Peyronie’s disease is most commonly found between the ages of 40 and 70 but men of any age can be affected, even teenagers. The cause is thought to be trauma, damage or injury to the penile tissues, usually just from aggressive sexual activity. The initial injury can be quite minimal and it’s unclear why only some men develop Peyronie’s while others don’t. A genetic component is suspected since Peyronie’s tends to run in families. Left alone, Peyronie’s disease will tend to improve over time in about 12-13% of patients, remain stable in about 40-50% and worsen in the remainder. In a small percentage, perhaps 10% or less of patients with the milder form of the disease, the condition will resolve itself without causing any significant or lasting harm. More severe cases can result in significant curvatures over 90 degrees and can make intercourse impossible. Penile injection therapy for ED and radical prostate surgery appear to increase the incidence of Peyronie’s. Other conditions associated with Peyronie’s include Dupuytren’s contractures (scarring in the hands) in up to 20% of patients with Peyronie’s and tympanosclerosis (scarring involving the inner ear.

There are three general types of treatments: Medical Non-invasive Therapy (pills, topical creams, traction devices), Penile Injections and Surgery.

Medical Non-Invasive Therapies

Initial treatment of Peyronie’s has generally been with medical therapy even though results are often disappointing and there is a general lack of studies demonstrating effective or optimal treatment. Patients generally want to at least try a non-invasive approach first. Most of the treatments mentioned have not been adequately studied to determine their true effectiveness in treating Peyronie’s. In these circumstances, until sufficient scientific information is available to make rational decisions, we rely on the consensus opinion and experience of experts to help us decide on a reasonable plan of therapy. Traditionally, physicians have used and continue to use Vitamin E and/or Potaba although newer medical treatments appear more promising today.

Vitamin E is a commonly used anti-oxidant that may have benefits in cancer prevention and wellness. Its use for Peyronie’s disease is based on a study done in 1948 that suggested it reduced the penile deformity and eliminated penile scarring. However, better studies since then have not confirmed any benefit in Peyronie’s and there are potential toxicities from Vitamin E if more than 400 mg daily is used. Its low cost, wide availability and almost total lack of adverse side effects make it an attractive initial therapy even if its only benefit is purely psychological as a placebo.

Potaba (potassium amino-benzoate) is a prescription medication that has shown some activity in reducing the size of the plaque although it may not relieve the deformity. There is also some evidence that it may stabilize the plaque and prevent scar progression. Unfortunately, the drug has very significant gastrointestinal side effects, is relatively expensive and requires large numbers of daily tablets. Most experts no longer recommend this drug for Peyronie’s.

Colchicine is a prescription medicine often used to treat gout. It also blocks scar tissue production. Initial reports in 1994 suggested effectiveness in Peyronie’s disease. More recently, colchicine has been tested more extensively and found to be no better than placebo. Worse, it can cause significant diarrhea, nausea, vomiting and rarely a severe anemia. Most experts no longer recommend colchicine for Peyronie’s disease.

Carnitine is a naturally occurring antioxidant that is commonly used as a nutritional supplement. Its main function in human nutrition is to facilitate the transport of essential fatty acids into the mitochondria, especially in muscle cells. It also acts to reduce inflammation in blood vessels. A single study in 2001 found that carnitine did appear to improve curvature and reduce pain somewhat in patients with Peyronie’s disease. Carnitine is relatively inexpensive, does not require a prescription and appears to be safe as side effects are uncommon. More conclusive evidence of its effectiveness is needed before it can be routinely recommended for Peyronie’s disease. A dose of one gram twice a day has been suggested.

Arginine is an essential amino acid and nutritional supplement that is a normal part of our everyday diet. When given as a supplement, it has been shown to reduce plaque size 80-95% in animal models of Peyronie’s disease, presumably by increasing nitric oxide production. Arginine has also been found to have a natural ability to decrease scar tissue formation, particularly when used together with other scar tissue inhibitors like vardenafil (Cialis) and pentoxifylline (Trental) which are reviewed below. However, the lack of any human studies using arginine in Peyronie’s disease means that its actual benefit remains unproven. Still, a number of experts recommend arginine since it’s inexpensive, doesn’t require a prescription and is very well tolerated. A dosage of 500 mg twice a day or 300 mg three times a day has been suggested although the optimal dose is unclear.

Trental (pentoxifylline) is a prescription medication that has been used extensively for vascular disease. Experimental data indicates that it also decreases inflammation, prevents scar tissue buildup, and successfully treated Peyronie’s disease in an animal model. Only anecdotal reports have been published to date on the use of Trental in treating Peyronie’s in humans. However, several Peyronie’s disease experts use Trental to treat Peyronie’s because of its reasonable scientific rationale, low cost and high tolerability. The usual dose of Trental is 400 mg three times daily.

Viagra, Levitra and Cialis are being considered as possible oral therapies for Peyronie’s in addition to their standard function as prescription medications for ED. They all help release nitric oxide, which not only benefits the erection process, but theoretically should also reduce scar tissue production. They have also been shown to be helpful in the animal model of Peyronie’s where plaque buildup has actually been reversed using these drugs. Since they would need to be taken regularly, the most appropriate medication of this class would probably be Cialis (Vardenafil) because it’s available as a once a day pill. Its relatively high cost would make it less accessible to patients without prescription insurance coverage.

Verapamil is one of the more effective medications currently in use today for Peyronie’s, particularly as an intralesional injection. Unfortunately, oral verapamil therapy is unable to deliver sufficient verapamil to the Peyronie’s lesion to have any noticeable effect as a very high local concentration of verapamil is needed in the penis. Early reports of verapamil applied topically as a gel appeared promising, but subsequent evaluation revealed that virtually none of the drug actually reached the plaque area when applied on the skin. The gel is quite expensive and is not generally recommended by most experts due to its high cost and inconsistent efficacy. The only licensed U.S. manufacturer of Verapamil gel is PD Labs.

Electromotive Drug Administration (EMDA) or iontophoresis is a painless, noninvasive technique to increase tissue absorption and penetration of topical medications. EMDA uses a very mild and gentle electrical current to carry the medication into the deeper tissues of the penis. Experimental evidence has shown that this technique can allow significant amounts of medication to penetrate the Peyronie’s plaque. A combination of verapamil and dexamethasone (a steroid) are the typical agents used. Results suggest there is an average improvement in penile curvature of about 10 to 15 degrees as well as a reduction in pain. Optimal candidates for this treatment would be those with a curvature of no more than 45 degrees. If the curvature is downwards, then EMDA should not be used.

Two to four treatments a week is recommended. The main problem with this treatment method is the high cost of the device. At this time, only the Physion EMDA device is specifically recommended.

Penile Traction Devices

Early reports suggest a reasonably substantial benefit from the use of a medical grade penile traction device. The device is worn for 2-8 hours daily for 6 months. Initially intended to increase penile length, it was subsequently noted that they actually seemed to reduce the severity of penile curvatures, which led to their use specifically for Peyronie’s. So far, only a limited number of preliminary studies have been done, but almost every patient who used the device long enough saw a benefit. The main disadvantages of the penile traction device are the need to wear it for hours at a time over a period of months and the initial cost. The particular device used in the studies is called “FastSize” and is available directly from our office (440-985-9898).

External Vacuum Devices have also been used to treat Peyronie’s disease. Their function is similar to the penis extenders and traction devices in that they attempt to mechanically stretch the scarred areas to increase their effective length. The problem with the vacuum devices is that they are too uncomfortable and unwieldy to be used continuously although some small benefit has occasionally been reported with their use. At this time, we only recommend the external vacuum device to men with Peyronie’s who also have an ED problem that is not otherwise resolved with other treatment.

Direct Intralesional Injections

Injections of medication directly into the Peyronie’s plaque provide much higher concentrations of the drug than could be tolerated by just taking tablets or pills. Local anesthesia is used to minimize the discomfort and the injections are usually given about every two weeks for periods of 6 to 12 months. (Steroid and Botox injections are specifically not recommended.)

Verapamil, when used as an intralesional injection, is one of the most effective medical remedies available. It appears to increase collagenase activity, interfere with scar tissue formation and modify the inflammatory response. Published studies on Verapamil injections for Peyronie’s have consistently shown beneficial effects with relatively few side effects. The standard injectable dose is 10 mg of Verapamil (5 mg/2cc) diluted to 10 cc and injected with a 25-gauge needle directly into the plaque. Most patients who respond will begin to notice an improvement by the sixth injection. The dosage can be increased to 20 mg if no improvement is noted.

Interferon is part of the body’s natural immune response to foreign bodies and substances. Direct injection of interferon has generally been reported as successful in reducing Peyronie’s plaques. Possible side effects include muscle and joint pain, fever and flu-like symptoms. At this time, it’s unclear if interferon is equal to verapamil as an injectable agent for Peyronie’s disease. There is also no data on the use of both of these agents together.

Surgery

For most patients with Peyronie’s disease, the problem never becomes severe enough to warrant a surgical procedure. Surgery is generally reserved for those patients with mature and stable disease (usually at least 1 year) where the curvature is so severe that intercourse is no longer possible and all other reasonable treatment options have failed. It must be understood that no medical or surgical treatment can promise to recover the full length of the original penis before the Peyronie’s and most patients have a straighter, but shorter penis.

There are two basic surgical options. The first involves just suturing the “longer” side in a way that makes it closer in size to the opposite, affected side. This will straighten the penis without actually cutting out the abnormal fibrous tissue. The technique is called “plicating” and the procedure is called the “Nesbit” procedure. It works best with relatively mild curvatures in patients with good erection ability. The other technique involves cutting out portions of the abnormal plaque and replacing it with a graft. While this seems simple and logical, grafts tend to contract and erectile dysfunction is more common than with plication methods. That’s why this type of surgery is often done together with a penile prosthesis. Graft type procedures are preferred for the more severe cases (curvature of 60-70 degrees or more), but have higher complication rates, so we recommend selecting a surgeon with significant experience in this particular type of surgery. The goal in surgery is to reduce the resulting curvature to 20 degrees or less. While not perfect, this is sufficient to allow normal intercourse.

Choosing the Optimal Treatment

At the current time, there is no general consensus about an optimal treatment plan for patients with Peyronie’s disease. With so many treatment options available and so few published valid studies to help us select a therapy, for the moment we are left with grossly inadequate data to make these difficult treatment decisions. Therefore, until definitive studies are published and available to help us optimize therapy, we rely instead on trying to select treatments that make reasonable scientific sense as well as the published opinions and experience of experts in the field. A reasonable trial of medical therapy prior to an invasive or surgical approach would seem to make sense. At the current time, we are recommending daily use of the “Fastsize” penile traction device together with a daily combination of Arginine, Carnitine, Trental and Cialis. If this approach fails after six months, we add verapamil injections or EMDA for another six months. If this also fails, then a surgical intervention is considered. It seems reasonable to try a penile traction device together with oral medical therapies to maximize the results, but we don’t know just yet which combination will be the most effective. When additional validated studies are available, we’ll modify the treatment plan accordingly.

A Final Word

Peyronie’s disease is not the end of the world and it’s not a terminal illness. We have treatments that can help most patients although a definitive cure is not yet available. Now that it’s getting some attention by medical researchers, there is new hope in eventually resolving many of the mysteries of this troublesome disorder. Promising new treatments being developed by leading researchers may eventually provide the ultimate remedies and cures for Peyronie’s we are anxiously awaiting. For more information on Peyronie’s, check the links below.