Peyronie’s disease

Peyronie’s disease is a disease of the connective tissue of the penis. The tunica albuginea, the coarse connective tissue covering of the corpora cavernosa, develops fibrotic plaques. Affected patients feel thickening under the skin, which can be painful at times and sometimes leads to deviation of the penis, which shows bending during erection. Erectile dysfunction may occur as a result of the disease.

The disease is named after its first describer Francois Gigot de la Peyronie, the court physician of King Louis XIV.

Peyronie’s disease is more common than thought

The disease used to be seen as a rarity, but in fact the incidence seems to be many times higher. Depending on the study, 3–16% of men are affected, the average is about 5%. The condition often goes untreated for a variety of reasons. During the consultation, some patients do not mention the problem because they are uncomfortable talking about it. Others suffer from erectile dysfunction, which they accept as age-related, and consequently do not notice any deformation of the penis, which is not visible when flaccid.

Risk factors for the development of Peyronie’s disease

There is a clear correlation only with Dupuytren’s disease, another connective tissue disorder. This leads to the excessive formation of collagen fibres in the palm of the hand, where painful contractures of the fingers can develop.

The cardiovascular risk factors, i.e. diabetes mellitus, nicotine consumption, high blood pressure, etc., are more likely to lead to erectile dysfunction than to be triggers for Peyronie’s disease.

The course of Peyronie’s disease

The exact causes of Peyronie’s disease are still unknown. A combination of genetic predisposition, microtrauma and oxygen deficiency in the tissue is suspected. The underlying fibrotic plaques are local condensations of the connective tissue. These are located on the surface of the erectile tissue and contain excessive amounts of collagen and damaged elastic fibres. Small injuries, which presumably occur during sexual intercourse, lead to excessive wound healing. This causes the fibrotic plaques, which sometimes even show calcification. Pain is most likely to occur during an erection.

In the active phase of the disease, pain and changes in shape occur, while in the chronic phase a stable state is reached. Deformities no longer change.

Only in a minority of 12% does the disease heal spontaneously. In about 40% of patients the penile deformity increases, in the remaining approx. 50% the deformity reaches a stable state. The majority of deformities are dorsal (dorsum of the penis), sometimes lateral, and rarely ventral (underside of the penis).

The diagnosis is primarily made clinically, i.e. the patient’s complaints, palpable indurations on the penis and changes in shape. If there is any doubt about the diagnosis, an ultrasound examination can provide further information.

What are the treatment options for Peyronie’s disease?

– at the beginning of the active phase: during the first three months, a restrained treatment is advised. Conventional analgesics of the NSAID type (Irfen, Brufen etc.) to treat the pain; pentoxifylline as a non-specific phosphodiesterase inhibitor reduces fibrosis formation;

– Once the the disorder has reached a stable level, injections of PRP (platelet-rich plasma) have a positive effect on the disease, which is ultimately considered a wound healing disorder. Shock wave therapy improves vascualar regeneration and would healing. Other substances (vitamin E, potaba, colchicine, tamoxifen) have little efficacy and sometimes major side effects. Alternatively, injections with collagenase are available, which can reduce the size of the plaques but have no effect on any deformity. However, the treatment is expensive and bears quite some risks. Radiation has not shown convincing effects.

– in the chronic phase: If the disorder has been stable for a long time, shock wave therapy or PRP-injections no longer work. For deformities with an angle of up to 30°, a wait-and-see approach is more recommended. Injections with collagenase in combination with traction therapy may bring improvement, but the studies on this are not convincing. In addition, collagenase is costly and bears certain risks. Surgical treatment may be necessary for severe deformities over 30°, “hourglass” deformities or severe erectile dysfunction.

What side effects are to be expected?

Medication with NSAIDs and pentoxyfilline is usually well tolerated, but individual contraindications must be considered. PRP injections can cause haematoma (bruising). Caution is advised when taking anticoagulants (Marcoumar^®, Xarelto^®, Eliquis^®, Lixiana^®).

What are the costs for a complete treatment? Which part is covered by the health insurance?

The consultations and any laboratory analyses are covered by the basic insurance. The patient’s share of the costs is calculated according to their individual insurance conditions regarding their deductible and excess. PRP injections, however, are at the patient’s expense because there is no recognised treatment protocol for them yet.