through the tunica albuginea carried down to the prosthesis on the concave surface of the curvature may be necessary. Multiple small incisions may be made and it was once recommended that they be left open and a gap between the edges of tunica albuginea allowed to granulate in with the prosthesis left about three-quarters inflated for 2 months.11 However, with the powerful girth expansion of the CX and alpha cylinders, rupture and aneurysmal protrusion through these defects may occur. One single large relaxing incision through the center of the plaque carried through the tissue to expose the prosthesis cylinder followed by inflation of the cylinder to full rigidity will adequately straighten the erection. Mobilization of the corpus spongiosum or dorsal neurovascular bundle may be necessary when performing such a relaxing incision. This latter manoeuver may cause temporary impairment of sensation to the distal penis which should return fully in 6 to 9 months. A patch graft can then be used to cover the defect (Figure 1). Synthetic materials such as gortex or Dacron attached to the edges of the native tunica albuginea with permanent soft suture such as Ticron or Ethibond have been successfully used. Naturally harvested grafts such as dermis and vein are less likely to be successful as they have only one surface available for imbibition. Newer materials such as cadaver pericardium (Tutoplast12) or small intestinal submucosa (Surgisis13) are suitable graft materials in this circumstance. The edges of these grafts are attached to the tunica albuginea with a long-term absorbable suture such as PDS or Maxon. These materials provide a matrix over which the body develops its own scar covering within 3 months. The penis should be kept about 75% inflated for prolonged periods during this interval to allow the healing process to occur with good length expansion of the phallus.
A modification of the Nesbit procedure can also be used to straighten the curved erection with an implant in place.14 An ellipse of tunica albuginea on the convex side of the curve is removed using electrocautery set at 35 W or less.15 The tissue above the prosthesis cylinder is removed and the defect closed with PDS or maxon sutures (Figure 2). This technique, however, will shorten the penis but avoids the use of grafts when the modeling procedure is not completely successful. The use of combined manoeuvers, ie modeling, incision and grafting, and modified Nesbit procedure may be helpful in achieving adequate straightening in cases of extreme curvature.
In the post-operative period following any of these procedures for straightening the penis the cylinders should be kept in a modestly inflated state. The penis should also be positioned pointing in the cephalad direction. Healing and the resultant deposition of scar tissue in the postoperative period will occur in the position in which the penis is kept. It is desirous to keep the penis in the position of function, ie pointing in the upward direction. The modeling procedure has rarely resulted in urethral injury. When this occurs it is usually in the area of the fossa navicularis and this area should be inspected for bleeding following the modeling manoeuver. When the patient returns in 6 weeks for instructions on operating his prosthesis the gentle manual modeling manoeuver should be performed with the penis in the almost fully erect position. This will break up any scars which could be starting to form or reforming which would tend to contribute to the curvature.
An hour glass or waist deformity may occasionally be present in Peyronie's disease. This defect is frequently expanded with cylinder inflation. If it persists following cylinder placement and inflation the indentation may be incised longitudinally throughout its extent and a graft placed as described above to cover the elliptical defect which occurs. However, with time and repeated expansion of the cylinder the waist defect becomes less prominent and eventually will disappear. It is probably wise not to attempt correction of hour glass deformities at the time of prosthesis placement. When performing incision and grafting or Nesbit type procedures degloving of the foreskin will give optimal exposure. When the foreskin is reattached redundant foreskin should be excised. If redundant foreskin is left it will tend to fall over the suture line resulting in maceration, premature dissolution of the sutures and infection. Lymphedema of the redundant foreskin may also occur if it is left behind. When degloving the foreskin a deep natural plane of dissection should be used. If a superficial plane is employed areas of skin necrosis may result.
Malleable or semi-rigid rod prostheses may also be used in patients with Peyronie's disease. These devices are more suitable for the patients with impaired mental or manual dexterity and for whom operation of a three-piece or two-piece inflatable device may prove difficult and frustrating. It is important to dilate to one size larger than the girth of the cylinder to be implanted. Also downsizing the length of the cylinder by about 0.5 cm less than the measured total corporal length will allow better bendability especially in the presence of extensive curvature and scar tissue. As with the three-piece inflatable cylinders the malleable or mechanical rods will usually straighten the erection adequately. The modeling procedure may also be used in these circumstances if placement of the rods does not adequately straighten the erection. The small relaxing incisions on the concave surface of the curvature may be performed without the necessity of tunical closure. Semi-rigid rods do not expand to herniate through the small defects in the erectile body covering. The two-piece hydraulic prosthesis, the Ambicor, can be used in Peyronie's disease when placement of an intra-abdominal reservoir may pose a problem. However, these devices do not have as good intrinsic axial rigidity and are not as reliable in straightening the erection as the three-piece inflatable models.
Placement of penile prosthesis in patients with Peyronie's disease can be a challenging undertaking, however, with proper selection of prosthesis model, cylinder size, and attention to detail in achieving a straight erection a very gratifying result can be achieved in most circumstances. Proper preoperative counseling that the erection will be shorter due to aging of the tunica albuginea, the original scar tissue from the tunical injury, the scar created in the tunica from placement of the prosthesis, and the scar forming around the cylinders as the body's reaction to healing after placement of these foreign bodies will help to lessen the disappointment which some patients will experience when the erection is now straight and functional but apparently decreased in length.
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Cite this article
Mulcahy, J., Wilson, S. Management of Peyronie's disease with penile prostheses. Int J Impot Res 14, 384–388 (2002). https://doi.org/10.1038/sj.ijir.3900865
- penile prosthesis
- Peyronie's disease
- penile curvature
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