Peyronie's Disease | Dr. Andrew Y. Sun

Peyronie’s Disease

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About Peyronie’s Disease

Peyronie’s disease is an acquired physical deformity of the penis. It is most often caused by scar tissue (which we call “plaque”) in the fibrous coating of the penile erectile bodies that causes a curvature or a constriction of erections. It is a psychologically traumatic condition that lowers men’s self-esteem, inhibits normal sexual function and frequently stresses relationships. There is not always a direct cause for Peyronie’s, though it is believed to be caused by repetitive micro-trauma to the semi-erect penis, essentially a “wear-and-tear” phenomenon over time. Only about 10-15% of men will remember a physically traumatic sexual experience that caused the penis to bend forcibly and often painfully. Some people are genetically predisposed to the condition. Francois Gigot de la Peyronie was a court physician for King Louis XV of France in the 1700s. He first wrote about the condition and as such, it has carried his name for the last 300 years.

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90%

Success rate with advanced treatments like Xiaflex®.

80%

Significant improvement with personalized care.

Symptoms of Peyronie’s Disease

With Peyronie’s Disease, most men will notice one or more of the following:

visible bend or curve

Most often up, but also can be left, right, or down

penis shortening

and length loss

Hourglass deformity

Narrowing of the penis at the site of plaque

Hinge Defect

The penis is weak and bends easily at the plaque

penis narrowing

at the plaque, and decreased girth past the plaque

pain during erection

or during intercourse

Diagnosing Peyronie’s Disease

The analogy that I often use is that of a long balloon – the kind that you fold into balloon animals. Normally when you blow it up, it’s straight. Now imagine a big piece of tape slapped on one side – what happens when you blow up the balloon now? It will bend towards the side with the tape because that side can’t expand anymore. It will also constrict it’s length-wise expansion. That’s essentially what’s happening in Peyronie’s – the penis is the balloon, and the plaque is the piece of tape.

The patient usually makes the diagnosis of Peyronie’s when he notices his penis develops a curve with erections. Some men will develop severe curvature overnight, others will take months to develop the deformity. It can be painful, especially in the first few months of development. Specialists divide PD into 2 categories: acute and chronic. The acute phase can last up to a couple of years but most men evolve into the chronic phase in the first 6-12 months after noticing the curvature. Along with curvature, most men will notice loss of penile length which can sometimes be dramatic. Some men claim losing up to ½ of their former erect penis length. Penile shortening occurs because the thick fibers of the penis are usually elastic and stretch with blood flow, but the plaque prevents the tissue from stretching, and men find themselves with a smaller erect penis. Talk about adding insult to injury.

As with most things in medicine, there are a few general options, which I divide into categories. I use this mnemonic a lot, and it applies to both Peyronie’s and ED.

Prevention
Pills
Pokes
Pulling
Procedures
Pulses

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Treatment Options for Peyronie’s Disease

One important thing to consider is what the treatment goals for a man with Peyronie’s are. If ever a surgeon tells you that they can give you back the penis you had when you were 18, you should run in the other direction, because that is simply not possible. What then, are reasonable treatment goals? We will set these together, but generally, what we are aiming for is a rigid, reliable, physiologically straight (usually meaning 5-10 degrees or less), penetrative penis that can be used to have intercourse without pain. That’s really the goal, isn’t it?

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As we discussed earlier – it is a minority (10-15%) of patients who remember a clear inciting event, like a missed entry, a “partner on top” situation gone awry, or something similar. Most of the time, the condition appears to come out of nowhere, which only further adds to the distress. The prevailing theory of Peyronie’s formation goes like this: as men enter their 40s and 50s, their erections are not quite as strong as they used to be. The daily wear-and-tear on the penis that comes with having sex with an 8/10 erection is enough to induce “micro-trauma” into the lining of the erectile bodies. In some men, this does nothing. In others, often those with a genetic predisposition, abnormal healing occurs and develops into a plaque. Just as everyone heals scars differently, everyone heals their penis differently. Eventually this plaque becomes Peyronie’s. Following this theory, the best prevention against further damage is to optimize the erectile strength – often with medications such as daily cialis – and avoid or be cautious about what sexual positions you engage in. As one of my mentors told me: “choose a position where you’re in control of the rhythm.” So that means no cowgirl, and definitely no reverse-cowgirl. Sorry if that’s your favorite! Another point is that the penetrative force required for anal intercourse is generally higher than that for vaginal intercourse, so often this leads to a higher risk of Peyronie’s as well, unfortunately.

Most physicians initiate treatment with medical therapy, usually pills or topical creams to the penis. The history of pill therapy for Peyronie’s includes many drugs, none of which are FDA approved. As discussed above, use of pro-erectile agents such as Cialis (tadalafil) can be helpful, mostly to help prevent further damage by supporting erectile strength. One interesting drug is Pentoxifylline, a drug initially used to improve blood flow to the legs of patients with vascular insufficiency. In Peyronie’s, pentoxifylline inhibits some of the inflammatory proteins that lead to abnormal scar formation. Many clinical trials have demonstrated that pentoxifylline has a modest effect, about a 40% chance of improving the plaque after 6 months of therapy. It has a pretty good safety profile with few side effects. Older medications like colchicine have fallen out of favor due to lack of improvement and higher side effect profile. Some urologists prescribe a topical medication called verapamil, a cream you rub into the plaque on the penis once or twice a day. Sadly it’s expensive and doesn’t have a shred of good data to support its use. Vitamin E was used for a long time as well, and while we wish it worked, sadly it doesn’t do a damn thing.

Intralesional injection therapy for Peyronie’s is in the midst of a revolution. Urologists have injected verapamil (a blood pressure medication) into plaques for years with middling success. Interferon injections have also been used with similar modest success. Neither of these therapies are FDA approved. As of 2013, there is only one FDA approved intralesional therapy: Xiaflex (collagenase clostridium histolyticum) is a biological agent that a urologist injects directly into the plaque. The enzyme digests the abnormal collagen deposits in the plaque to decrease the abnormal force exerted on the penis. In the initial clinical studies men had an average 40% improvement in their curvature and reported improvements in their distress suffered from the disease. Side effects of this therapy are usually mild and included temporary pain, bruising and swelling. A few men in the clinical trials had a penile injury severe enough to need surgical correction, but very rarely. All of these men regained sexual function post surgery. Newer data has shown that when combining Xiaflex with Traction therapy, results are further improved to about 70-75% – more on that later. Xiaflex has truly revolutionized the treatment of Peyronies’s as we now have an effective, non-surgical therapy with excellent results. What is unique about this treatment is that it is a restorative treatment, one that is actually trying to melt down the plaque and return the penis to a healthier state. This is the only reasonable intralesional therapy to offer, and anyone still offering Verapamil injections is stuck in the stone age. As a Peyronie’s Disease Center of Excellence, here at the UPNT Center for Men’s Health we perform over 60% of all the Xiaflex injections in the entire DFW Metroplex, and serve as a national model in the treatment and education surrounding this condition.

Penile traction and vacuum erection devices are two therapies a lot of urologists combine with either pill therapy or injection therapy. The idea is simple, and it works like braces for your teeth: mechanical traction, over time, can remold otherwise seemingly solid parts of the anatomy. Studies demonstrate improvement in both lost penile length and penile curvature with consistent traction use, especially combined with other therapies. At the end of this document, traction is explained in further detail. Vacuum devices don’t have quite the same statistical success rates but also don’t have to be worn for so many hours. Vacuum devices are especially useful for men with hourglass and constrictive deformities, as we are using the mechanical force of the vacuum to draw blood into the penis and give it the mechanical stretch, to try and restore some girth. These are powerful adjuncts to treatment and consistent use can nearly double the efficacy of Xiaflex injections. We highly recommend traction therapy in our Xiaflex patients, almost to the point of making it a mandatory requirement.

Long the mainstay of Peyronie’s management (before the Xiaflex revolution), there are three surgical approaches for Peyronie’s. The most straightforward is called a penile plication. This is a 1 hour-long, same-day surgery done under general anesthesia, where we place sutures on the opposite side of the penis to the bend, and essentially pull the deep tissues of the penis together to straighten the penis. In my balloon analogy, this equates to putting an equal sized piece of tape on the other side of the penis. Fundamentally, it is a compensatory action, as opposed to a restorative action. You’re not actually treating the plaque here, you’re compensative for the deformity – by shortening the long side of the penis to match the side that has been shortened by the plaque. However, despite this, in the carefully selected patients, this is still a very good options. The rate of success is extremely high, and the fix is immediate. For a man with good erectile function but a bothersome curve, who desires a quick-fix, and doesn’t mind sacrificing a bit of length, this is a reasonable option. Unfortunately, this doesn’t do much for a guy with a primary hourglass-type deformity.

The next surgical option is far more involved. Penile plaque excision and graft surgery is exactly that, degloving the penis, chipping out the plaque, and grafting a piece of artificial material to take its place. This is a highly complex operation and there are only a small handful of surgeons around the country who are trained to perform this. The plaque sits underneath a complex neurovascular bundle where the sensation nerves and some of the penile blood vessels run. One of the trickiest parts of this surgery is to elevate this bundle without cutting any of the fibers to expose the plaque. Injury to these fibers can lead to penile numbness, impotence and long-lasting fluid collections called lymphedema. The other tough part of this operation is figuring where to get the patch. Surgeons have tried many materials ranging from tissue harvested from the patient’s own body, artificial materials, animal tissue and lastly tissue harvested from human cadavers. With this many options and surgeon opinions, one may rightly assume there is no consensus on the best material. Risks of plaque incision and grafting include temporary or permanent penile numbness, reduced erection strength, scarring and shortening. In an experienced surgeon’s hands, however, this represents a powerful and effective treatment option, especially for severe, calcified plaques. Dr. Sun is one of only two surgeons in the DFW metroplex trained to perform this complex surgery, doing about 10-15 per year.

If a man suffers from both Peyronie’s and severe erectile dysfunction, we have to change our strategy a bit. A man with severe erectile dysfunction does not benefit from a surgery to correct a curvature alone – all that gives him is a straighter, but still floppy and ultimately useless penis. For these patients, a penile implant with intraoperative modeling, plication, or plaque incision is likely the best surgical option. Surgeons have been placing implants for over 50 years. This is a one hour, outpatient procedure done through a 1 inch incision, which installs an implant into the penis that can correct both the Erectile Dysfunction and the Peyronie’s deformity because the cylinders will act as beams to straighten the penis. Once the surgeon places the implant, adjunctive surgical maneuvers can be used to straighten the penis. With the cylinders in place, the penis has a good chance of holding straight once the man heals. This can often be the best option to accomplish the ultimate goal – which is a straight, rigid, reliable, penetrative penis.

Shockwave therapy is the newest craze in Men’s Health. Currently, unscrupulous “Men’s clinics” are offering shockwave to treat seemingly everything under the sun, including Peyronie’s Disease. A variety of fantastical statements are given to desperate men seeking a solution, cash is collected, and almost universally, the men end up disappointed with their treatment results. It is really a tragedy. The truth is, that for Peyronie’s Disease, shockwave has very limited value. There is some data showing that shockwave therapy can help the pain associated with acute phase Peyronie’s. There is absolutely no good data showing that shockwave will magically “break up” the plaque and reduce curvature. In fact, all the available data shows that it does nothing for the plaque. Don’t fall prey to false advertising. This is not to say that shockwave, specifically linear focused shockwaves delivered with an FDA Class III device, are not useful for erectile dysfunction. The data on erectile dysfunction is fairly robust at this point, and shockwave has been used for ED with excellent results. This is something we also offer at UPNT. To sum it up, in a man with concurrent PD and ED, shockwave may be helpful for erectile strength, but not for breaking up the plaque.

Penile traction and vacuum erection devices are two therapies a lot of urologists combine with either pill therapy or injection therapy to increase therapeutic benefits. The traction devices can be a bit cumbersome. Older models had to be worn for several hours a day, but newer models have reduced this time. Importantly, the data supporting their use is good – studies demonstrate improvement in both lost penile length and penile curvature, some patients report gains of up to an inch or more. Vacuum devices don’t have quite the same statistical success rates, but also don’t have to be worn for so many hours, and are usually less expensive. Vacuum devices also have the benefit of helping stretch the penile tissues, keeping the “muscle” of the penis active, helping to ward off against length loss.

The traction device with the best data is called the RestoreX® device, developed by a urologist and Men’s Health expert from the Mayo Clinic. It can be directly purchased online from their website or here at the UPNT Pharmacy for about $500. Their website is www.restorex.com. An older traction device that was used for a long time (and that has a great name) is the Penimaster Pro®. It is also a bit cumbersome to use but was the industry standard until the RestoreX® was developed. It can be purchased at www.urologyhealthstore.com and currently runs $390. Personally, I will always recommend the RestoreX because they have done the most thorough clinical trials on the devices with the greatest scientific rigor. Another comparable device is the AndroPenis®, also available online at www.andropenis.com

Vacuum devices are generally used for erectile dysfunction but have found a home in the treatment of Peyronie’s Disease as well. These devices work by generating a negative pressure vacuum around the penis to draw in blood, generating an artificial erection and stretching out the tissues of the penis. A variety of models exist, from cheap, $50 mechanical models at an XXX store, to professional medical grade ones in the $150-300 range. For men who will utilize the VED consistently, we always recommend going with a professional model with greater reliable, safety, and a warranty. We carry several models at UPNT Pharmacy.

Unfortunately these devices are usually not covered by insurance, however they are usually HSA/FSA eligible. Please note that none of your UPNT Men’s clinic providers have any financial relationship with any of these companies.

If you’ve made it this far down this document, congratulations, you’re a trooper, and you’re clearly invested in exploring the right treatment for you. One of my mentors used to say “ultimately, it’s not the patient or the doctor, but the penis that picks the right treatment for it.” All penises are different, all plaques are unique, and patients differ in terms of timelines, risk tolerance, erectile function, cosmetic desire, partner status, and a whole host of other factors. As someone who has advanced fellowship training in Peyronie’s Disease, and whose practice is entirely devoted to Men’s Health, I’m confident that we can work together to find the solution that works for you.

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Video about Peyronie’s Disease

What Patients Are Saying

Anthony

Dr. Sun is one of the few doctors who really listens to you and will always take the time to address your concerns and answer questions and is highly knowledgeable. Very highly recommended.
Jesus M

Dr. Sun was recommended by a friend of mine, and I’m glad he was. He is not only obviously knowledgeable, he’s personable and as dedicated to providing the best experience as any man can hope. Himself and his Assistant, Deja, made me feel comfortable throughout the entire process. I recently contacted him about a specimen count as I was overseas and wasn’t available after the short healing time. An entire year since the procedure Dr. Sun is still as attentive to my needs as the day I met him. Thank you so much, Doc!
Guoliang Wang

Dr. Sun was referred to me by my daughter who is a MD. I consulted Dr. Sun for my health remotely and was very impressed by his eagerness to treat patients and by his intelligence and deep domain knowledge in the field. He was very polite and asked detailed questions to really understand my situation. Then he explained to me patiently in full detail about the different medications, procedures/surgical options, and each of their advantages and side effects. I was so happy consulting with Dr. Sun as he helped me understand my health situation in a deeper and broader aspect. I highly recommend Dr. Sun.
Ty Turkett

Never heard of Peyronie’s disease at 55 before speaking to Dr Sun but after him giving me an explanation and best direction for correction I felt much more comfortable moving forward with surgery. I am happy to say he did a fantastic job of correcting curvature and explaining after care stretching. I highly recommend Dr Andrew Sun as your urologist as he will continue to be mine moving forward.
James B. Bobo

I was referred to Dr. Sun by a friend of mine, after reading his Bio I chose to have a consult with him. Dr. Sun is extremely intelligent and knowledgeable on many things when it comes down to male health. I chose Dr. Sun to do my NSV & was amazed by how little pain there was. I felt no pain during or after the procedure. Dr. Sun was gentle and accurate with every motion. He also possesses a very outgoing and comedic personality! Which made the entire procedure a breeze. Highly Recommend Dr. Sun!
Ross

Dr. Andrew Yang Sun MD.., is a great surgeon, he explained the procedure very well, it helped me with my erectile dysfunction. It resolved my problem and provide self confidence as man. I highly recommend talking to Dr. Sun. His rate: AAA+++ January 2024
Lorraine Ellis

My husband sees Dr. Sun. We both find him to be very knowledgeable and he has helped improve my husband’s health a lot! He is honest, caring and friendly. His front and back office staff are amazing! Smiles can be seen on every face working there. We highly recommend Dr. Sun and his practice!
Gehrig Saldana

I gladly submit my personal referral for my excellent urologist, Andrew Y. Sun, MD. Dr. Sun has been my urologist for almost a year to date. I’m 71 years young, & noticed over the past few years I had to wake up too many times to use the restroom disrupting my sleep along with having ED creep up on me as I aged to my present age. My primary physician referred me to Dr. Sun & I’m glad he did! Dr. Sun’s care for my prostrate (multiple trips to restroom at night) issue & my ED issue are now resolved to a point where I sleep much better at night. Top that off with my ED issue now pretty much in my rear view mirror. In short, I feel like I’m living the life of a 50 year old dude! Thank you Dr. Sun! Gehrig Saldana
Michael Mcclenon, Sr.

Dr. Sun is a great doctor, he explains things to you so you can understand it. He is a very cool professional, thank you Dr. Sun for taking care of me, GOD BLESS YOU AND YOUR FAMILY.
Alex Hernandez

Awesome experience. Doctor Sun is very knowledgeable & explains things simply to ensure I understand exactly what’s going on & what he plans to do to help. I recommend him highly.
Orlando Villegas

Doc was very informative and very direct and explained in real people language, not Doctor lingo. LOL The options are there and he is willing to explain all of them and I asked many what if scenarios, he was very understanding.
Julie Johnson

I have never encountered a more kind and patient doctor. He takes the time to answer all the questions I have had in detail, and until I’m comfortable. I would recommend Dr. Yang to anyone!
Jerry Carbajal

I felt comfortable speaking with Dr. Sun about my ED problem. He answered all of my questions and explained all of my options. I feel real good about my journey together!
Steve M. Walker

I didn't have any issues and Dr. Sun and Dr. White kept a check on me through the whole process.
Ken Abrams

Excellent service and answered questions
Shane Derby

Have been with Dr Sun for five years. Extremely knowledgeable and friendly.
Neil Landers

Excellent listener and makes you feel like a partner in your care decisions. Highly recommend!
Joe Bouch

He is very knowledgeable, communicates well, and is efficient.
Earl Pigg

Talked to me and my wife so we can understand what's going on with problems
Chris Stratton

The Best.
Jeffrey Hawthorne

Outstanding Physician and Surgeon
Tasha Taylor

Very professional