Peyronie disease treatment: from watchful waiting to surgery

Treatment for Peyronie disease depends almost entirely on which phase you are in. In the active phase, with pain and a changing curvature, watchful waiting is usually the starting point. Only once the curvature has been stable for around six months and the pain has gone do options such as injections or surgery come into view.

Peyronie disease is a hardening of connective tissue in the wall of the erectile bodies. As a result the penis stretches less on one side during an erection, which creates a curve.

I find this one of the most underrated male complaints. It is visible, it affects your sex life directly, and men still wait months before mentioning it.

How common is Peyronie disease?

More common than most men assume. Review articles cite prevalence figures running up to around 9 percent of the male population, depending on how it is measured. It occurs most between roughly 40 and 70 years of age.

That figure is higher than most estimates from the consulting room. Underdiagnosis plays a part, because far from everyone reports it.

A slight curve of the penis is normal, by the way, and has nothing to do with Peyronie. This is about a curve that changes, often with a lump you can feel.

What causes it?

The exact cause is not settled. The most used explanation is that small injuries to the wall of the erectile bodies, for example from an unexpected bend during sex, heal with too much scar tissue in some men. Why that happens to one man and not another is unclear.

Links have been described with Dupuytren disease, where connective tissue in the palm hardens. That points to a predisposition to excessive connective tissue formation.

Diabetes appears in that list too. We wrote about the broader link between blood sugar and erections in diabetes and erection problems.

The two phases, and why that distinction matters

Peyronie runs in two phases, and clinicians pick their approach accordingly. The active phase is marked by pain and a curvature that is still changing. The stable phase means the situation has not changed for several months and the pain has gone.

Surgery during the active phase makes little sense, because the curvature can still change afterwards. A European position statement on surgery for Peyronie therefore stresses stability and freedom from pain before operating.

That is the nuance missing from most pages. They list treatments without saying when each one applies.

Take two men with the same curvature of roughly 30 degrees. One has pain and the angle visibly changed within two months, so he is in the active phase and waiting is the starting point. The other has had the same angle for a year without pain, and only then do procedures come into view.

Same degrees, different phase, different advice.

Which treatments exist?

The options run from watchful waiting to surgery, and which one fits is decided by the urologist together with you. In the active phase it is usually about pain relief and reassurance. In the stable phase, traction therapy, injections into the plaque and various surgical techniques come into view.

In some men the curvature reduces slightly over time on its own. In others it stays the same or worsens.

The best known operation is the Nesbitt technique, where a wedge of connective tissue is removed on the opposite side so the penis straightens again. That costs some length, which is discussed beforehand.

Reliable Dutch-language information on penile curvature is available from Thuisarts and from hospital urology departments.

Peyronie and erection problems

The two often occur together, for several reasons. The scar tissue itself can affect blood flow, the pain can discourage sex, and the tension around it does the rest. That makes it hard to tell cause from consequence.

ED medications are sometimes used in Peyronie to support the erection itself, not to treat the curvature. The available options are in ED medications compared.

If low desire or fatigue play a role too, hormonal values come into view. A testosterone test can show part of that, and you discuss the meaning with your GP. See also low libido in men and impotence: what it means.

When do you take it to a doctor?

My advice: earlier than you are currently planning. A lump you can feel, pain during an erection, or a curve that changes within weeks are all reasons to have it looked at.

Photograph the curvature at home during an erection, from above and from the side. That sounds awkward, but it is the only way a doctor can judge the change over time.

We described how such a conversation goes in discussing erection problems with your GP. For Peyronie, the GP usually refers you to a urologist.

Every blood test result includes a professional assessment from a BIG-registered doctor. For treatment decisions, discuss your results with your GP.

References

• Ostrowski KA, et al. A review of the epidemiology and treatment of Peyronie disease. Res Rep Urol, 2016. PMID: 27200305
• Yafi FA, et al. Therapeutic advances in the treatment of Peyronie disease. Andrology, 2015. PMID: 26097120
• Osmonov D, et al. ESSM position statement on surgical treatment of Peyronie disease. Sex Med, 2022. PMID: 34823053
• Thuisarts, information on penile curvature.