What is a penile curvature & how to treat it?

Penile curvature (a bent penis or Peyronie's disease) is a medical condition, which leads to curved and painful erections. The curvature is caused by development of fibrous scar tissue inside the penis (tunica albuginea - tough fibrous layer of connective tissue that surrounds erctile tissue, also known as the corpora cavernosa, of the penis). Peyronie's disease is a common condition affecting 3-9 % men (Pryor & Ralph, 2002) with a higher prevalence in patients with ED and diabetes (EAU guidelines, 2018). Frankly speaking, aetiology of penile curvature remains unclear but it may be a result of abnormal healing process following either trauma or repetetive microvascular injury to the tunica albuginea of the erect penis in a genetically susceptible individual (Marinkovic JM, Sipetic SB, Vlajinac HO & Bjekic MD, 2006, Pastuszak AW & Herati AS, 2016, EAU guidelines, 2018). A prolonged inflammatory response will result in the remodelling of connective tissue within the tunica albugea into a fibrotic plaque. Penile plaque formation can result in curvature which, if severe, may prevent penetrative sexual intercourse. There is also an assumption that penile curvature may also have an aetiology of an autoimmune collagen disease, as it is often associated with the fibromatoses Dupuytren's and Lederhose disease (Ralph DJ et al., 2010). Dupuytren’s contracture is more common in patients with Peyronie's disease affecting 9-39% of patients while 4% of patients with Dupuytren’s contracture reported Peyronie’s disease (EAU guidelines, 2018).

Peyronie's disease has two phases:

I. Acute inflammatory phase

During the 1st phase a man may experience pain in the flaccid state his penis or painful erections. There may be a palpable nodule or plaque within the penis. Typically, along with these symptoms, a penile curvature begins to develop.

Pain is present in 35-45% of patients during the early stages of the disease. Pain tends to resolve with time in 90% of men, usually during the first twelve months after the onset of the disease.

II. Fibrotic phase (chronic phase)

During the 2nd phase hard palpable plaques that can be calcified begin to form. The disease stabilises, which is defined by no further progression of a curvature.

With time, penile curvature is expected to worsen in 30-50% of patients or stabilise in 47-67% of patients, while spontaneous improvement has been reported by only 3-13% of patients.

Unfortunately, the penile curvature rarely improves spontaneously and in addition to the physiological and functional alteration of the penis, affected men also suffer significant distress. Validated mental health questionnaires have shown that 48% of men with Peyronie's disease suffer from mild or moderate depression, sufficient to warrant medical evaluation. (EAU guidelines, 2018).

So... WHAT ARE THE TREATMENT OPTIONS AVAILABLE?

There are two options available: surgical and non-surgical.

>>> I. Non-surgical treatment

Conservative treatment includes oral medications, intralesional injections, topical agents, shockwave therapy and traction devices.

However, Clostridium collagenase is the only drug approved for the treatment of Peyronie's disease by the FDA (The Food and Drug Administration of the United States Department of Health and Human Services) and the EMA (European Medicines Agency).

The results of the studies on conservative treatment for penile curvature are often contradictory making it difficult to provide recommendations in the everyday, real-life setting. This is due to several methodological problems including uncontrolled studies, limited number of patients treated, short-term follow-up and different outcome measures. Moreover, the efficacy of conservative treatment in distinct patient populations in terms of early (inflammatory) or late (fibrotic) phases of the disease is not yet available.

I.I. Non-surgical treatment - oral medications:

1. Vitamin E

2. Potassium para-aminobenzoate ("Potaba")

3. Tamoxifen

4. Colchicine

5. Acetyl esters of carnitine

6. Pentoxifylline

7. Phosphodiesterase type 5 inhibitors

I.II. Non-surgical treatment - intralesional injections:

1. Steroids

2. Verapamil

3. Clostridium collagenase